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Acute intestinal obstruction occurs when there is an interruption in the forward flow of intes-
tinal contents. This interruption can occur at any point along the length of the gastrointestinal
tract, and clinical symptoms often vary based on the level of obstruction. Intestinal obstruc-
tion is most commonly caused by intra-abdominal adhesions, malignancy, or intestinal hernia-
tion. The clinical presentation generally includes nausea and emesis, colicky abdominal pain,
and a failure to pass flatus or bowel movements. The classic physical examination findings of
abdominal distension, tympany to percussion, and high-pitched bowel sounds suggest the
diagnosis. Radiologic imaging can confirm the diagnosis, and can also serve as useful adjunc-
tive investigations when the diagnosis is less certain. Although radiography is often the initial
study, non-contrast computed tomography is recommended if the index of suspicion is high or
if suspicion persists despite negative radiography. Management of uncomplicated obstructions
includes fluid resuscitation with correction of metabolic derangements, intestinal decompres-
sion, and bowel rest. Evidence of vascular compromise or perforation, or failure to resolve with
adequate bowel decompression is an indication for surgical intervention. (Am Fam Physician.
2011;83(2):159-165. Copyright © 2011 American Academy of Family Physicians.)
I
ntestinal obstruction accounts for pass through the intestinal tract leads to a
▲
Patient information:
A handout on intestinal approximately 15 percent of all emer- cessation of flatus and bowel movements.
obstruction, written by the
gency department visits for acute Intestinal obstruction can be broadly dif-
authors of this article, is
provided on page 166. abdominal pain.1 Complications of ferentiated into small bowel and large bowel
intestinal obstruction include bowel isch- obstruction.
emia and perforation. Morbidity and mor- Fluid loss from emesis, bowel edema, and
tality associated with intestinal obstruction loss of absorptive capacity leads to dehydra-
have declined since the advent of more tion. Emesis leads to loss of gastric potassium,
sophisticated diagnostic tests, but the condi- hydrogen, and chloride ions, and signifi-
tion remains a challenging surgical diagno- cant dehydration stimulates renal proximal
sis. Physicians who are treating patients with tubule reabsorption of bicarbonate and loss
intestinal obstruction must weigh the risks of of chloride, perpetuating the metabolic alka-
surgery with the consequences of inappropri- losis.3 In addition to derangements in fluid
ate conservative management. A suggested and electrolyte balance, intestinal stasis leads
approach to the patient with suspected small to overgrowth of intestinal flora, which may
bowel obstruction is shown in Figure 1. lead to the development of feculent emesis.
Additionally, overgrowth of intestinal flora
Pathophysiology in the small bowel leads to bacterial translo-
The fundamental concerns about intesti- cation across the bowel wall.4
nal obstruction are its effect on whole body Ongoing dilation of the intestine increases
fluid/electrolyte balances and the mechani- luminal pressures. When luminal pressures
cal effect that increased pressure has on exceed venous pressures, loss of venous
intestinal perfusion. Proximal to the point drainage causes increasing edema and
of obstruction, the intestinal tract dilates as hyperemia of the bowel. This may eventu-
it fills with intestinal secretions and swal- ally lead to compromised arterial flow to
lowed air.2 Failure of intestinal contents to the bowel, causing ischemia, necrosis, and
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use2011
◆ Volume 83, Number 2
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Contact copyrights@aafp.org American
for copyright questions and/or permission Physician 159
Familyrequests.
Intestinal Obstruction
Clinically stable?
No Yes
Exploratory Radiography or
laparotomy computed tomography
Yes No
No Yes Yes No
Yes
Advance diet Resolution?
No
Exploratory
laparotomy
Figure 1. Algorithm for evaluation and treatment of patients with suspected small bowel
obstruction.
160 American Family Physician www.aafp.org/afp Volume 83, Number 2 ◆ January 15, 2011
Intestinal Obstruction
Table 1. Causes of Intestinal
Obstruction
January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 161
Intestinal Obstruction
COMPUTED TOMOGRAPHY
162 American Family Physician www.aafp.org/afp Volume 83, Number 2 ◆ January 15, 2011
Intestinal Obstruction
Contrast studies, such as a small bowel Magnetic resonance imaging (MRI) may be
follow-through, can be helpful in the diag- more sensitive than CT in the evaluation of
nosis of a partial intestinal obstruction in intestinal obstruction.20 MRI enteroclysis,
patients with high clinical suspicion and in which involves intubation of the duodenum
clinically stable patients in whom initial con- and infusion of contrast material directly
servative management was not effective.14 into the small bowel, can more reliably
The use of water-soluble contrast material is determine the location and cause of obstruc-
not only diagnostic, but may also be thera- tion.21 However, because of the ease and cost-
peutic in patients with partial small-bowel effectiveness of abdominal CT, MRI remains
obstruction. A randomized controlled trial an investigational or adjunctive imaging
of 124 patients showed a 74 percent reduc- modality for intestinal obstruction.
tion in the need for surgical intervention in
patients receiving gastrografin fluoroscopy Treatment
within 24 hours of initial presentation.15 Management of intestinal obstruction is
Contrast fluoroscopy may also be useful in directed at correcting physiologic derange-
determining the need for surgery; the pres- ments caused by the obstruction, bowel rest,
ence of contrast material in the rectum and removing the source of obstruction. The
January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 163
Intestinal Obstruction
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References Comments
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
164 American Family Physician www.aafp.org/afp Volume 83, Number 2 ◆ January 15, 2011
Intestinal Obstruction
January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 165