Transcript Large Bowel Obstruction - St. Luke's

Large Bowel Obstruction
Katherine Jahnes MD
Colorectal Conference
St Luke’s Roosevelt Hospital Center
November 10, 2005
Case A
• 83 yo male presents with increasing abdominal
distention s/p failed sigmoidoscopy/ colonoscopy
• PMH: Alzheimer’s Disease, HTN, COPD,
glaucoma
• PSH: pacemaker placement (2001 for
bradycardia) and left hip repair (2001)
• PE: Lungs clear, Abdomen distended but soft
with hyperactive BS, TTP diffusely, LLQ>LUQ,
no rebound
Case A
• 20 year history of sigmoid volvulus
• Managed by sigmoidoscopy reduction as
outpatient three time a week
• On day of admission attempts at reduction
where unsuccessful
• Films were obtained
Case A
Case A
• Pt underwent a sigmoid resection
• Findings:
– Sigmoid volvulus with 3 360 degree turns
around mesentery
– No sigmoid ischemia
– Rectum, descending colon healthy and viable
– Sigmoid resected with primary anastomosis of
descending colon to rectum
Case B
• 71 year old female with 2 week history of
increasing abdominal distention and no
bowel movements
• PMH: HTN, DM, CVA- residual aphasia,
hemiparesis
• PSH: none
• PE: Abdomen:
– (? Rectal- gas in vault?)
– NT, Bowel sounds present, tympanitic
Case B
• Radiology:
Case B
• Operative findings:
Large Bowel Obstruction:
Causes
• Obstruction- mechanical interruption of the flow
of intestinal contents
– Volvulus
– Intussuception
– Neoplasia (60% of cases)
• Colorectal
• CLL
– Diverticular Strictures/ IBD
• Pseudo-obstruction- dilation of the bowel in the
absence of a causative anatomic lesion
Pseudoobstruction- Ogilvie’s
syndrome
• Distention of colon with signs and symptoms of colonic obstruction
without a mechanical cause for the obstruction
• May be acute or chronic
– Acute: usually involves only colon, and more commonly effects patients
with chronic renal, respiratory, cerebral or cardiovascular disease
– Chronic: can effect other parts of the GI tract and tends to recur
• Primary pseudoobstruction- a motility disorder
– familial visceral myopathy
– Diffuse disorder involving autonomic innervation of intestinal wall
• Secondary – more common.
– Associated with: neuroleptics, opiates, metabolic illness, myxedema,
DM, uremia, hyperPTH, lupus, scleroderma, Parkinson’s, traumatic
retroperitoneal hematomas
• Associated with sympathetic overactivity suppressing parasympathetics
Pseudoobstruction- Ogilvie’s
syndrome
• Diagnosis
– Water soluable contrast enema
• Can differentiate between mechanical and pseudoobstruction
– Colonoscopy
• Can also be used for treatment
• Initial treatment
– NGT
– Resuscitation
– Neostigmine (parasympathomimetic)
• 2.5 mg IV over 3 minutes, with resolution in 10 minutes
– Bradycardia is a side effect- atropine must be available
Volvulus
• Bowel is twisted on mesenteric axis resulting in complete
or partial obstruction of the bowel lumen as well as
possible vascular impairment
• Represents about 5% of large bowel obstructions
• Associated factors– chronic constipation
– Aging
– institutionalization (neuropyschiatric conditions treated with
pyschotrophic drugs)
– in the developing world- possible association with high fiber diets
• Characteristically affected bowel is attached to long
floppy mesentery fixed to retroperitoneum with a narrow
base
Volvulus
• Most commonly sigmoid,
also right colon and
terminal ileum (cecal
volvulus), cecum alone
(due to a highly mobile
cecum called a cecal
bascule- mobile in
caudad to cephalad
direction), and rarely
transverse colon
•
(photo: barium enema of cecal volvulus,
contrast stops at hepatic flexure (arrowhead)
and air filled cecum crosses midline of
abdomen in LUQ)
Volvulus
• Presentation: may be
acute or subacute
– Sudden onset of severe
abdominal pain, vomiting,
obstipation
– Abdomen is distended and
tympanitic, often
dramatically
• Radiographic findings– AXR: markedly dilated
colon with an air-fluid level,
no gas in rectum
– CT: mesenteric whirl (at
right)
– Contrast enema: bird’s
beak
Volvulus
• Treatment:
– Decompression with rectal tube placed via
proctoscope or colonoscopy, with rectal tube left in
place for 1-2 days. Often a sudden gush of gas and
fluid is released upon decompression
– Detorsion with colonoscope
– Sigmoid resection
• Hartmann’s procedure- emergent if decompression not
successful
• If decompression is successful; redundant bowel may be
removed laparoscopically with primary anastomosis
electively (perform colonoscopy first to r/o neoplasm)
Neoplasm
• Presentation, treatment, and multivariate
anaysis of risk factors for obstructive and
perforative colorectal carcinoma
– Alvarez et al, American Journal of Surgery
190(3): Sept 2005
• A high proportion of colon cancers present
as surgical emergencies
– Acute obstruction, perforation or both
– Associated with high morbidity and mortality
• Retrospective study
– 936 consecutive pts underwent surgery for primary
colorectal carcinoma
– 107 (11.4%) underwent emergency surgery
• Indications:
– history and physical consistent with peritonitis
– Intrabdominal abscess with systemic signs of sepsis
– Clinical signs of obstruction and radiographic evidence thereof
not responding to conservative measures within 4 days of
hospitalization
» Study excluded pts with crohn’s, UC, other types of
neoplasm, FAP, h/o operations at outside hospitals, and
those not requiring surgery
• Of 107 pts, 83 (78%) had complete obstruction and 24
(22%) had perforation
– Sigmoid was most common location
– Comorbid conditions were present in 70% of pts- HTN, CV,
COPD, DM.
– Males predominated in the obstruction group
– Advance tumor stage was seen in 70% of the obstructing pts and
in 54% of the perforated pts
– Overall/ curative resection rate for obstructed pts was 85/ 83%
respectively
– Mean OR time was 145.7 minutes (SD 57.1)
– 37% required a blood transfusion
Tables
•
Table 2 . Surgical procedures in patients with complicated colorectal carcinoma
Obstruction (n = 83)Perforation (n = 24)Total n (%)Right colon nLeft colon
nRight colon nLeft colon nNo resection16 (14.9)†Colostomy only7411Colostomy
only with intention for staged resection22Bypass anastomosis only22Laparotomy
only11Resection91 (85.1)†Resection + anastomosis1921⁎4347Resection +
stoma3111244⁎ Two patients had proximal diverting colostomy and primary
anastomosis.
† The comparison between the obstructing and perforating groups was not
significant.
• Major postop complications in 33%- most
frequently GI and pulmonary
• Factors associated with major
complications or mortality included:
– Older age, female sex, perioperative blood
transfusion, high ASA or APACHE II score
– Not associated: location of lesion
Diverticular Strictures/ IBD
• Crohn’s disease
– Obstruction most commonly in terminal ileum
Intussusception
• A segment of bowel and its associated mesentery
(intussusceptum) invaginates into the lumen of an
adjacent bowel segment (intussuscipiens)
• Leading cause of bowel obstruction in children
• May be caused by intramural, mural, or extramural
process– intraluminal mass pulled forward by peristalsis and drags bowel
wall with it
• Ie pedunculated tumors, inverted meckel’s diverticulum or appendix
– Segment of bowel wall that does not contract normally and the
opposite wall rotates the abnormal segment inward causing a
kink that acts as a lead point
• Ie sessile malignancies, local inflammation, suture lines, lymphoid
hyperplasia
– Adhesion causes focal area of abnormal peristalsis and kinking
Intussusception
• In the colon, most frequently are colocolic or sigmoidrectal, and
comprise 38% of adult intussusceptions
• Neoplasia causes 2/3 of cases in adults
– Adenocarcinoma, leiomyosarcoma, reticular cell sarcoma, mets
• Association with AIDS- secondary to lymphoma, Kaposi’s sarcoma,
reative lymphoid hyperplasia, atypical mycobacteria infection, CMV,
Camphylobacter enteritis
• Childhood presenting symptoms: acute presentation with episodic
crampy abdominal pain and bloody currant jelly stool
• Adult presentation: often nonspecific chronic or subacute symptomscrampy abdominal pain, nausea and vomiting, constipation or
diarrhea, rarely bleeding or presence of a palpable mass
Intussusception
•
•
Radiology:
– Abdominal plain film
• Air crescent sign- intraluminal air between the walls of the the
intussusceptum and the intussuscipiens
– Barium enema
• Coiled spring appearance (fig 12)- a thin central barium stream with or
without a leading mass
– US
• More useful in childhood intussusceptions
• Target or doughnut mass with outer hypoechoic rim
– Ct
• Target lesion, whirling pattern of mesenteric vessels
• May see air bubble between opposed layers of bowel
• Underlying etiology may be difficult to determine
Treatment
– Surgery
• Reduce or not?