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Clinical science
Bowel obstruction is the interruption of the normal passage of bowel contents either
due to a functional decrease in peristalsis or mechanical obstruction. Functional bowel
obstruction, or paralytic ileus, is a temporary disturbance of peristalsis in the absence of
mechanical obstruction. Postoperative ileus is the most common cause of paralytic ileus,
which can also be caused by metabolic disturbances (e.g., hypokalemia),
endocrinopathies (e.g., hypothyroidism), and certain drugs (e.g., anticholinergics).
Mechanical bowel obstruction is classified according to the location as either small bowel
obstruction (SBO) or large bowel obstruction (LBO) and, depending on the severity of
obstruction, as either partial or complete. The most common cause of SBO is
postoperative bowel adhesions, while the most common cause of LBO is malignant
tumors. Regardless of the cause, bowel obstruction typically manifests with nausea,
vomiting, abdominal pain, abdominal distention, and constipation or obstipation. In
paralytic ileus, bowel sounds are usually absent on auscultation, whereas a high-pitched
tinkling sound would be heard in the early phase of a mechanical bowel obstruction.
Bowel distention leads to third-space volume loss, resulting in dehydration and
electrolyte abnormalities. Symptoms are less severe in partial bowel obstruction.
Diagnosis is confirmed on imaging with contrast-enhanced CT scan and abdominal x-
rays. Typical findings in mechanical bowel obstruction include dilated bowel loops
proximal to the obstruction, collapse of bowel loops distal to the obstruction, and, on
contrast-enhanced imaging, a cut-off or transition point at the site of obstruction. In
paralytic ileus, findings include generalized dilatation of bowel loops with no transition
point and air that is visible in the rectum. Additional laboratory tests include CBC and
BGA for the assessment of infection, electrolyte imbalances (e.g., hypokalemia), and
metabolic imbalances (e.g., alkalosis). Surgical intervention (i.e., exploratory laparotomy)
is recommended for suspected closed-loop bowel obstruction, if there are signs of
perforation or peritonitis, or if there is no improvement following conservative
management. In all other cases, conservative treatment is usually successful and
involves bowel rest, gastric decompression (nasogastric suction), fluid resuscitation, and
correction of electrolyte abnormalities.
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Adhesions (e.g., Recent abdominal
prior abdominal surgery
surgery, Atherosclerotic
abdominal disease
tuberculosis) Abdominal
Incarcerated infections or
hernias: second inflammatory
most common conditions
cause of SBO Certain
medications
(opioids,
anticholinergics,
antiparkinsonian
agents)
References: [1][2][3][4]
Etiology
Mechanical bowel obstruction: an interruption in the normal passage of intestinal
contents due to a structural barrier (e.g., bowel cancer, adhesions)
Paralytic ileus: a temporary impairment of peristalsis in the absence of a
mechanical obstruction
Degree of obstruction
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Partial bowel obstruction: bowel obstruction in which passage of some intestinal
content through the blocked segment is possible
Complete bowel obstruction: total interruption of the passage of intestinal
contents
Closed loop obstruction: a type of complete mechanical bowel obstruction in which
a segment of bowel is occluded at two contiguous points (e.g., volvulus)
Site of obstruction
Progression
Simple bowel obstruction: obstruction without evidence of bowel ischemia
Strangulated bowel obstruction: obstruction with compromised intestinal blood
flow, resulting in bowel ischemia
Reference:[5]
Other Diverticulitis
causes Adhesions (e.g.,
postoperative, prior
abdominal surgery)
Strictures (e.g.,
inflammatory bowel
disease, congenital
strictures)
Fecal impaction
Foreign body impaction
Specific to
infants and
children
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Pathophysiology [7]
Bowel obstruction → stasis of luminal contents and gas proximal to the obstruction
→ ↑ intraluminal pressure, which leads to the following:
Gaseous abdominal distention → sequestration of fluids within the distended
bowel loops (third spacing) → dehydration and hypovolemia
Vomiting → loss of fluid and Na +, K+, H +, and Cl - → hypokalemia, metabolic
alkalosis, and hypovolemia
Compression of intestinal veins and lymphatics → bowel wall edema →
compression of intestinal arterioles and capillaries → bowel ischemia
→ ↑ Bowel wall permeability → translocation of intestinal microbes to
the peritoneal cavity → sepsis
→ Necrosis and perforation of the bowel wall → peritonitis
→ Anaerobic metabolism and lysis of ischemic cells → accumulation of
lactic acid and release of intracellular K +→ metabolic acidosis and
hyperkalemia
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Examination Dehydration and possible hypovolemia (hypotension, dry
findings mucous membranes)
Diffuse abdominal tenderness
Tympanic percussion
Increased high-pitched, tinkling bowel sounds (early) or absent
bowel sounds (late)
Collapsed, empty rectum on digital rectal examination
Partial bowel obstruction causes gradually progressive symptoms that are milder than
those of complete obstruction. Obstipation is absent in partial bowel obstruction.
Diagnostics
In the workup of suspected mechanical bowel obstruction, imaging allows for quick
confirmation of the diagnosis as well as detection of conditions requiring immediate
surgery (e.g., perforation). Laboratory tests may further help to assess the severity of the
condition (e.g., electrolyte imbalance due to vomiting).
Laboratory tests
If recurrent vomiting
Hypochloremic hypokalemic metabolic alkalosis
Hyponetremia
If bowel strangulation
Metabolic acidosis
Hyperkalemia
Neutrophilic leukocytosis (left shift)
If dehydration: ↑ Hct
If sepsis: abnormal coagulation profile
Potentially prerenal azotemia
Imaging [10][11][12][13]
Abdominal series
Consists of erect and supine abdominal x-rays and an erect chest x-ray.
Indications
With IV and oral contrast: Best initial test in hemodynamically stable patients
with suspected partial bowel obstruction [14][15] [16]
With IV contrast: Indicated in patients with suspected complete bowel
obstruction.
Non-contrast: Indicated in patients with contrast-allergy and suspected
complete bowel obstruction.
Findings
Transition point: sudden narrowing of bowel lumen at the site of obstruction
Dilatation of proximal loops
Signs of bowel ischemia
Unenhanced bowel loops
Pneumatosis intestinalis
Mesenteric fat stranding
Pneumoperitoneum indicates bowel perforation
Abdominal ultrasound
Indication: critically ill patients (easy bedside test) or patients with a suspected SBO
and a contraindication for CT (e.g., contrast allergy) or radiation exposure (e.g.,
pregnancy)
Findings
Treatment
Conservative management
Indications
Partial bowel obstruction cases
Complete bowel obstruction with no signs of ischemia/necrosis or signs of
clinical deterioration
Measures
Fluid resuscitation, correction of electrolyte imbalance
Intestinal decompression: nasogastric tube insertion
Bowel rest (NPO)
Administration of IV analgesics and antiemetics
Gradual increase of oral intake, starting with clear fluids, can be initiated once
the abdominal pain and distention subside and bowel sounds return to
normal.
Etiology-specific treatments
Fecal impaction: stool evacuation (manual disimpaction, distal
softening/washout with enemas or suppositories, proximal
softening/washout with oral solutions such as polyethylene glycol or sodium
phosphate)
Sigmoid volvulus with no signs of strangulation: rigid/flexible sigmoidoscopic
detorsion
Surgery
Indications
Suspected bowel obstruction and hemodynamic instability or features of
sepsis
Complete bowel obstruction with signs of ischemia/necrosis or clinical
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deterioration
Persistent partial obstruction (> 3–5 days)
Closed-loop obstruction
Procedure: exploratory laparotomy
Restoration of intestinal transit: depends on intraoperative findings
If bowel resection is required, the intervention may be carried out in a single
procedure with anastomosis or permanent ostomy creation, or in a
multistaged procedure with a temporary diverting ostomy.
Prognosis
100% mortality in cases of untreated intestinal strangulation
Mortality rate for those undergoing surgery: 8–25%
High risk of recurrence, particularly with chronic or recurring etiologies (Crohn
disease, adhesions, radiation enteritis, volvulus, etc.)
References: [10][18][19][11][20]
Definition
Paralytic ileus: temporarily impaired peristalsis of the gastrointestinal tract in the
absence of mechanical obstruction
Etiology
Intra-abdominal surgery (postoperative ileus)
Abdominal trauma (e.g., due to retroperitoneal hemorrhage)
Endocrine abnormalities (e.g., hypothyroidism, porphyria, uremia)
Electrolyte disturbances (e.g., hypokalemia)
Neuropathy (e.g., diabetes mellitus, spinal injury)
Neurosurgical procedures (e.g., spinal surgery)
Vascular diseases (e.g., mesenteric ischemia)
Peritonitis
Inflammation of intra-abdominal organs (e.g., appendicitis, cholecystitis,
pancreatitis, severe gastroenteritis)
Medications (e.g., anticholinergics, opioids, antidepressants)
The common causes of paralytic ileus can be memorized using “5 Ps”: Peritonitis,
Postoperative, low Potassium, Pelvic and spinal fractures, and Parturition. [21]
References: [22][20]
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Pathophysiology
Stressful stimuli to the bowel (e.g., surgery, peritonitis) → sympathetic nervous
system activation → decreased/arrested peristalsis
Inflammation or intraoperative manipulation → local release of nitric oxide →
relaxation of intestinal smooth muscles → decreased/arrested peristalsis
Decreased/arrested peristalsis → bowel wall distention → progresses as detailed
above in mechanical bowel obstruction
Clinical features
Continuous (noncolicky) abdominal pain or discomfort
Nausea, vomiting
Abdominal distention
Percussion: tympany
Palpation: no tenderness unless peritonitis is present
Auscultation: bowel sounds are absent (silent abdomen) or decreased (early
paralytic ileus)
Diagnostics
Laboratory[23]
Leukocytosis with left shift suggests intestinal infection or ischemia.
Anemia may be a sign of intra-abdominal hemorrhage (e.g., in postoperative or
trauma patients).
Hypokalemia, hypomagnesemia
Imaging[24][25]
Abdominal x-ray: best initial test
Generalized small and large bowel gaseous distention
Visible gas shadows in the rectum
No transition or cut-off point on contrast x-rays, such as enteroclysis or
barium/water-soluble contrast enema
If caused by retroperitoneal hemorrhage: obliteration of the psoas muscle
outline
Abdominal CT: to rule out suspected mechanical bowel obstruction or if abdominal
x-ray is inconclusive
Has the highest sensitivity and specificity for differentiating ileus from
mechanical obstruction
Identifies uniformly distended loops with no transition point and no
structural/mechanical cause
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Treatment
Conservative treatment: in patients with no signs of localized or diffuse sepsis (e.g.,
appendicitis, secondary peritonitis)
Bowel rest
Nasogastric tube insertion
IV fluids and electrolyte repletion
Stop or decrease causative medications (e.g., opioids).
Gradual increase in enteral feeding as tolerated by the patient
Early postoperative ambulation (although still recommended to prevent DVT)
and use of prokinetics have not been proven to improve peristalsis.
Surgical intervention: in patients with signs of peritonitis (e.g., appendectomy,
exploratory laparotomy)
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