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CLINICAL SCIENCE PHYSICIAN

Bowel obstruction

Summary

Bowel obstruction is the interruption of the normal passage of bowel contents either due to a functional decrease in peristalsis or mechanical obstruction.
Functional bowel obstruction , or paralytic ileus, is a temporary disturbance of peristalsis in the absence of mechanical obstruction. Postoperative ileus is the
most common cause of paralytic ileus, which can also be caused by metabolic disturbances (e.g., hypokalemia), endocrinopathies (e.g., hypothyroidism), and
certain drugs (e.g., anticholinergics). Mechanical bowel obstruction is classified according to the location as either small bowel obstruction (SBO) or large
bowel obstruction (LBO) and, depending on the severity of obstruction, as either partial or complete. The most common cause of SBO is postoperative bowel
adhesions, while the most common cause of LBO is malignant tumors. Regardless of the cause, bowel obstruction typically manifests with nausea, vomiting,
abdominal pain, abdominal distention, and constipation or obstipation. In paralytic ileus, bowel sounds are usually absent on auscultation, whereas a
high-pitched tinkling sound would be heard in the early phase of a mechanical bowel obstruction . Bowel distention leads to third-space volume loss, resulting
in dehydration and electrolyte abnormalities. Symptoms are less severe in partial bowel obstruction. Diagnosis is confirmed on imaging with contrast-enhanced
CT scan and abdominal x-rays. Typical findings in mechanical bowel obstruction include dilated bowel loops proximal to the obstruction, collapse of bowel
loops distal to the obstruction, and, on contrast-enhanced imaging, a cut-off or transition point at the site of obstruction. In paralytic ileus, findings include
generalized dilatation of bowel loops with no transition point and air that is visible in the rectum. Additional laboratory tests include CBC and BGA for the
assessment of infection, electrolyte imbalances (e.g., hypokalemia), and metabolic imbalances (e.g., alkalosis). Surgical intervention (i.e., exploratory
laparotomy) is recommended for suspected closed-loop bowel obstruction, if there are signs of perforation or peritonitis, or if there is no improvement following
conservative management. In all other cases, conservative treatment is usually successful and involves bowel rest, gastric decompression (nasogastric
suction), fluid resuscitation, and correction of electrolyte abnormalities.

Overview

Mechanical bowel obstruction Paralytic ileus

Small bowel obstruction (SBO) Large bowel obstruction

(LBO)

Etiology Interruption in the normal passage due to a structural barrier Temporary impairment of peristalsis in the absence
of a mechanical obstruction
Bowel adhesions (e.g., prior abdominal Malignant tumors (e.g., Recent abdominal surgery
surgery, abdominal tuberculosis) colorectal carcinoma) Atherosclerotic disease
Incarcerated hernias: second most common Volvulus Abdominal infections or inflammatory conditions
cause of SBO Certain medications (opioids, anticholinergics,
antiparkinsonian agents)

Clinical Colicky abdominal pain Diffuse, continuous abdominal pain

features Vomiting Vomiting
Bilious vomiting is an early symptom of SBO. Obstipation or constipation
Feculent vomiting is a late symptom of LBO. Marked abdominal distention
Obstipation or constipation Tympany on percussion
Abdominal distention Absent bowel sounds
High-pitched, tinkling bowel sounds (early)
Absent bowel sounds (late)

Findings on Dilated bowel loops proximal to obstruction Diffusely dilated small and large bowel loops
imaging Collapsed bowel loops distal to obstruction Air within rectum
No air within rectum No evidence of mechanical obstruction
Multiple air-fluid levels
Cause of obstruction (e.g., tumor)

References:[1][2][3][4]
Definition

Bowel obstruction
An interruption in the normal passage of bowel contents.

Etiology
Mechanical bowel obstruction : an interruption in the normal passage of intestinal contents due to a structural barrier (e.g., bowel cancer, adhesions)
Paralytic ileus: a temporary impairment of peristalsis in the absence of a mechanical obstruction

Degree of obstruction
Partial bowel obstruction: bowel obstruction in which passage of some intestinal content through the blocked segment is possible
Complete bowel obstruction: total interruption of the passage of intestinal contents
Closed loop obstruction: a type of complete mechanical bowel obstruction in which a segment of bowel is occluded at two contiguous points (e.g., volvulus)

Site of obstruction
Small bowel obstruction (SBO): obstruction occurring in the duodenum, jejunum, or ileum
Large bowel obstruction (LBO): obstruction occurring in the cecum, colon, or rectum

Progression
Simple bowel obstruction: obstruction without evidence of bowel ischemia
Strangulated bowel obstruction: obstruction with compromised intestinal blood flow, resulting in bowel ischemia
Reference:[5]

Mechanical bowel obstruction

Etiology [1] [6]

Small bowel obstruction Large bowel obstruction

Most common Adhesions (e.g., prior abdominal surgery , abdominal tuberculosis): most common cause of Malignant tumors (e.g., colorectal
causes SBO carcinoma): most common cause of
Incarcerated hernias: second most common cause of SBO LBO
Volvulus: second most common cause
of LBO

Other causes Meckel diverticulum Diverticulitis

Strictures (e.g., Crohn disease) Adhesions (e.g., postoperative, prior
Malignant tumors or metastases abdominal surgery)
Gall stone ileus Strictures (e.g., inflammatory bowel
Superior mesenteric artery syndrome (bowel obstruction due to compression of the third disease, congenital strictures)
portion of the duodenum in between the aorta and the superior mesenteric artery) Fecal impaction
Foreign body impaction Foreign body impaction
Tumor
Internal hernia

Specific to Congenital intestinal atresia (e.g., duodenal atresia, jejunal atresia) Hirschsprung disease
infants and Intussusception (e.g., secondary to Meckel diverticulum) Congenital strictures and bands (e.g.,
children Congenital strictures and bands (e.g., Ladd bands in intestinal malrotation) Ladd bands in intestinal malrotation)
Meconium ileus
Rectal atresia

Pathophysiology [7]
Bowel obstruction → stasis of luminal contents and gas proximal to the obstruction → ↑ intraluminal pressure , which leads to the following:
Gaseous abdominal distention → sequestration of fluids within the distended bowel loops ( third spacing) → dehydration and hypovolemia
Vomiting → loss of fluid and Na +, K +, H +, and Cl - → hypokalemia, metabolic alkalosis, and hypovolemia
Compression of intestinal veins and lymphatics → bowel wall edema → compression of intestinal arterioles and capillaries → bowel ischemia
→ ↑ Bowel wall permeability → translocation of intestinal microbes to the peritoneal cavity → sepsis
→ Necrosis and perforation of the bowel wall → peritonitis
→ Anaerobic metabolism and lysis of ischemic cells → accumulation of lactic acid and release of intracellular K +→ metabolic acidosis and hyperkalemia

Clinical features [4][8][9]

Clinical features SBO LBO

Abdominal pain Colicky, periumbilical Colicky or constant

Vomiting/nausea Early-onset Late-onset

Large volume Initially bilious
Bilious Progresses to fecal vomiting (presence of feces in vomitus)

Constipation or obstipation Late-onset in proximal SBO Early-onset in distal LBO

Abdominal distention Typically less significant than in LBO Early and significant abdominal distention

Examination findings Dehydration and possible hypovolemia (hypotension, dry mucous membranes)
Diffuse abdominal tenderness
 Clinical features Tympanic percussion
SBO LBO
Increased high-pitched, tinkling bowel sounds (early) or absent bowel sounds (late)
Collapsed, empty rectum on digital rectal examination
Partial bowel obstruction causes gradually progressive symptoms that are milder than those of complete obstruction. Obstipation is absent in partial
bowel obstruction.

Diagnostics
In the workup of suspected mechanical bowel obstruction , imaging allows for quick confirmation of the diagnosis as well as detection of conditions requiring
immediate surgery (e.g., perforation). Laboratory tests may further help to assess the severity of the condition (e.g., electrolyte imbalance due to vomiting).

Laboratory tests
If recurrent vomiting
Hypochloremic hypokalemic metabolic alkalosis
Hyponatremia
If bowel strangulation
Metabolic acidosis
Hyperkalemia
Neutrophilic leukocytosis (left shift)
If dehydration: ↑ Hct
If sepsis: abnormal coagulation profile
Potentially prerenal azotemia

Imaging [10][11][12][13]
Abdominal series
Consists of erect and supine abdominal x-rays and an erect chest x-ray.
Indication: Best initial test in hemodynamically unstable patients or in resource-poor health centers
Findings
Dilatation of bowel loops proximal to the obstruction
3-6-9 rule to define bowel dilatation on imaging
Small bowel dilatation if > 3 cm
Large bowel dilatation if > 6 cm
Cecal dilatation if > 9 cm
In SBO: The dilated loops are predominantly central.
In LBO (esp. distal LBO): The dilated loops are predominantly peripheral.
Minimal/no air within the bowel loops distal to the obstruction
Stepladder sign (x-ray)
Multiple air-fluid levels and a stacked appearance of dilated small bowel loops
Best seen on an erect abdominal x-ray

CT abdomen and pelvis

More sensitive than x-ray
Indications
With IV and oral contrast: Best initial test in hemodynamically stable patients with suspected partial bowel obstruction [14][15] [16]

With IV contrast: Indicated in patients with suspected complete bowel obstruction.

Non-contrast: Indicated in patients with contrast-allergy and suspected complete bowel obstruction.
Findings
Transition point: sudden narrowing of bowel lumen at the site of obstruction
Dilatation of proximal loops
Signs of bowel ischemia
Unenhanced bowel loops
Pneumatosis intestinalis
Mesenteric fat stranding
Pneumoperitoneum indicates bowel perforation

MRI abdomen and pelvis (with and/or without IV contrast)[17] [16]

Indication: patients who have a contraindication for radiation exposure

Findings: similar to CT

Abdominal ultrasound
Indication: critically ill patients (easy bedside test) or patients with a suspected SBO and a contraindication for CT (e.g., contrast allergy) or radiation
exposure (e.g., pregnancy)
Findings
Stepladder sign (ultrasound): prominent plicae circulares of dilated small bowel loops
Pendular peristalsis: dysfunctional “to-and-fro” peristalsis
Keyboard sign: prominent plicae circulares within the dilated bowel loops
Thickening of the bowel wall

Barium or water-soluble contrast enema

Indication: in suspected distal LBO
Findings
Tapering of bowel lumen at the site of obstruction
 Complete bowel obstruction: contrast would not be visible beyond obstruction
Partial bowel obstruction: a trickle of contrast would be visible beyond obstruction
Bird beak sign seen in volvulus
Apple core sign seen in colonic malignancy

When imaging with contrast (CT, enema) and perforation is expected, use water-soluble oral contrast.

Treatment
Conservative management
Indications
Partial bowel obstruction cases
Complete bowel obstruction with no signs of ischemia/necrosis or signs of clinical deterioration
Measures
Fluid resuscitation, correction of electrolyte imbalance
Intestinal decompression: nasogastric tube insertion
Bowel rest (NPO)
Administration of IV analgesics and antiemetics
Gradual increase of oral intake, starting with clear fluids, can be initiated once the abdominal pain and distention subside and bowel sounds return to
normal.
Etiology-specific treatments
Fecal impaction: stool evacuation (manual disimpaction, distal softening/washout with enemas or suppositories, proximal softening/washout with oral
solutions such as polyethylene glycol or sodium phosphate)
Sigmoid volvulus with no signs of strangulation: rigid/flexible sigmoidoscopic detorsion

Peristalsis-inducing medication (e.g., metoclopramide) is contraindicated in complete mechanical bowel obstruction .

Surgery
Indications
Suspected bowel obstruction and hemodynamic instability or features of sepsis
Complete bowel obstruction with signs of ischemia/necrosis or clinical deterioration
Persistent partial obstruction (> 3–5 days)
Closed-loop obstruction
Procedure: exploratory laparotomy
Restoration of intestinal transit: depends on intraoperative findings
If bowel resection is required, the intervention may be carried out in a single procedure with anastomosis or permanent ostomy creation, or in a
multistaged procedure with a temporary diverting ostomy.

Bowel obstruction requires a swift workup to establish whether emergent surgery is necessary!

Prognosis
100% mortality in cases of untreated intestinal strangulation
Mortality rate for those undergoing surgery: 8–25%
High risk of recurrence, particularly with chronic or recurring etiologies ( Crohn disease, adhesions, radiation enteritis, volvulus, etc.)
References:[10][19][20][11][21]

Paralytic ileus

Definition
Paralytic ileus: temporarily impaired peristalsis of the gastrointestinal tract in the absence of mechanical obstruction

Etiology
Intra-abdominal surgery (postoperative ileus)
Abdominal trauma (e.g., due to retroperitoneal hemorrhage)
Endocrine abnormalities (e.g., hypothyroidism, porphyria, uremia)
Electrolyte disturbances (e.g., hypokalemia)
Neuropathy (e.g., diabetes mellitus, spinal injury)
Neurosurgical procedures (e.g., spinal surgery)
Vascular diseases (e.g., mesenteric ischemia)
Peritonitis
Inflammation of intra-abdominal organs (e.g., appendicitis, cholecystitis, pancreatitis, severe gastroenteritis)
Medications (e.g., anticholinergics, opioids, antidepressants)

The common causes of paralytic ileus can be memorized using “5 Ps”: Peritonitis, Postoperative, low Potassium, Pelvic and spinal fractures, and
Parturition.[22]

[23][21]
References:[23][21]

Pathophysiology
Stressful stimuli to the bowel (e.g., surgery, peritonitis) → sympathetic nervous system activation → decreased/arrested peristalsis
Inflammation or intraoperative manipulation → local release of nitric oxide → relaxation of intestinal smooth muscles → decreased/arrested peristalsis
Decreased/arrested peristalsis → bowel wall distention → progresses as detailed above in mechanical bowel obstruction

Clinical features
Continuous (noncolicky) abdominal pain or discomfort
Nausea, vomiting
Abdominal distention
Percussion: tympany
Palpation: no tenderness unless peritonitis is present
Auscultation: bowel sounds are absent (silent abdomen) or decreased (early paralytic ileus)

Diagnostics
Laboratory [24]
Leukocytosis with left shift suggests intestinal infection or ischemia.
Anemia may be a sign of intra-abdominal hemorrhage (e.g., in postoperative or trauma patients).
Hypokalemia, hypomagnesemia

Imaging[25][26]
Abdominal x-ray: best initial test
Generalized small and large bowel gaseous distention
Visible gas shadows in the rectum
No transition or cut-off point on contrast x-rays, such as enteroclysis or barium/water-soluble contrast enema
If caused by retroperitoneal hemorrhage: obliteration of the psoas muscle outline
Abdominal CT: to rule out suspected mechanical bowel obstruction or if abdominal x-ray is inconclusive
Has the highest sensitivity and specificity for differentiating ileus from mechanical obstruction
Identifies uniformly distended loops with no transition point and no structural/mechanical cause

Treatment
Conservative treatment: in patients with no signs of localized or diffuse sepsis (e.g., appendicitis, secondary peritonitis)
Bowel rest
Nasogastric tube insertion
IV fluids and electrolyte repletion
Stop or decrease causative medications (e.g., opioids).
Gradual increase in enteral feeding as tolerated by the patient
Early postoperative ambulation (although still recommended to prevent DVT) and use of prokinetics have not been proven to improve peristalsis.
Surgical intervention: in patients with signs of peritonitis (e.g., appendectomy, exploratory laparotomy)
Reference:[23]

Differential diagnoses

Differential diagnosis of bowel obstruction

Bowel perforation (secondary peritonitis)
Mesenteric ischemia
Inflammatory bowel disease
Ovarian torsion
Differential diagnosis of SBO
Acute appendicitis
Acute pancreatitis
Pelvic inflammatory disease
Differential diagnosis of LBO
Diverticulitis
Toxic megacolon
Chronic megacolon
See differential diagnoses of acute abdomen .
References:[1][2][3][4]

The differential diagnoses listed here are not exhaustive.

Complications

Bowel ischemia
Bowel perforation
Peritonitis

A change in the character of pain (colicky pain becoming continuous), rebound tenderness on examination, and/or signs of sepsis in a patient with
bowel obstruction indicate the onset of complications and necessitate emergency surgical intervention!
We list the most important complications. The selection is not exhaustive.

last updated 01/30/2020

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