Who treats large bowel obstruction?

Treatment of Large Bowel Obstruction

Large bowel obstruction is primarily treated by surgeons, with specific management approaches determined by the underlying cause, patient condition, and presence of complications. 1

Initial Management

• All patients with large bowel obstruction require supportive care including IV fluid resuscitation, nasogastric tube decompression, and Foley catheter placement for monitoring urine output 1
• Multidetector CT with intravenous contrast is essential for determining the cause, location, and complications of the obstruction 1
• Close monitoring for signs of ischemia or perforation through clinical assessment, laboratory values, and imaging findings is crucial 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 is recommended 2
• Endoscopic detorsion alone should be reserved only for high-surgical-risk patients, though recurrence rates reach up to 71% 2
• Immediate surgical intervention is necessary for ischemic volvulus or failed derotation 2
• Laparoscopic approach has limitations due to the absence of fixation and excessive length of the sigmoid colon 2

Cecal Volvulus

• Right hemicolectomy is the only treatment option as endoscopy has no role 2, 3

Diverticular Disease

• Resection with primary anastomosis is preferred after successful conservative management, regardless of bowel preparation status 2
• Conservative therapy or Hartmann procedure may be more appropriate for high-risk patients 2

Malignant Obstruction

• Colorectal cancer accounts for over 60% of all large bowel obstructions 4
• For left-sided colonic cancer, self-expanding metallic stents can serve as a bridge to elective surgery, offering better short-term outcomes with lower stoma rates 2
• Resection with primary anastomosis is recommended for patients without significant risk factors or perforation 2
• For high-risk patients or those with perforation, a staged procedure such as Hartmann procedure is preferred 2
• For extraperitoneal rectal cancer, postponing primary tumor resection and creating a diverting stoma allows for proper staging and appropriate neoadjuvant treatment 2
• Anastomotic leak rates range from 2.2-12%, comparable to the 2-8% rate after elective procedures 2

Special Considerations

Surgical Approach

• Laparoscopic surgery should be limited to selected cases in specialized centers for malignant large bowel obstruction 2
• For frail patients with sigmoid volvulus, a limited left lower quadrant transverse laparotomy incision without laparoscopy may be beneficial to avoid risks associated with pneumoperitoneum 5

Colonic Pseudo-obstruction

• Distinguishing true mechanical obstruction from pseudo-obstruction (functional obstruction without mechanical blockage) is critical as management differs significantly 6, 7
• Water-soluble contrast studies are important in making this distinction 7
• Pseudo-obstruction can usually be managed non-operatively with treatment of underlying conditions 7

Monitoring and Follow-up

• Regular reassessment is essential to determine if surgical intervention becomes necessary for patients managed conservatively 1
• Immediate surgery is necessary if signs of clinical deterioration develop, such as peritonism, increasing white blood cell count, or rising lactate 1

Pitfalls to Avoid

• Delaying surgical intervention when signs of ischemia or perforation are present can significantly increase mortality 3
• Failing to recognize the difference between mechanical obstruction and pseudo-obstruction can lead to unnecessary surgery 6
• Underestimating the high recurrence risk (up to 71%) when managing sigmoid volvulus with endoscopic detorsion alone 2