Intestinal Obstructions

Intestinal Obstructions

 

Definition

Intestinal obstruction refers to the partial or complete mechanical or nonmechanical blockage of the small or large intestine.

Description

There are two types of intestinal obstructions, mechanical and nonmechanical. Mechanical obstructions occur because the bowel is physically blocked and its contents cannot get past the obstruction. Mechanical obstructions can occur for several reasons. Sometimes the bowel twists on itself (volvulus) or telescopes into itself (intussusception). Mechanical obstruction can also result from hernias, impacted feces, abnormal tissue growth, the presence of foreign bodies in the intestines (including gallstones), or inflammatory bowel disease (Crohn's disease). Nonmechanical obstruction, called ileus, occurs because the wavelike muscular contractions of the intestine (peristalsis) that ordinarily move food through the digestive tract stop.

Mechanical obstruction in infants

Infants under one year of age are most likely to have intestinal obstruction caused by meconium ileus, volvulus, and intussusception. Meconium ileus, which is the inability to pass the first fecal excretion after birth (meconium), is a disorder of newborns. It is an early clue that the infant has cystic fibrosis, but may also occur in very low birth weight (VLBW) infants. In meconium ileus, the material that is blocking the intestine is thick and stringy, rather than the collection of mucus and bile that is passed by normal infants. The abnormal meconium must be removed with an enema or through surgery.
Volvulus is the medical term for twisting of either the small or large bowel. The twisting may cut off the blood supply to the bowel, leading to tissue death (gangrene). This development is called a strangulating obstruction.
In intussusception, the bowel telescopes into itself like a radio antenna folding up. Intussusception is most common in children between the ages of three and nine months, although it also occurs in older children. Almost twice as many boys suffer intussusception as girls. It is, however, difficult for doctors to predict which infants will suffer from intestinal obstruction.

Mechanical obstruction in adults

Obstructions in adults are usually caused by tumors, trauma, volvulus, the presence of foreign bodies such as gallstones, or hernias, although they have also been reported in adults with cystic fibrosis. Volvulus occurs most often in elderly adults and psychiatrically disturbed patients. Intussusception in adults is usually associated with tumors in the bowel, whether benign or malignant.
More recently, gastroenterologists have described a postsurgical complication known as early postoperative small bowel obstruction, or EPSBO. Although this condition was at one time confused with postoperative ileus, it is now known to be caused by mechanical obstructions resulting from radiation therapy for cancer or laparoscopic surgery. Most casses can be succesfully treated within 10-14 days of surgery.

Causes and symptoms

One of the earliest signs of mechanical intestinal obstruction is abdominal pain or cramps that come and go in waves. Infants typically pull up their legs and cry in pain, then stop crying suddenly. They will then behave normally for as long as 15-30 minutes, only to start crying again when the next cramp begins. The cramping results from the inability of the muscular contractions of the bowel to push the digested food past the obstruction.
Vomiting is another symptom of intestinal obstruction. The speed of its onset is a clue to the location of the obstruction. Vomiting follows shortly after the pain if the obstruction is in the small intestine but is delayed if it is in the large intestine. The vomited material may be fecal in character. When the patient has a mechanical obstruction, the doctor will first hear active, high-pitched gurgling and splashing bowel sounds while listening with a stethoscope. Later these sounds decrease, then stop. If the blockage is complete, the patient will not pass any gas or feces. If the blockage is only partial, however, the patient may have diarrhea. Initially there is little or no fever.
When the material in the bowel cannot move past the obstruction, the body reabsorbs large amounts of fluid and the abdomen becomes sore to the touch and swollen. The balance of certain important chemicals (electrolytes) in the blood is upset. Persistent vomiting can cause the patient to become dehydrated. Without treatment, the patient can suffer shock and kidney failure.
Strangulation occurs when a loop of the intestine is cut off from its blood supply. Strangulation occurs in about 25% of cases of small bowel obstruction. It is a serious condition that can progress to gangrene within six hours.

Diagnosis

Imaging studies

If the doctor suspects intestinal obstruction based on the physical examination and patient history, he or she will order x rays, a computed tomography scan (CT scan), or an ultrasound evaluation of the abdomen. In many cases the patient is given a barium enema. Barium sulfate, which is a white powder, is inserted through the rectum and the intestinal area is photographed. Barium acts as a contrast material and allows the location of the obstruction to be pinpointed on film.

Laboratory tests

The first blood test of a patient with an intestinal obstruction usually gives normal results, but later tests indicate electrolyte imbalances. There is no way to determine if an obstruction is simple or strangulated except surgery.

Treatment

Initial assessment

All patients with suspected intestinal obstruction are hospitalized. Treatment must be rapid, because strangulating obstructions can be fatal. The first step in treatment is inserting a nasogastric tube to suction out the contents of the stomach and intestines. The patient is then given intravenous fluids to prevent dehydration and correct electrolyte imbalances.

Nonsurgical approaches

Surgery can be avoided for some patients. In some cases of volvulus, guiding a rectal tube into the intestines will straighten the twisted bowels. In infants, a barium enema may reverse intussusception in 50-90%. An air enema is sometimes used instead of a barium enema. This treatment successfully relieves the obstruction in many infants. The children are usually hospitalized for observation for two to three days after these procedures. In patients with only partial obstruction, a barium enema may dissolve the blockage.

Surgical treatment

If these efforts fail, surgery is necessary. Strangulated obstructions require emergency surgery. The obstructed area is removed and part of the bowel is cut away. If the obstruction is caused by tumors, polyps, or scar tissue, they are removed. Hernias, if present, are repaired. Antibiotics are given to reduce the possibility of infection.

Alternative treatment

Alternative practitioners offer few suggestions for treatment. They focus on preventive strategies, particularly the use of high-fiber diets to keep the bowels healthy through regular elimination.

Prognosis

Mortality

Untreated intestinal obstructions can be fatal. Delayed diagnosis of volvulus in infants has a mortality rate of 23-33% with prompt diagnosis and treatment the mortality rate is 3-9%. The bowel either strangulates or perforates, causing massive infection. With prompt treatment, however, most patients recover without complications.

Recurrence

As many as 80% of patients whose volvulus is treated without surgery have recurrences. Recurrences in infants with intussusception are most likely to happen during the first 36 hours after the blockage has been cleared. The mortality rate for unsuccessfully treated infants is 1-2%.

Prevention

Most cases of intestinal obstruction are not preventable. Surgery to remove tumors, polyps, or gallstones helps prevent recurrences.

Key terms

Electrolytes — Salts and minerals that ionize in body fluids. Electrolytes control the body's fluid balance as well as performing other important functions.
Gangrene — The death of soft tissue in any part of the body when the blood supply is obstructed.
Ileus — Obstruction of the intestines caused by the absence of peristalsis.
Intussusception — The slipping or telescoping of one part of the intestine into the section next to it.
Meconium — A greenish fecal material that forms the first bowel movement of an infant.
Peristalsis — The waves of muscular contraction in the intestines that push the food along during the process of digestion.
Strangulated obstruction — An obstruction in which a loop of the intestine has its blood supply cut off.
Volvulus — A twisting of the intestine that causes an obstruction.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Mechanical Intestinal Obstruction." Section 3, Chapter 25. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Chahine, A. Alfred, MD. "Intussusception." eMedicine June 10, 2004. http://www.emedicine.com/ped/topic1208.htm.
Dray, X., T. Bienvenu, N. Desmazes-Dufeu, et al. "Distal Intestinal Obstruction Syndrome in Adults with Cystic Fibrosis." Clinical Gastroenterology and Hepatology 2 (June 2004): 498-503.
Emil, S., T. Nguyen, J. Sills, and G. Padilla. "Meconium Obstruction in Extremely Low-Birth-Weight Neonates: Guidelines for Diagnosis and Management." Journal of Pediatric Surgery 39 (May 2004): 731-737.
Hebra, Andre, MD, and Melissa Miller, MD. "Intestinal Volvulus." eMedicine February 25, 2004. http://www.emedicine.com/ped/topic1205.htm.
Sajja, S. B., and M. Schein. "Early Postoperative Small Bowel Obstruction." British Journal of Surgery 91 (June 2004): 683-691.

Other

HealthAnswers.com. "Intestinal Obstruction." 〈http://www.healthanswers.com/database/ami/converted/000260.html〉.
"Intussusception: A Case Study for Nurses." University of New Brunswick Nursing Faculty Page. 〈http://www.unb.ca/courses/nur4284/intu.htm〉.

Patient discussion about Intestinal Obstructions

Q. I recently had my surgery for bowel obstruction? I recently had my surgery for bowel obstruction? None of the diet was restricted for me by doctor but should I go for any special diet.

A. I had surgery in 08/08 during having a c-section and hernia repair, and I'm having diarrhea all the time. I don't know what to eat nor what medicines to take. Only Immodium AD helps temporary. If I have an appointment, I don't eat breakfast or lunch. I come home and eat dinner. About 30 minutes after eating, I'm in the bathroom. Can someone help me please? I have to return back to work next month, and I don't want to be in the bathroom more than I am at my desk.

More discussions about Intestinal Obstructions
References in periodicals archive ?
In studies by Ramrao BS et al, Malik AM et al, Mohamed AY et al and Markogiannakis H et al, more of small intestinal obstructions were seen.
Although this phenomenon is rare, we should keep in mind that intestinal diverticulosis may induce intestinal obstructions of different kinds.
This pathology may often be accompanied by intestinal obstructions or recurrent enterocutaneous fistulas.
Caecal volvulus accounts for approximately 1 to 3 percent of all large intestinal obstructions with an average incidence of from 2.
Ras Al Khaimah: A newborn Emirati girl was successfully operated for a rare congenital abnormality that accounts for one per cent of all intestinal obstructions in the paediatric population.
A hospital in Ras Al Khaimah has successfuly operated a new born Emirati baby girl suffering from a rare congenital disorder of pancreas, which accounts for one per cent of all intestinal obstructions in the pediatric population.
The water in Telde contains magnesium too, which gives the water laxative properties, an excellent way to cure the lack of appetite and digestive problems such as flatulence and intestinal obstructions (Viera y Clavijo 2004).
Chewy candy and gums potentially can choke them or cause intestinal obstructions.
Although gallstone ileus is a cause of only 14% of intestinal obstructions in the general population, the incidence increases in the elderly accounting for 25% of nonstrangulated small bowel obstructions.
Some dog owners, aware that the maker of Greenies had been sued by owners of dogs who died, allegedly from intestinal obstructions caused by an undigested Greenies chew, assumed the company had ceased manufacturing the "dental treat.
Intestinal obstructions are usually associated with such disorders as Hirschsprung's disease, anorectal malformations, meconium plug syndrome, and small left colon syndrome (Loening-Baucke & Kimura, 1999).
Cohen and Larson counter that 5 to 10 percent of human newborns with the cystic fibrosis mutation die from similar intestinal obstructions.

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