What is the treatment approach for large bowel obstruction?

Treatment Approach for Large Bowel Obstruction

The treatment of large bowel obstruction should be tailored to the underlying cause, with surgical intervention being the mainstay of therapy for most cases, while self-expanding metallic stents serve as an effective bridge to surgery for left-sided malignant obstructions. 1

Initial Management

• Begin with supportive care including intravenous crystalloid fluid resuscitation, nasogastric tube decompression, and insertion of a Foley catheter to monitor urine output 1
• Obtain multidetector computed tomography (CT) with intravenous contrast as the imaging modality of choice to determine the cause, location, and complications of the obstruction 1
• Monitor for signs of ischemia or perforation through clinical assessment (peritonism), laboratory values (white blood cell count, lactate), and imaging findings 1

Cause-Specific Treatment Approaches

Sigmoid Volvulus

• For sigmoid volvulus without ischemia or perforation: endoscopic detorsion followed by same-admission sigmoid colectomy with primary anastomosis 1
• Endoscopic detorsion alone (without subsequent surgery) should be reserved only for high-surgical-risk patients, though recurrence rates are high (70-95% success rate with 4% morbidity) 1
• For ischemic volvulus or failed derotation: immediate surgical intervention 1
• For cecal volvulus: endoscopy has no role; right hemicolectomy is the only option 1

Diverticular Disease

• Resection with primary anastomosis is the preferred approach after successful conservative management, regardless of bowel preparation status 1
• For high-risk patients: consider conservative therapy or Hartmann procedure (resection with end colostomy) 1

Malignant Obstruction

• For left-sided colonic cancer causing obstruction: self-expanding metallic stents as a bridge to elective surgery offers better short-term outcomes than emergency surgery with lower stoma rates 1
• For patients without significant risk factors or perforation: resection with primary anastomosis 1
• For high-risk patients or those with perforation: staged procedure (e.g., Hartmann procedure) 1
• For extraperitoneal rectal cancer: postpone primary tumor resection and create a diverting stoma to allow proper staging and appropriate neoadjuvant treatment 1
• Laparoscopic approach should be limited to selected cases in specialized centers 1

Special Considerations

• Anastomotic leak rates in emergency surgery for malignant large bowel obstruction range from 2.2-12%, comparable to the 2-8% rate after elective procedures 1
• Stents are becoming increasingly important in managing malignant large bowel obstruction, converting emergency operations to elective cases with decreased complications and stoma formation 1
• For patients with advanced malignancy presenting with peritoneal carcinomatosis or multiple levels of obstruction, palliative care consultation should be considered 2
• Prognosis for malignant bowel obstruction is generally poor, with median survival ranging from 26 to 192 days 2

Monitoring and Follow-up

• Closely monitor patients for clinical deterioration (peritonism, increasing white blood cell count, rising lactate) 1
• Perform immediate surgery if signs of clinical deterioration develop 1
• For patients managed conservatively, regular reassessment is essential to determine if surgical intervention becomes necessary 1

Pitfalls and Caveats

• Avoid prolonged conservative management with nasogastric suction and intravenous fluids alone in terminally ill patients with malignant bowel obstruction 3
• Recognize that surgery should not be routinely undertaken in patients with poor prognostic criteria such as intra-abdominal carcinomatosis, poor performance status, and massive ascites 4
• Be aware that laparoscopic approach for sigmoid volvulus has limitations due to the absence of fixation and excessive length of the sigmoid colon 1