Large Bowel Obstruction
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Large Bowel Obstruction- Key Concepts
- Left-Sided Colonic Obstruction (Splenic Flexure to Rectosigmoid)
- Segmental Versus Total Colectomy
- Covered Versus Uncovered Stents
- Obstructing Rectal Cancer
- Unresectable Disease
- Cecal Volvulus
- Ileosigmoid Knotting
- Acute Colonic Pseudo-obstruction
- Medical Therapy
- Pharmacotherapy
- Colonic Decompression
- Surgical Therapy
- Rare Causes of LBO
- References
- Introduction
- Pathophysiology
- Clinical Presentation
- Initial Management
- Imaging
- Malignant Large Bowel Obstruction
- Perforation
- Right-Sided Colonic Obstruction (Cecum to Distal Transverse Colon)
Malignancy- A 67-year-old man who has never had colonoscopy presented to the emergency room reporting abdominal pain, distention, constipation, and blood per rectum for the past 2 days. He says his bowel movements are thin in caliber. Computed tomography (CT) of abdomen and pelvis shows a large mass in the mid rectum with proximal colonic distention. Magnetic resonance imaging (MRI) of the pelvis with rectal cancer protocol shows a mid-rectal T4N2M0 lesion. The mass is not amendable to endoscopic placement of stent due to angulation. The best next step is
- A 76-year-old man with a history of left-sided colon cancer presents with a 2-day history of obstipation, increasing abominal distension, and cramping. He has progressed on third-line chemotherapy. Cross-sectional imaging shows normal caliber small bowel, dilated cecum, ascending, and transverse colon with a mass in the distal descending colon. He has bilobar liver disease and multiple thoracic metastases. He is hemodynamically stable. What is the best option for revieving the obstruction?
- A 56-year-old obese man with locally advanced distal rectal cancer is treated with total neoadjuvant chemoradiation therapy. His is a 45-pack-per-year smoker. Restaging reveals no sign of metastasis. Magnetic resonance imaging (MRI) rectal protocol reveals partial clinical response and flexible sigmoidsociopy that shows a 3-cm tumor involving the sphincteric complex. What is the best surgical approach in his care?
- A 43-year-old woman with familial adenomatous polyposis (FAP) and history of total proctocolectomy and ileal pouch anal anastomosis presents with an 9 x 8 x 6 cm desmoid tumor at the root of the small-bowel mesentery causing obstruction. What is the best next treatment of choice is?
- A 37-year-old female patient with no prior colonoscopy and without chronic medical conditions undergoes an urgent laparotomy for a high-grade large bowel obstruction. At surgery, an obstructing rectosigmoid mass is discovered, with significant distention of the colon proximal to the mass. The cecum demonstrates significant distention with several partial-thickness serosal tears secondary to overdistention. The patient’s vital signs are stable, the patient’s small intestine and rectum are not distended, and there is no gross contamination. The best surgical option is
- A 78-year-old woman with coronary artery disease and congestive heart failure presents with symptoms of large bowel obstruction. Computed tomography (CT) shows a large obstructing descending colon mass with numerous hepatic and pulmonary lesions suggestive of metastatic disease. There is no evidence of bowel perforation or ischemia. Flexible endoscopy shows a large near complete obstructing carcinoma in the descending colon. Which of the following is the most appropriate next step?
- A 62-year-old woman is found to have a large near-obstructing sigmoid cancer on colonoscopy; biopsy returns as adenocarcinoma. Preoperative staging includes a carcinoembryonic antigen (CEA) level of 8 ng/mL, and imaging shows a few prominent lymph nodes near the sigmoid lesion. She is referred for surgical management. Frozen section on peritoneal nodules found near the lesion return as adenocarcinoma, and oncological resection is completed. Which of the following is the best determinant of the prognosis for this patient?
- A 50-year-old man presents with abdominal pain. Colonoscopy with biopsy revealed a large B cell lymphoma in the ascending colon. Staging workup reveals a nonobstructing mass in the ascending colon without evidence of metastatic or multifocal disease. The best next step is
- Perioperative
Benign Disease- A 43-year-old morbidly obese man is undergoing a Hartmann procedure for Hinchey IV perforated diverticulitis. Two days postoperatively, the ostomy has retracted below the skin and appears purple. The patient remains afebrile and hemodynamically normal without peritonitis. Intubation of the colostomy with a test tube reveals black mucosa proximal to the fascia. What is the next step in management?
- A 75-year-old man presents with a 1-week history of progressive abdominal distention and a 2-day history of obstipation. He is afebrile and his vital signs are within normal limits. On examination, he has massive abdominal distention and there is tympany to percussion, but no signs of peritonitis. Computed tomography reveals a large bowel obstruction with a whirl sign on the left side of the abdomen. There are no signs of bowel ischemia or perforation. What is the best next step in management?
- A 37-year-old man with fibrostenotic ileal Crohn’s disease is taken to the operating room for ileocecectomy for treatment of chronic intermittent partial small bowel obstruction. Preoperatively, the patient has no evidence of colonic Crohn’s disease. Intraoperatively, the patient is found to have an ileosigmoid fistula. The sigmoid colon is otherwise without evidence of Crohn’s disease. The best next step in management of the sigmoid colon is:
- A 78-year-old woman comes to the emergency department with a long history of chronic constipation and obstipation, nausea, abdominal pain, and distention for the past 5 days. Physical examination reveals abdominal distention with bilateral lower abdominal discomfort and fullness. On digital rectal examination, fecal impaction is noted and an attempt at manual disimpaction is unsuccessful. Computed tomography shows the findings in the Figure. The best next step in management for this patient is:
- Malignancy
- A 46-year-old woman who underwent restorative proctocolectomy 5 years ago for a history of familial adenomatous polyposis is admitted for persistent abdominal pain of 3 months’ duration, nausea, vomiting, and progressive distention of her abdomen. She typically has 4 to 6 bowel movements per day but has recently been having only 1 to 2 watery bowel movements. Computed tomography of the abdomen demonstrates dilated loops of proximal bowel with air fluid levels. There is also a 10×10–cm mass at the root of the small-bowel mesentery near a clear transition point with decompressed distal small bowel. Nasogastric tube decompression has started. Which of the following is the most appropriate management strategy?
- You are consulted by the emergency department about a patient with a large bowel obstruction caused by an obstructing right colonic mass. On exploration, you note that she has peritoneal carcinomatosis in the right lower quadrant, with a normal-appearing liver and ovaries. You perform a right colectomy with primary anastomosis, and a biopsy of her metastatic disease. Final pathology report is consistent with metastatic appendiceal mucinous neoplasm. Staging shows no evidence of distant metastatic disease aside from her known isolated peritoneal lesions. What is the best treatment option to improve her overall survival?
- A 74-year-old woman presents with a 2-week history of obstipation and a nearly obstructing cancer of the distal sigmoid. Computed tomography of the chest, abdomen, and pelvis also shows evidence of extensive lung and liver metastases. What is the best initial treatment option for this patient?
- A 62-year-old man with abdominal pain and distention presents to the emergency room. Computed tomography of the abdomen and pelvis demonstrates an obstructing mass in the upper sigmoid colon with a single right hepatic metastatic lesion. The cecum measures 8 cm in diameter, and the small bowel is decompressed. What is the best next step in treatment?
- A 68-year-old man with a history of a hemorrhoidectomy and fecal urgency presents with a T3n1m0 rectal cancer 5 cm from the anal verge. He has no family history of colorectal cancer. What is the most important consideration when counseling the patient about his surgical treatment options?
- Miscellaneous
- Endoscopic Management of Polyps and Endoluminal Surgery
Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction (2021)- Intestinal Stomas
- General Postoperative Complications
- Colonic Diverticular Disease
- Complications of the Pelvic Pouch
- Treatment of Difficult/Obstructive Defecation
- Colon Cancer Surgical Treatment: Principles of Colectomy
- Gastrointestinal Stromal Tumors, Neuroendocrine Tumors, and Lymphoma
- Anastomotic Complications
- Benign Disease
- A 50-year-old man presents to the emergency department with the sudden onset of periumbilical pain, abdominal distention and vomiting. The right lower abdominal quadrant is tender to palpation. Computed tomography (CT) results are below. The most appropriate treatment is
- A 65-year-old man who underwent a recent colostomy for fecal incontinence presents to your office with a symptomatic parastomal hernia, despite multiple appliance changes. What is the best step for definitive treatment?
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