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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.
Acute small bowel obstruction (SBO) is an ever increasing clinical problem. Successful management depends on comprehensive knowledge of the etiology and pathophysiology of SBO, familiarity with imaging methods, good clinical judgment, and sound technical skills.
Definition, classification, and etiology
Bowel obstruction describes failure of aboral progression of intestinal contents. Based on the nature, severity, location and etiology, several terms are used to describe bowel obstruction (table I).
Table I
Etiology of acute small bowel obstruction.
Bowel obstruction may be functional, due to bowel wall or splanchnic nerve dysfunction, or mechanical, due to a mechanical barrier. Obstruction may occur in the small bowel (SBO) or large bowel (LBO). Large bowel obstruction or disease states may be associated with or masquerade as SBO. Acute functional dilatation of the colon is referred to as “colonic pseudo-obstruction”. Acute functional small bowel dilatation is referred to as “adynamic or paralytic ileus”. Small intestinal pseudo-obstruction describes a clinical syndrome characterized by manifestations of mechanical bowel obstruction in the absence of an obstructive lesion. A multitude of conditions cause functional bowel obstruction. Mechanical SBO may be due to a luminal, mural, or extra-mural mechanical barrier. Mechanical SBO may be proximal (high SBO) or distal (low SBO), closed loop or open-ended obstruction. In closed loop obstruction the lumen of the bowel is occluded at two points thus preventing prograde and retrograde movement of bowel contents. In open-ended obstruction a one-point obstruction interferes with the prograde propulsion of bowel contents.
Bowel obstruction may be partial or complete, simple or complicated. Partial obstruction allows some liquid contents and gas to pass through the point of obstruction, whereas complete obstruction impedes passage of all bowel contents. Unlike simple obstruction, complicated obstruction indicates compromise of the circulation to a segment of bowel with resultant ischemia, infarction, and perforation.
Intussusception is a unique type of obstruction that results from invagination of a segment of bowel into another. It may occur anywhere along the gastrointestinal tract distal to the gastric cardia. Intussusception may occur in a down ward direction or may be retrograde, and is classified into enteric . The exact mechanism colic and enterocolic of itussuception is not known but an organic lesion, diseased segment of bowel, or an adjacent area of normal bowel may serve as a lead point in initiating the process. Accordingly, intussusception is classified into idiopathic, postoperative, and intussusception due to an organic lesion. In adults, a neoplasm is the lead point in 80–90% of cases. A Meckel's diverticulum (MD) may invaginate into the ileum and sometimes, thence, into the colon (1). Volvulus is axial twist of the gastrointestinal tract around its mesentery resulting in partial or complete luminal obstruction (closed loop) of the bowel and a variable degree of arterial or venous obstruction. Volvulus commonly occurs in the colon and may affect the stomach or SB. Volvulus occurs when the small bowel twists around a MD that is attached by a fibrous cord to the umbilicus (1), or when a closed loop obstruction twists along its long axis. Gallstone ileus is a mechanical bowel obstruction caused by migration of gallstones from the biliary system through a biliary-enteric fistula with impaction within lumen of the bowel. Littre's hernia is incarcerated MD in an external hernia.
Pathophysiologic changes
Acute SBO results in local as well as systemic physiologic and pathologic derangements. Significant partial or complete obstruction is associated with increased incidence of migrating clustered contractions (MCC) proximal to the site of obstruction. Such contractions are associated with abdominal cramps. With partial obstruction MCC propel intraluminal contents and allow them to pass distal to the point of obstruction. With complete unrelieved obstruction, bowel contents fail to pass distally, with resultant progressive accumulation of intraluminal fluids and distention of the proximal bowel. This eventually initiates retrograde giant contractions (RGC) in the small bowel (SB) as the first phase of vomiting. In adynamic ileus migratory motor complexes (MMC) (contractions initiated in the stomach and proximal SB almost simultaneously and propagate distally to clear the intestine of secretions and debris) and fed contractions (intermittent and irregular contractions that provide mixing and slow distal propulsion) are inhibited.
As intraluminal pressure in the bowel proximal to the obstruction increases, venous flow in the bowel wall and adjacent mesentery decreases, and ceases if pressure reaches systolic pressure. Blood flow to the mucosa decreases, followed by capillary rupture and hemorrhagic infiltration. A twist of the mesentery or direct pressure on the mesenteric vessels results in venous and/or arterial occlusion. Intestinal epithelium is very vulnerable to anoxia and is the first to suffer necrosis. Perforation may occur as a result of ischemic or pressure necrosis. Pressure necrosis may occur at site where a tight band adhesion passes across a loop of bowel, or where an impacted gall stone or fecoloma produces stercoral ulceration and subsequent perforation. In simple obstruction the bowel proximal to the obstruction appears heavy, edematous, and even cyanosed. In advanced cases serosal tears appear at the antimesenteric border of the bowel.
Acute SBO results in volume depletion and electrolyte disturbances. Intestinal contents are cut off from the absorptive surface of the colon. Further loss of volume occurs as bowel contents stagnate in the dilated loops of obstructed bowel, lost through vomiting, or sequestrated in the bowel wall or peritoneal cavity. Water loss is accompanied by electrolyte loss, and depending upon the level of obstruction specific electrolyte concentration changes. As intraluminal pressure increases, absorption of water and sodium decreases and luminal secretion of water, sodium, and potassium increases. In addition there is edema of the bowel wall and leakage of proteins. With strangulation, protein and electrolyte rich exudate accumulate in the peritoneal cavity, and with infarction sequestration of blood in bowel wall occurs. The peritoneal fluid exudate changes from plasma-like clear fluid, to bloody, then foul dark exudate. There is also change in the ecology of bacterial population with increase fecal type of bacterial colonies in the bowel proximal to the obstruction and altered proximal-to-distal gradient change in bacterial flora. Bacterial breakdown of stagnant bowel contents results in formation of “feculent fluid”. With strangulation physiologic changes are complicated by blood loss in the infarcted bowel, death of tissues, gut translocation of bacteria and toxins (2), and the final insult of perforation.
Diagnosis of acute small bowel obstruction
The diagnosis of majority of cases of bowel obstruction can be made based on clinical presentation and initial plain radiograph of the abdomen. Luminal contrast studies, computed tomography (CT scan), and ultrasonography (US) are utilized in select cases. Once the diagnosis of bowel obstruction is entertained, location, severity and etiology are to be determined. Most importantly is the differentiation between simple and complicated obstruction.
Past surgical and medical history may shed light on etiology of SBO. In the absence of prior surgery and any apparent cause, or in presence of clinically confusing clinical picture, intussusception, MD, gall stone ileus, and neoplasms are suspects. The four cardinal symptoms of bowel obstruction are pain, vomiting, obstipation/absolute constipation, and distention. Obstipation, change in bowel habits, complete constipation, and abdominal distention are the predominant symptoms in LBO. Vomiting occurs late in the course of the desease. On the other hand, pain, vomiting, and distention are commonly seen in SBO. The pain is colicky in nature and becomes dull late in the course of SBO. Vomiting is a pronounced symptom in high SBO. The vomitus is bilious or semi-indigested food in high SBO, and feculant in low SBO. Obstipation and constipation are present to a variable degree. “Tumbling SBO” describes intermittent symptoms of obstruction seen in patients with gallstone ileus. These episodes correspond to stone impaction, subsequent release, and reobstruction. Biliary symptoms are present before the onset of obstruction in 20–56% of cases. Intermittent partial bowel obstructive symptoms are also suggestive of intussusception.
The presence of strangulation/gangrene in SBO cannot always be reliably excluded or confirmed even in the hands of the most experienced clinician (3) (Grade C). Four classical findings are often used as indicators of strangulation: tachycardia, localized abdominal tenderness or pain, leuckocytosis, and fever. The absence of these four signs indicates simple obstruction, the development of any of the indicators raises the index of suspicion of strangulation, and the presence of multiple clinical parameters is correct in 70% of SBO with strangulation.
Plain radiograph of the abdomen is the most valuable initial diagnostic test in acute SBO. This imaging method gives information diagnostic of SBO in 50–60% of cases and provide enough information needed for clinical decision making (4, 5) (table II). In 20–30% the radiographic findings are equivocal, and in 10–20% are normal. The typical air fluid levels seen in the dilated bowel proximal to the obstruction may be absent in high SBO, closed loop obstruction or late obstruction. Low grade obstruction is difficult to assess with plain radiograph of the abdomen.
Table II
Plain radiograph of the abdomen in acute bowel obstruction.
Intraluminal contrast studies (small bowel follow-through, enteroclysis, barium enema) are utilized in certain clinical situations. Small bowel follow - through (SBFT) is indicated when: 1) clinical presentation of bowel obstruction is confusing; 2) plain radiograph of the abdomen is non-diagnostic, and 3) response to nonoperative management is inadequate, and more diagnostic accuracy is needed to aid in decision making i.e. to continue with nonoperative treatment or resort to surgical intervention. The study is particularly indicated when a trial of medical treatment is warranted: postoperative or adynamic ileus, partial SBO, malignant SBO (carcinomatosis, intraabdominal recurrent or metastatic cancer), radiation enteritis, recurrent adhesive SBO, and SBO in Crohn's disease. Small bowel follow-through (SBFT) differentiates adynamic ileus from mechanical SBO. In adynamic ileus oral contrast moves to colon in 4–6 hrs. In complete mechanical SBO contrast shows dilated SB and stops at site of obstruction in one hour or less, and in partial SBO transit time of the dye is prolonged. In carcinomatosis multiple points of obstruction with pooling of contrast is noted. In gallstone ileus, SBFT detects the biliary enteric fistula and filling defect (corresponding to the impacted gall stone) in the small bowel. A beak-like point of obstruction or a mass is suggestive of intussusception.
Enteroclysis (small bowel enema) is a barium infusion study that allows close examination of mucosal pattern, distensibility, and motility of individual bowel loops. It is superior to SBFT and has greater diagnostic yield (Stage C). Enteroclysis is used when SBFT is inconclusive for partial SBO and is valuable in the diagnosis of tumors, intussusception, strictures, radiation enteritis, and occasionally Crohn's disease. A “stretched spring” appearance with intermittent large thick concentric rings as opposed to fine rings in close proximity suggest the presence of vascular compromise in intussusception. Enteroclysis can suggest whether a lead point is benign (causing longer and permanent intussusception) or malignant (short and transient intussusception). A combination of thickened valvulae conniventes mucosal folds measuring greater than 2 mm, mural thickening (wall thickness greater than 2 mm when adjacent bowel loops are parallel for at least 4 cm under compression) are the commonest features noted in radiation enteritis. Other findings include, single or multiple stenoses of variable lengths, stenoses at site or origin of sinus or fistula, and adhesions as evidenced by constant angulation of bowel loops and relative fixity within the pelvis. There is also pooling of barium that represent barium-filled, matted loops of terminal ileum in which individual loops are not distinguishable nor are mucosal folds discernable. In Crohn's disease there is a combination of thickened valvulae conniventes, stenoses, sinuses, fistulae, discrete fissure ulcers, longitudinal ulcers, cobblestoning, skip lesions, and asymmetrical involvement.
Barium enema is not sensitive in the diagnosis of SBO except in distal SBO where LBO masquerades as SBO. Barium (or gastrografin, a water soluble hyperosmolar contrast) enema is utilized more frequently in LBO to differentiate pseudo-obstruction from mechanical obstruction, confirm the diagnosis of volvulus, and intussusception, and accurately determine site of obstruction (Stage C).
Ultrasonography (US) is a valuable diagnostic tool in the evaluation of acute abdomen when used selectively. It is useful in the diagnosis of gallstone ileus, intussusception, pelvic disease, and gallbladder disease, and can aid in the exclusion of SBO. In gallstone ileus, US reveals diseased gall bladder (GB), gas in the GB or bile ducts or both, and fluid filled bowels that can be followed to the stone in the intestine. The presence of stones in the GB will modify the planned operative procedure in the treatment of gallstone ileus. In intussusception, US reveals the diagnostic “target sign”, a mass with sonolucent periphery (due to edematous bowel) and a strongly hyperechoic center (from compressed center of intussusception). Paralytic ileus is differentiated from mechanical SBO by the presence of peristaltic movement that is easily observed by US. The location of obstruction is determined by analysis of dilated bowel loops in terms of location and valvulae conniventes. Adhesion is considered the cause of SBO when there is no apparent cause of obstruction.
Computed tomography (CT scan) is emerging as a valuable tool in the management of bowel obstruction. It confirms the diagnosis, differentiates between mechanical and functional obstruction, provides information about cause and site of obstruction, and helps differentiate between simple and complicated SBO (Stage C). Furthermore, CT scan can diagnose other disease states (6, 7) (table III). Hence CT scan helps in decision making for early surgical intervention, and prevents delay in treatment. CT scan may give false positive results and may be difficult to interpret when colonic abnormalities cause predominantly SB dilatation. CT scan is unable to identify location and cause of obstruction accurately in 18% of cases. Furthermore, CT scan cannot predict who will benefit from conservative treatment in cases of partial SBO. In these situations SBFT or enteroclysis are more helpful.
Table III
Computed tomography in acute bowel obstruction.
Endoscopy plays a pivotal role in the initial management and definitive treatment of LBO. Colonoscopy is both diagnostic and therapeutic in cases of colonic pseudo-obstruction, sigmoid colon volvulus, and neoplasms.
Treatment of acute small bowel obstruction
A three step approach is paramount in the successful management of bowel obstruction: resuscitation, investigation, and definitive therapy (table IV).
Table IV
Treatment strategies of small bowel obstruction.
Aggressive intravenous fluid therapy and correction of electrolyte imbalance are crucial in the initial management of acute SBO. A Foley catheter and occasionally central venous or even a swan ganz catheter are needed to monitor fluid resuscitation. Blood tests identify electrolyte imbalance, elevated leukocyte count, abnormal liver function tests, elevated amylase level, acidosis, anemia, and bleeding tendency. A nasogastric tube allows decompression of the stomach and prevents aspiration. There is no convincing evidence that long intestinal tube is more efficacious than nasogastric tubes in decompression of SBO (Stage C). Plain radiograph of the abdomen is the initial diagnostic test and luminal contrasts tests are used selectively. The indications of CT scan are expanding and benefits of its early utilization are becoming more apparent (6, 7). Repeated examination of the patient during this period of management cannot be overemphasized.
Emergent surgery is indicated in incarcerated external hernia and when there is clinical and radiologic evidence of strangulation, gangrene, or perforation. Otherwise, carefully monitored nonoperative treatment is indicated, at least initially, while specific imaging methods are utilized to identify specific etiology of SBO or to monitor progression of SBO.
Adhesive SBO (3)
With nonoperative treatment, complete SBO resolves far less frequently than partial SBO, 15–36% vs. 55–75%. Surgical intervention is indicated when strangulation is suspected to develop during nonoperative treatment, or when conservative treatment fails. The appearance of the bowel before and after release of adhesion is compared. Vascular compromise is recognized by bluish discoloration of intestinal wall, loss of arterial pulsation, subserosal and mesenteric hemorrhage, and lack of peristalsis. If the bowel loop pinks up, resection is avoided, otherwise resection is indicated.
To prevent subsequent adhesion formation various mechanical and chemical methods have been employed. Mechanical methods include plication (small bowel and mesenteric), and stenting with long intestinal tubes. In addition to failure to prevent re-obstruction, plication is time consuming and tedious, and carries the risk of injury to the bowel or mesenteric vessels. Similarly, long intestinal tubes, in addition to difficulty in positioning distal to ligament of Treitz, are not without complications, and long terms results are not adequately evaluated. Although high dose steroids with or without promethazine, antihistamines, and dextran-70 proved to reduce adhesion formation in animals, the potential for disastrous complications prevented their use in humans. A variety of other chemicals have been used to prevent adhesions with mixed results and associated significant complications. Sodium hyaluronatebased bioabsorbable membrane have been shown to reduce adhesion formation in human, but its effect on intestinal obstruction is yet to be determined (8) (Stage A).
Gallstone ileus (9, 10, 11)
The diagnosis of gallstone ileus is often difficult to make. The majority of patients are elderly (average age between 65 and 75 years), and are multimorbid. Time from onset of symptoms to surgical intervention is often long, and correct diagnosis is made preoperative only in 13–60% of cases. In the SB, the site of obstruction is usually the distal ileum, and multiple stones are present in 3–15%.
While extracorporeal shock wave lithotripsy is successful in fragmenting duodenal stone inpaction, treatment of SB inpaction is surgical, either enterolithotomy to relieve the obstruction, or one stage procedure i.e. relief of obstruction, cholecystectomy with closure of fistula with or without common bile duct exploration. Following enterolithotomy alone the risk of recurrent obstruction and incidence of cholangitis are low, 5% and 10% respectively. There is increased risk of carcinoma of the gallbladder and a 30% incidence of recurrent biliary pain. Simple enterolithotomy carries a mortality of 11.7% compared to 16.9% for one-stage procedure. The most common source of operative morbidity is wound infection occurring in 30–40% ranges from 11 to 75% of cases.
Relief of obstruction i.e. enterolithotomy alone is safe and effective in the treatment of gallstone ileus. The entire bowel and GB are palpated for other gallstones to safe guard against recurrence. Interval cholecystectomy is performed for continued biliary symptoms. In select group of low risk patients, a onestage procedure is appropriate (Stage C).
Crohn's disease (12, 13, 14)
Initial treatment with steroids and parenteral nutrition (TPN) is successful for first time presentation or while patient is on no or minimal medications. Patients with recurring obstruction, especially with palpable mass, and while on adequate medical therapy, are candidates for earlier surgical intervention, namely resection. Stricturoplasty is a bowel preserving surgery indicated in a select group of patients (Grade C).
Early post-operative obstruction (15)
This is defined as SBO within 30 days after celiotomy. In this clinical situation bowel activity may not return (prolonged ileus) or there is initial temporary return of bowel function. The obstruction is due to adhesions (92%), phlegmon or abscess, intussusception (2.5–4%), or internal hernia. The treatment is conservative in the absence of bowel ischemia or mechanical obstruction. Nasogastric decompression, intravenous fluid therapy, and even TPN for up to 10-14 days is indicated if the patient is stable and exhibiting clinical and radiologic improvement continues. After this time further improvement is unlikely and operation should be performed (Stage C).
Radiation enteritis
Radiation causes actinic damage to intestinal mucosa, connective tissue, and vessels. The SB is extremely sensitive to radiation damage. The disease has a progressive nature. The final stage of damage is abnormal bowel, perforation, or stricture formation. Patients become intestinal cripples due to chronic partial intestinal obstruction and malnutrition. In the chronic stage, the serosa of the bowel involved appears thickened, dull, and gray with decreased peristalsis. Normal tissue planes are obliterated, intestines are friable, and fibrosis may be extensive (frozen pelvis). Multiple adhesions exist between damaged loops of bowel and other organs. Local factors in the intestine and mesentery (vascular injury, interstitial infection, and scarring) prevent satisfactory healing and recovery from acute injury making surgical correction hazardous. Although chances of improvement with conservative treatment are high, the relief is not long lasting.
When surgery is indicated, manipulation of the bowel is kept to a minimum and attempts to dissect the damaged bowels loop that are glued together by serositis and fibrosis will result in bowel injury and spillage. Transition from diseased to normal bowel is gradual making it difficult to exclude actinic damage with the naked eye, and the circulation is marginal. The type of surgical management depends on findings at operation i.e. perforation vs. stricture, extent of tissue damage, frozen pelvis, etc. A bypass procedure is safe and effective except in patients with limited involvement of freely mobile bowel where resection is optimal (Stage C).
Malignant SBO
This refers to obstruction occurring after treatment of a primary malignancy. Obstruction is due to benign causes (adhesion, radiation enteritis, internal hernia) occurs in 18–38% of cases. Ten percent to 30% of patients will have relief of obstruction with nonoperative management alone, and about 40% will eventually require surgery. Resolution with nasograstric decompression occurs in 68% of cases and within 3 days. About 35–80% of patients will obtain relief of symptoms with surgery depending on nature of obstruction. Patients presenting in shock, with carcinomatosis, ascites, or palpable mass have a 54% to 100 % mortality. Patients with carcinoma of the ovary, for whom effective chemotherapy is available, have better than average outcome. Bowel strangulation rarely occurs when carcinomatosis is present.
Hence, patients with known cancers should be treated as any other patient presenting with SBO, and final decision making regarding surgical intervention must be individualized. Early surgical intervention is indicated in patients with no known recurrence or long interval to the development of SBO. In patients with carcinomatosis, ascites, or palpable masses, more prolonged course of nonoperative treatment is justifiable. Surgical intervention is indicated if nasogastric decompression fails or if re-obstruction develops after removal of nasogastric tube. Selection of surgical procedure, resection, bypass, gastrostomy, or tube jejunostomy is based on extent of the disease. Used selectively, percutaneous gastrostomy can improve quality of life.
Intussusception
In adults 85–90% of intussusceptions are associated with a discrete, pathologic process leading the intussusception, and neoplasms account for majority of cases. Malignant lesions are being recognized with increasing frequency. A recently recognized subtype is postoperative intussusception. The point of origin of the intussusception is the small bowel and more specifically, the jejunum, particularly proximal jejunum, and dense desmoplastic inflammatory reaction within the mesentery may be the underlying mechanism precipitating the intussusception.
Treatment of intussusception in adults is surgical without attempts at hydrostatic reduction. Optimal surgical procedure depends on the anatomic location, present of a lead point, and local factors, such as edema, inflammation, and ischemia of involved bowel. While resection is the treatment of colic andenterocolic intussusception, the choice in enteric type i.e. attempt at operative reduction vs. resection without attempt at reduction, depends on presence of underlying lesion, chances the lesion is malignant, and viability of involved bowel.
NSAIDS-induced SBO (16)
Chronic use of NSAIDS is associated with a wide range of pathology in the stomach, small bowel and colon. In the small bowel NSAIDS induce enteropathy (asymptomatic in 60–70% of patients, or may be associated with low grade protein and blood loss), perforation, ulceration, and stricture formation. The strictures are multiple and appear broad based or diaphragm-like that narrow down the lumen to a pinhole resulting in subacute SBO. Small intestinal diaphragms are difficult to diagnose. Radiologically NSAID strictures mimic exaggerated plica circularis and at surgery are difficult to feel. Inflation of the bowel with air facilitates detection of these stricture. Once identified treatment is with intestinal resection or stricturoplasty although balloon dilatation has been reported to be effective.
While conventional laparotomy is routinely performed in the surgical management of the acute abdomen, the indication for laparoscopic approach are evolving (17, 18). Criteria used for laparoscopic management of SBO include mild abdominal distention, proximal SBO, anticipated single band adhesion, and partial obstruction.
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