Friday, April 29, 2011

Large Bowel Obstruction

It cannot be emphasized enough: suspicion of a large bowel obstruction mandates an early surgical evaluation---- even if you think it's just a little old lady with another episode of constipation. LBO represents a potential surgical emergency. These patients ought not to be sitting on regular nursing floors for days and days. Within hours of arrival, a surgeon needs to be on the case. The consequences of delay can be catastrophic. Patients who perforate and dump liters of feces into their own abdominal cavities don't do so well.

Here's what to look for:
1) Colonic dilatation, especially cecal, greater than 6-8 cm.
2) Severe distention with tympany
3) PAIN. This is a sign of impending vascular compromise.
4) Don't be fooled by a report of "patient had some diarrhea". In a high grade colonic obstruction, sometimes passage of liquid fecal matter is the only stuff that gets through. Never assume that this suggests complete resolution of the blockage.

Here's what you do:
1)Consult surgery
2)Bowel rest, possible NG tube
3)Do not give oral motility or bowel cleansing agents

Here's what we will do:
1)Review films and examine patient. Pain on exam sets off our alarm systems.
2) Obtain barium enema study vs flexible sigmoidoscopy (usually in concert with our GI colleagues)
3) Operate

The type of operation can vary from case to case. Left sided obstructions usually result in a colostomy (unless you have endoscopic stenting specialists in your hospital). Right sided blockages can be addressed in a single stage without diverting ostomies. Sometimes all you can do is decompress the patient with a loop colostomy or even a cecostomy. But you can't let these patients with 10 cm cecums linger on the floor. The Law of LaPlace is an immutable physical reality.


Anonymous said...

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"Torture may have slowed hunt for bin laden, not hastened it":

Anonymous said...

Thanks for this post, it helped me to understand what happened. Two weeks ago I had an obstruction, caused by a colon stricture (8 previous operations the last 2 years due to gallstone necrotizing pancreatitis).
Fiber clogged my plumbing up, but it was resolved nonsurgically, through a balloon dilatation. I was so glad I didn't have to have surgery #9 (and another ostomy, as mine was successfully reversed. I guess I have to give up salads and fresh fruit, but I will happily do so if it prevents another surgery.

Vicki B said...

Hi Dr Buckeye, I just found your blog when I was searching online for information on what, if any, changes will occur due to my cecal volvulus surgery. I hope you can help me because so far, nothing. I had the surgery Saturday night, Sept 3rd. The surgeon said he removed 1/3 of my colon. I just want to know what I can expect to be different in my bowels, etc due to this surgery. Thank you Dr for any info you can give.
(p.s. Go Buckeyes!!!)