Tuesday, April 14, 2009

Large Bowel Obstruction

I've had a run of large bowel obstructions (LBO) lately. The images above are illustrative. When we talk about "bowel obstruction", usually we're referring to small bowel obstruction (SBO), generally caused by adhesions and scar tissue from previous surgery. SBO's can be managed non-operatively about 75% of the time.

LBO is a different animal. Adhesions don't (in general) cause an obstruction of your colon. Cancer, volvulus, and hernias are the usual culprits and an operation is often mandated. A colonic obstruction is technically a surgical emergency. The cecum is very thin walled and, with the ileocecal valve, can form a closed loop situation with a distal obstruction. Ischemia and frank perforation are eventual consequences. The resultant poopy belly is not in anyone's best interest.

The first picture shows a dilated cecum secondary to a hepatic flexure tumor. Pictures 2 and 3 demonstrate a LBO caused by a splenic flexure cancer. Both patients had formal resections with primary anastomoses.


Bongi said...

open or laparoscopic?

Jeffrey Parks MD FACS said...

Open. I don't like to dick around laparoscopically with a colonic obstruction. Plus, both patients were sort of toxic-looking. Better to get in and out quick.

Anonymous said...

Just operated on a lady with incarcerated ascending and transverse colon in a ventral hernia causing a LBO. Resection, ostomy, mucous fistula. Interesting case.

Gary M. Levin said...

Nasty problem,emergent, indeed...came home one night with spouse writhing in bed with distended abdomen..911 to ER 11 PM open exploration..volvulus.Right hemicolectomy... Surgeon reanastomosed endings together.... even I as an ophthalmologist knew there should have been a iliostomy until things settled down....more disaster...MRSA sepsis, multiple abcesses,enterocutaneous fistual, 8 mos of TPN.....God awful!!

Jeffrey Parks MD FACS said...

Nothing fundamentally wrong with a primary anastomosis after a right hemicolectomy, unless patient unstable, hypotensive, etc...

Surgeon In My Dreams said...

I have a comment about this post.

My dad is 76 years old. He still works, and not because he needs the money by any means, lol. He works out at the gym several days a week. He still takes care of his own house and 1.5 acre lawn.

He went to his family doctor for several months with complaints of stomach pain, nausea, heartburn. He was treated for GERD. He went over and over and over. Same answer.

One Monday a few weeks ago, he went and told the doctor, whatever he was throwing up seemed like it should be "coming out the other end". His words. He was sent home again with the same diagnosis and some other pills to take.

By the next afternoon, my father was in ICU after having surgery for his bowel being blocked and aspirating during surgery. He was in ICU for 4 days and in the hospital for two weeks.

My father, who had never been sick nor had he ever been on any medications in his life nearly died because his family doctor is so busy and so popular he couldn't take the time to listen to what the man was telling him.

I have no medical training other than a surgical technology program I completed, but if you came to me and told me you were "vomiting something that seemed like it should be coming out the other end", I would have immediately thought blockage.

I have wanted to badly to call this doctor, or visit him or write him a letter, but I won't do that.


(Surgeon In My Dreams)