Bowel Obstruction Symptoms and Treatment
Bowel obstruction presents with typical symptoms of abdominal pain, vomiting, distension, and constipation, requiring prompt diagnosis and management with either conservative measures or surgical intervention depending on severity and etiology. 1
Clinical Presentation
Common Symptoms
- Abdominal pain (typically crampy and intermittent in nature) 1, 2
- Vomiting (may become bilious or feculent in complete obstruction) 1, 3
- Abdominal distension (has a positive likelihood ratio of 16.8 for bowel obstruction) 2, 4
- Constipation or absence of passage of flatus and/or feces (present in 80-90% of cases) 4
- Abnormal bowel sounds (high-pitched, rushes, or absent) 2, 5
Red Flag Symptoms Suggesting Complications
- Fever, hypotension, or tachycardia (suggesting strangulation or peritonitis) 2, 6
- Diffuse abdominal pain or peritoneal signs (indicating possible perforation) 2, 4
- Marked leukocytosis >10,000/mm³ (suggesting inflammation or infection) 2
- Elevated lactate levels (indicating potential intestinal ischemia) 2
Diagnostic Approach
Initial Assessment
- Complete history focusing on previous abdominal surgeries (85% sensitivity for adhesive obstruction) 2
- Physical examination including all hernia orifices and previous surgical incision sites 2
- Digital rectal examination to detect masses or impacted stool 2
- Basic laboratory tests including complete blood count, electrolytes, renal function, and lactate 2
Imaging Studies
- CT scan with IV contrast is the preferred initial imaging with >90% diagnostic accuracy 2
- Plain abdominal X-rays have limited diagnostic value (50-60% sensitivity) 2
- Ultrasound can be useful with 90% sensitivity, especially in children and pregnant women 2
- Water-soluble contrast studies can be both diagnostic and therapeutic in adhesive small bowel obstruction 2
Management
Initial Supportive Care
- Intravenous fluid resuscitation to correct dehydration and electrolyte imbalances 2, 6
- Nasogastric tube placement for decompression and to prevent aspiration 2, 6
- Foley catheter insertion to monitor urine output 2
- Pain management and antiemetics for symptom control 2, 6
- Bowel rest (nothing by mouth) 6
Conservative Management
- Appropriate for partial obstructions and selected cases of complete obstruction 2, 6
- Continued nasogastric decompression and IV fluid support 6
- Serial abdominal examinations to monitor for clinical improvement or deterioration 2
- Water-soluble contrast agents may have therapeutic effects in adhesive small bowel obstruction 1, 2
Surgical Management
- Indicated for complete obstruction with signs of strangulation, ischemia, or perforation 2, 4
- Also necessary for obstructions that fail to resolve with conservative management 6
- The specific surgical approach depends on the cause of obstruction 4
- Adhesiolysis for adhesive obstruction 1, 4
- Hernia repair for incarcerated hernias 4
- Resection for malignant obstructions or necrotic bowel 4
Alternative Interventions
- Stent placement can be considered for malignant large bowel obstruction (97% technical success rate) 1
- Percutaneous endoscopic gastrostomy tube placement for palliation in inoperable cases 1
- Octreotide may help control symptoms in malignant bowel obstruction 1
Special Considerations
Malignant Bowel Obstruction
- Common in advanced ovarian and colorectal cancers 1
- Management options include surgery, stenting, decompression tubes, or medical management 1
- Surgical intervention should be avoided in patients with poor prognostic indicators (massive ascites, poor performance status) 1
Contraindications
- Enemas are contraindicated in bowel obstruction as they can increase the risk of perforation 7
- Prokinetic medications like metoclopramide should be avoided in complete obstruction 1
Prognosis and Complications
- Bowel ischemia occurs in approximately 14% of cases 4
- Bowel necrosis in 9.3% and perforation in 5.3% of cases 4
- Incarcerated hernias carry a significantly higher risk of strangulation compared to other causes 4
- Mortality rates increase significantly when surgical intervention is delayed in the presence of ischemia (up to 25%) 2