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Bowel Obstruction
Authors

David A. Smith1; Sara M. Nehring2.

Affiliations
1 Salus University/PVAMC
2 St Bernards Medical Center

Last Update: November 12, 2019.

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]

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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

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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.

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.

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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]

Questions
To access free multiple choice questions on this topic, click here.

References
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