Introduction

A bowel obstruction can either be a mechanical or functional obstruction of the small or large
intestines. The obstruction occurs when the lumen of the bowel becomes either partially or
completely blocked. Obstruction frequently causes abdominal pain, nausea, vomiting,
constipation-to-obstipation, and distention. This, in turn, prevents the normal movement of
digested products. Small bowel obstructions (SBOs) are more common than large bowel
obstructions (LBOs) and are the most frequent indication for surgery on the small intestines.
Bowel obstructions are classified as a partial, complete, or closed loop. A closed-loop
obstruction refers to a type of obstruction in the small or large bowel in which there is complete
obstruction distally and proximally in the given segment of the intestine.[1][2][3]

Etiology
There are many potential etiologies of small and large bowel obstructions that are classified as
either extrinsic, intrinsic, or intraluminal. The most common cause of SBOs in industrialized
nations is from extrinsic sources, with post-surgical adhesions being the most common.
Significant adhesions can cause kinking of the bowel leading to obstruction. It is estimated that
at least two-thirds of patients with previous abdominal surgery have adhesions. Other common
extrinsic sources include cancer, which causes compression of the small bowel leading to
obstruction. Less common but still prevalent extrinsic causes are inguinal and umbilical hernias.
Untreated or symptomatic hernias may eventually become kinked as the small bowel protrudes
through the defect in the abdominal wall and becomes entrapped in the hernia sack. Hernias that
are not identified or are not reducible may progress to obstruction of the bowel and are
considered a surgical emergency with the strangulated or incarcerated bowel becoming
ischemic over time. Other causes of SBO include intrinsic disease, which can create an insidious
onset of bowel wall thickening. The bowel wall slowly becomes compromised, forming a
stricture. Crohn disease is the most common cause of benign stricture seen in the adult
population.  [4][5]
Intraluminal causes for SBOs are less common. This process occurs when there is an ingested
foreign body that causes impaction within the lumen of the bowel or navigates to the ileocecal
valve and is unable to pass, forming a barrier to the large intestine. However, it is noted that most
foreign bodies that pass through the pyloric sphincter will be able to pass through the rest of the
gastrointestinal tract. LBOs are less common and compromise only 10% to 15% of all intestinal
obstructions. The most common cause of all LBOs is adenocarcinoma, followed by diverticulitis
and volvulus. Colonic obstruction is most commonly seen in the sigmoid colon.     

Epidemiology
Small and large bowel obstructions are similar in incidence in both males and females. The
overriding factor affecting incidence and distribution depends on patient risk factors, including
but not limited to: prior abdominal surgery, colon or metastatic cancer, chronic intestinal
inflammatory disease, existing abdominal wall and/or an inguinal hernia, previous irradiation,
and foreign body ingestion. [6][7]

Pathophysiology
The normal physiology of the small intestine consists of the digestion of food and the absorption
of nutrients. The large bowel continues to aid in digestion and is responsible for vitamin
synthesis, water absorption, and bilirubin breakdown. Any obstructive mechanism will hinder
these physiologic components. Obstruction causes dilation of the bowel proximal to the
transition point and collapses distally. A result of partial or complete blockage of digested
products during obstruction is emesis. Frequent emesis can lead to fluid deficits and electrolyte
abnormalities. As the condition is left untreated and worsens, a bowel wall edema forms, and
third-spacing begins. A serious and life-threatening complication of bowel obstruction is
strangulation. Strangulation is more commonly seen in closed-loop obstructions. If the
strangulated bowel is not treated promptly, it eventually becomes ischemic, and tissue infarction
occurs. Tissue infarction progresses to bowel necrosis, perforation, and sepsis/septic shock. 

History and Physical

Suspected bowel obstruction requires the practitioner to obtain a detailed medical history
inquiring about significant risk factors related to bowel obstruction. Small and large bowel
obstruction have many overlapping symptoms. However, quality, timing, and presentation differ.
Commonly in SBO, abdominal pain is described as intermittent and colicky but improves with
vomiting, while the pain associated with LBO is continuous. The vomiting in SBO tends to be
more frequent, in larger volumes, and bilious, which is in contrast to vomiting during an LBO,
which typically presents as intermittent and feculent when present. Tenderness to palpation is
present in both conditions, but with SBO, it is more focal, and with LBO, it is more diffuse.
Additionally, distention is marked in LBO with obstipation more commonly present. It is
important to note that in certain situations, an LBO will mimic an SBO if the ileocecal valve is
incompetent. An incompetent ileocecal valve can allow for the insufflation of air from the large
bowel into the small bowel producing symptoms of an SBO.

Evaluation
Although bowel obstruction alone can be suspected with an accurate patient history and
presentation, the current standard of care to confirm the diagnosis in small and large bowel
obstruction is an abdominal CT with oral contrast. CT allows for visualization of the transition
point, the severity of obstruction, potential etiology, and assessment of any life-threatening
complications. This information enables the provider to be more effective in identifying patients
who will require surgical intervention.  Laboratory evaluation is essential to evaluate for any
leukocytosis, electrolyte derangements that may be present as a result of the emesis. Labs also
evaluate for elevated lactic acid that may be suggestive of sepsis or perforation, which at
times may not be visible on CT if it is a microperforation and early in the course, blood cultures,
or other signs of sepsis/septic shock. Although the lactic acid is often looked to in order to
determine if there is a sign of perforation or ischemic gut, it should be noted this can be normal
even with a microperforation present, initially. Physical examination of the patient remains an
essential diagnostic tool regarding the patient's severity and the need for emergent surgery vs.
medical management.[8]
Treatment / Management
Initial management should always include an assessment of the patient's airway, breathing, and
circulation. If resuscitation is required, it should be performed with isotonic saline and
electrolyte replacement. A Foley catheter should be inserted to monitor the patient's urine output
if the patient is unstable or septic. Nasogastric tube insertion will allow for bowel decompression
to relieve distention proximal to the obstruction. Nasogastric tube insertion will also help control
emesis, allow for accurate assessment of intake and output, and lower the risk of aspiration.
Management ultimately depends on the etiology and severity of the obstruction. Stable patients
with partial or low-grade obstruction resolve with nasogastric tube decompression and
supportive measures. Patients who present with reducible hernias will require non-emergent
surgical intervention to prevent future recurrence. Non-reducible or strangulated hernias require
emergency surgical intervention. Complete or high-grade obstructions often require urgent or
emergent surgical intervention as the risk of ischemia increases. Chronic disease states such as
Crohn disease and malignancy require initial supportive measures and longer periods of
nonoperative management. Treatment will ultimately depend on the patient's disposition and
surgeon's acumen.

Differential Diagnosis
 Abdominal hernias
 Abdominal pain in elderly people
 Appendicitis
 Chronic megacolon
 Colonic polyps
 Diverticulitis
 Diverticulitis empiric therapy
 Pseudomembranous colitis surgery
 Small bowel obstruction
 Toxic megacolon

Prognosis
When bowel obstruction is managed promptly, the outcome is good. In general, when bowel
obstruction is managed non surgically the recurrence rate is much higher than those treated
surgically.
Complications
 Intraabdominal abscess
 Sepsis
 Disability
 Wound dehiscence
 Aspiration
 Short bowel syndrome
 Pneumonia
 Bowel perforation
 Respiratory failure
 Anastomotic leak
 Renal failure
 Death

Postoperative and Rehabilitation Care

The postoperative recovery, in most cases of bowel obstruction, is slow. These patients need
prophylaxis against deep venous thrombosis and prevention of atelectasis. Ambulation is
necessary. Time to feeding can vary depending on the ileus.

Consultations
 General surgeon
 Radiologist for drainage of any abscess
 Stoma nurse
 Infectious disease

Pearls and Other Issues

Most bowel obstructions will require hospital admission and surgical consultation. Prompt
recognition and diagnosis are critical in improving morbidity and mortality. The most important
step in the initial management of bowel obstruction is identifying the type, severity, and cause.
Understanding the difference between emergent and non-emergent surgical intervention is
essential in improving outcomes and preventing sequelae of complications, including bowel
necrosis, perforation, and sepsis. Disposition ultimately depends on the type and etiology of the
obstruction, as well as the patient's past medical history, current health status, and risk factors.
Enhancing Healthcare Team Outcomes
The key to preventing the high mortality following a bowel obstruction is the early diagnosis,
resuscitation, and operative intervention. An interprofessional team is vital to ensure that the
patient receives prompt attention. The triage nurse must be fully aware of the signs of bowel
obstruction and expedite the admission. The emergency physician, nurse practitioner, or
physician assistant must examine the patient and get the appropriate radiological test. The
surgeon must be consulted even if no intervention is planned. While awaiting surgery, the bowel
may need to be decompressed with a nasogastric tube, and the nurse is essential for monitoring
of vital signs and worsening of the obstruction. Communication between healthcare workers is
critical. [9][4] [Level V]
Outcomes
The morbidity and mortality of bowel obstruction are dependent on early diagnosis and
management. If any strangulated bowel is left untreated, there is a mortality rate of close to
100%. However, if surgery is undertaken within 24-48 hours, the mortality rates are less than
10%. Factors that determine the morbidity include the age of patient, comorbidity, and delay in
treatment. Today, the overall mortality of bowel obstruction is still about 5%-8%.[3][10] [Level
3]