Large Bowel Obstruction

Original article by Tom Leach | Last updated on 27/5/2014
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Introduction

Typically causes a less severe disease than small bowel obstruction
  • Symptoms are more gradual in onset
  • There are often loud borborygmi (normal bowel sounds)
  • Rectum is usually empty, and the abdomen is non-tender
  • Pain is lower down in the abdomen
  • There may be greater distension than with small bowel obstruction
 

Causes

  • Colon cancer
  • Benign strictures – e.g. diverticular disease, IBD, ischaemic bowel, radiation damage
  • Sigmoid volvulus
  • Intussusception
  • Herniae – not as common as in small bowel obstruction
  • Psuedo-obstruction (same as paralytic ileus, except it affects the large bowel)
 

Presentation

 

Closed loop obstruction

Ileo-caecal valve is competent and as a result fluids and other materials can continue to pass into the large intestine (the bowel produces up to 9L of fluid per day, so even if NBM, intestinal activity cannot be completely suppressed).  Colon distends massively (>12cm – normal <6cm), and the caecum is at risk of rupture and life-threatening faecal peritonitis.
 

Incompetent IC valve

  • The obstruction causes the small bowel to distend, and may induce vomiting
  • Not as urgent as closed loop obstruction, because perforation isn’t as bigger risk
  • Can be safely imaged with barium enema / endoscopy
 

Colonic stenting

  • Can be used in palliative care where surgery isn’t appropriate
  • Can also be used to buy time – ‘bridge to surgery’. The stent may allow the patient to recover enough to be fit enough for an operation.
  • Usually, it is colonic cancer that is stented.
  • Apple core stricture - a sign of colon cancer – is a sign on barium enema,where the lumen of the bowel looks a bit like an apple core due to the cancer causing a stricture.
 

Pseudo-obstruction

  • Similar pathogenesis to paralytic ileus
  • You cant exclude mechanical obstruction without colonic imaging.
  • Mostly the same causes as paralytic ileus, but can be affected by drug use (e.g. anti-depressants), neurological disease and pneumonia.