Bowel Obstruction

Nkechi Nweke
Anatomy
The small bowel is about 6.5m long. It extends from the pylorus of the stomach to the ileocaecal junction where it joins the large
bowel.The main function of the small bowel is digestion and absorption of food.

The small bowel is divided into 3 parts - duodenum, jejunum and ileum. The jejunum is located in the left upper quadrant while the
ileum is in the right lower quadrant of the abdomen.

Vascular supply (arteries and corresponding veins)

- Duodenum (prox to major duodenal papilla - gastroduodenal artery, branch of hepatic artery
- Duodenum ( dist to major duodenal papilla - inferior pancreaticoduodenal artery, branch of SMA
- Jejunum/ileum - SMA

Lymphatic drainage

- Duodenum - pancreaticoduodenal and superior mesenteric nodes

- Duodenum, Jejunum, ileum - superior mesenteric nodes

Innervation

- Duodenum - vagus nerve (parasympathetic), greater splanchnic nerves >> celiac plexus (sympathetic)
- Jejunum/ileum - vagus nerve, lesser splanchnic nerves >> celiac plexus and superior mesenteric ganglia

Vagus nerve augments the peristaltic activity of the myenteric plexus of the midgut and the enteric nervous system in the submucosal
layer.
Epidemiology
Intestinal obstruction incidence is similar in males and females. Factors affecting incidence and distribution depend
on individual risk factors such as prior surgery, chronic inflammatory bowel disease, colon cancer, metastasis,
abdominal hernia, foreign body ingestion, previous irradiation.

Etiology
Pathophysiology
Proximal to obstruction, the bowel dilates, filling with GI secretions and swallowed air thereby increasing intraluminal pressures. When
the intraluminal pressure exceeds venous pressure, impaired venous drainage causes edema and bowel congestion. This may
compromise arterial supply, resulting in ischemia, necrosis and ultimately bowel perforation. In a closed loop obstruction, this process
may proceed rapidly and is considered a surgical emergency.

Fluid losses and electrolyte imbalance from vomiting, bowel wall edema and poor absorption lead to dehydration and metabolic
alkalosis.

Gut bacteria proximal to obstruction proliferate and can translocate into the bloodstream leading to sepsis.

Presentation
4 main cardinal features:

- Abdominal pain - commonly crampy, intermittent, colicky In SBO but improves with vomiting. Pain is continuous in LBO
- Vomiting - tends to be bilious, frequent and in larger volume in SBO. Intermittent and feculent when present in LBO
- Abdominal distension - is marked in LBO with obstipation
- Absolute constipation

* fever, tachycardia, peritoneal signs, leucocytosis may be late findings and associated with ischemia/strangulation
Physical exam
- Take a history. Ask of previous abdo or abdo surgery, hernia, IBD, intra abdominal neoplasia
- Assess cardiovascular status (pulse, BP< capillary refill time), other signs of SIRS (resp rate, temp) and general
health
- Check abdo for masses, peritonitis, hernias, scars for incisional hernias
- Bowel sounds are hyperactive and tinkling in mechanical obstruction while in adynamic obstruction it is hypoactive.
- Do a digital rectal exam

Differentials
- SBO
- Toxic megacolon
- Appendicitis
- Colonic polyps
- Abdominal hernias
- Diverticulitis empiric therapy
- Pseudomembranous colitis surgery
- Ogilvie syndrome (pseudo obstruction)
- Postoperative paralytic ileus
Investigations
- Blood tests: CBC, metabolic panel, serum lactate level.Elevated BUN, Hb and hematocrit levels suggest
dehydration. Metabolic acidosis, especially with an increasing serum lactate level, may signal bowel ischemia.
Leukocytosis may indicate bacterial translocation.
- Plain abdominal x ray usually erect views. CT with oral contrast (allows for visualization of transition point,
severity of obstruction and assessment of complications)
- MRI
- Contrast fluoroscopy
- Ultrasound ( for initial evaluation in hemodynamic unstable pts and in pregnant women)
Treatment
Management aims at correcting physiologic derangements, providing bowel rest and decompression, and removing source of
obstruction. It also depends on etiology and severity of the obstruction.

- Begin supportive asap with IV crystalloids, antiemetics and bowel rest. Nasogastric tube can be used for proximal
bowel decompression to prevent aspiration pneumonia. Insert a Foley catheter to monitor urine output. Oxygen may
also be required. Give antibiotics to cover gram negative and anaerobic organisms. Analgesia and antiemetic may be
given if clinically indicated.
- Low grade obstruction can be resolved with NG tube decompression and supportive measures.
- Reducible hernias require non surgical intervention. Non reducible or strangulated hernias will require surgical
interventions.
- High grade or complete obstructions require emergent surgical intervention.
Complications
- Sepsis
- Intraabdominal abscess
- Wound dehiscence
- Disability
- Short bowel syndrome
- Aspiration
- Bowel perforation
- Pneumonia
- Anastomotic leak
- Respiratory failure
- Renal failure
- Death
Prognosis

When management is prompt, outcome is good. For non surgically managed cases, recurrence is much higher than
surgically managed cases.

Mortality and morbidity depend on early recognition, correct diagnosis and prompt treatment. Strangulated
obstructions if left untreated can cause death in 100% of cases. Performing surgery within 36 hours decreases
mortality rate to 8%. Beyond 36 hours, mortality rate is 25%.
References
1. Catena, F., De Simone, B., Coccolini, F., Di Saverio, S., Sartelli, M., & Ansaloni, L. (2019). Bowel obstruction: a
narrative review for all physicians. World Journal of Emergency Surgery, 14(1).
https://doi.org/10.1186/s13017-019-0240-7
2. Griffiths, S., & Glancy, D. G. (2020). Intestinal obstruction. Surgery (Oxford), 38(1), 43–50.
https://doi.org/10.1016/j.mpsur.2019.10.014
3. Jackson, P., & Cruz, M. V. (2018). Intestinal Obstruction: Evaluation and Management. American Family Physician,
98(6), 362–367. https://www.aafp.org/pubs/afp/issues/2018/0915/p362.html
4. Small-Bowel Obstruction: Practice Essentials, Background, Pathophysiology. (2021). EMedicine.
https://emedicine.medscape.com/article/774140-overview#a6
5. Smith, D. A., & Nehring, S. M. (2018, November 15). Bowel Obstruction. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK441975/