Management of Large Bowel Obstruction
Management of large bowel obstruction is cause-specific and urgency-dependent: immediate surgery for ischemia/perforation, endoscopic detorsion followed by same-admission surgery for sigmoid volvulus, right hemicolectomy for cecal volvulus, and resection with primary anastomosis for malignant obstruction in suitable candidates. 1, 2
Initial Stabilization and Assessment
Begin with aggressive intravenous crystalloid resuscitation, nasogastric tube decompression, and Foley catheter placement to monitor urine output. 2 These measures address fluid losses, prevent aspiration, and allow monitoring of perfusion status.
Obtain multidetector CT with intravenous contrast immediately—this is the imaging modality of choice with >90% diagnostic accuracy. 2 The CT identifies the cause, location, presence of ischemia, and whether perforation has occurred. Plain films are insufficient for surgical planning.
Monitor continuously for clinical deterioration: worsening peritonitis, rising white blood cell count, and increasing lactate levels signal the need for immediate surgical intervention. 2 Delay in surgery when ischemia is present increases mortality to 25%. 3
Sigmoid Volvulus Management
For sigmoid volvulus without ischemia or perforation, perform endoscopic detorsion followed by sigmoid colectomy with primary anastomosis during the same hospital admission. 1, 2 This two-stage approach prevents recurrence while allowing initial stabilization.
- Endoscopic detorsion alone (without subsequent surgery) should only be used in high-surgical-risk patients who cannot tolerate operation, though recurrence rates are unacceptably high with this approach. 2
- If endoscopic detorsion fails or if ischemia is present, proceed directly to emergency surgery. 1, 2
- Laparoscopic surgery for sigmoid volvulus has limited utility due to the unfixed, excessively long sigmoid colon making exposure and dissection technically difficult. 1
Cecal Volvulus Management
Cecal volvulus requires immediate right hemicolectomy—endoscopy has no role. 1, 2 Unlike sigmoid volvulus, endoscopic detorsion is not effective for cecal volvulus, and surgical resection is the only definitive treatment.
Diverticular Disease Obstruction
Resection with primary anastomosis is the preferred procedure for diverticular large bowel obstruction, and should be attempted regardless of bowel preparation status after successful conservative treatment during the same admission. 1, 2 This approach avoids the need for staged procedures in most patients.
- For high-risk patients (significant comorbidities, hemodynamic instability), consider conservative therapy alone or Hartmann procedure. 1, 2
Malignant Large Bowel Obstruction
Resection with primary anastomosis is the best option for malignant large bowel obstruction in patients without significant risk factors or perforation. 1, 2 Anastomotic leak rates of 2.2-12% in emergency settings are comparable to the 2-8% rate in elective procedures, making primary anastomosis safe in appropriately selected patients. 1, 2
Risk-Stratified Approach:
- High-risk patients or those with perforation: Perform staged procedure such as Hartmann procedure. 1, 2
- Extraperitoneal rectal cancer: Postpone primary tumor resection and create a diverting stoma to permit proper staging and appropriate neoadjuvant treatment. 1, 2
- Left-sided colonic cancer: Self-expanding metallic stents as a bridge to elective surgery offer better short-term outcomes than emergency surgery. 2 Stents convert emergency operations to elective cases with decreased complications and stoma formation. 2
Laparoscopic Considerations:
Laparoscopic approach for malignant large bowel obstruction should be reserved for selected cases in specialized centers only. 1, 2 The technical challenges and risk of complications in emergency settings limit widespread applicability.
Critical Decision Points
When to Operate Emergently:
- Peritonitis or signs of perforation
- Clinical evidence of bowel ischemia (rising lactate, worsening leukocytosis, peritonism)
- Failed endoscopic detorsion in volvulus
- Any cecal volvulus
- Ischemic volvulus 1, 2
When Conservative Management May Be Attempted:
- Diverticular obstruction without perforation/ischemia (followed by same-admission surgery)
- High-surgical-risk patients with sigmoid volvulus after successful endoscopic detorsion
- Malignant obstruction in candidates for stenting as bridge to surgery 1, 2
Common Pitfalls to Avoid
Never delay surgical consultation when signs of ischemia are present—mortality increases dramatically with delayed intervention. 3 Clinical deterioration can occur rapidly in large bowel obstruction, particularly with cecal involvement where the risk of perforation is highest due to Laplace's law.
Do not rely on endoscopic detorsion alone for sigmoid volvulus in surgical candidates—same-admission definitive surgery is mandatory to prevent recurrence. 1, 2
Avoid attempting endoscopic detorsion for cecal volvulus—it is ineffective and delays necessary surgical intervention. 1, 2