What is the management of large bowel obstruction?

Management of Large Bowel Obstruction

Initial Resuscitation and Assessment

Begin immediately with intravenous crystalloid fluid resuscitation, nasogastric tube decompression, and Foley catheter insertion to monitor urine output. 1

• Obtain multidetector CT with intravenous contrast as the imaging modality of choice to determine cause, location, and complications 1
• Monitor continuously for signs of ischemia or perforation through serial abdominal exams, rising white blood cell count, and increasing lactate levels 1, 2
• Check complete blood count, C-reactive protein, lactate, electrolytes, BUN/creatinine, and coagulation profile 2

If peritonitis, septic shock, or imaging evidence of perforation/ischemia is present, proceed immediately to emergency surgery—do not attempt conservative management. 1, 2

Cause-Specific Management Algorithms

Sigmoid Volvulus (Most Common Left-Sided Obstruction)

For sigmoid volvulus without ischemia or perforation, perform endoscopic detorsion followed by same-admission sigmoid colectomy with primary anastomosis. 1

• Endoscopic detorsion alone should only be used in high-surgical-risk patients who cannot tolerate surgery, though recurrence rates are extremely high with this approach 1
• If endoscopic derotation fails or ischemia is present, proceed immediately to surgical intervention 1
• The laparoscopic approach has significant limitations due to the excessive length and lack of fixation of the sigmoid colon 1

Cecal Volvulus

Right hemicolectomy is the only recommended surgical option for cecal volvulus. 1

• Unlike sigmoid volvulus, endoscopic detorsion is not recommended for cecal volvulus 3
• Mortality is directly related to bowel viability, making prompt surgical intervention critical 3

Malignant Obstruction (60% of All Large Bowel Obstructions)

For left-sided colonic cancer causing obstruction, self-expanding metallic stents as a bridge to elective surgery offer superior short-term outcomes compared to emergency surgery. 1

• Stenting converts emergency operations to elective cases with decreased complications and stoma formation 1
• For patients without significant risk factors or perforation, perform resection with primary anastomosis 1
• For high-risk patients or those with perforation, perform a staged procedure such as Hartmann's procedure 1
• Anastomotic leak rates in emergency surgery range from 2.2-12%, comparable to the 2-8% rate after elective procedures 1

For right-sided obstructing colon cancer (up to and including splenic flexure), perform extended right hemicolectomy with immediate ileocolic anastomosis. 4, 3

• This approach allows adequate tumor removal with a safe immediate anastomosis 3
• Resection and primary anastomosis is preferable to Hartmann's procedure when patient and surgeon characteristics are permissive 4

For extraperitoneal rectal cancer, create a diverting stoma and postpone primary tumor resection to allow proper staging and neoadjuvant treatment. 1

• Right-sided loop colostomy is preferable when preoperative therapies are predicted 4

Diverticular Disease

After successful conservative management for diverticular disease, perform resection with primary anastomosis regardless of bowel preparation status. 1

• For high-risk patients, consider conservative therapy or Hartmann procedure 1

Special Clinical Scenarios

Malignant Bowel Obstruction in Advanced Cancer

For patients with years to months to live, surgery is the primary treatment after appropriate imaging. 2

For patients with advanced disease, poor performance status, intra-abdominal carcinomatosis, or massive ascites, medical management is preferable to surgery. 2, 5

• Use opioid analgesics according to WHO guidelines for pain control 2, 5
• Administer octreotide early due to high efficacy in reducing gastrointestinal secretions, particularly in high obstruction 2, 5
• Add anticholinergic drugs (hyoscine butylbromide) if octreotide fails 5
• Use antiemetics and corticosteroids to maintain intestinal function 2
• Consider total parenteral nutrition only in patients with longer life expectancy to improve quality of life 2
• Nasogastric drainage should only be a temporary measure 5

Inflammatory Bowel Disease

Free perforation is an absolute indication for emergency surgery. 2

• Any colorectal stricture must be assessed with endoscopic biopsies to rule out malignancy 2
• For symptomatic strictures not responding to medical therapy, endoscopic balloon dilation has 89-92% technical success rates for primary intestinal or anastomotic strictures 2
• Surgery is mandatory for symptomatic strictures that don't respond to medical therapy and aren't amenable to endoscopic dilatation 2

Surgical Decision-Making

When to Operate Emergently

Immediate surgical intervention is required for: 1, 2

• Signs of peritonitis on physical examination
• Strangulation or intestinal ischemia
• Free perforation with pneumoperitoneum
• Closed-loop obstruction on imaging
• Septic shock

Surgical Approach Selection

Laparotomy remains the surgical approach of choice in most large bowel obstruction cases. 2

• Laparoscopic approach should be limited to selected cases in specialized centers for malignant large bowel obstruction 1
• The laparoscopic approach may be considered in stable patients, though conversion rates can be high 2

Critical Pitfalls to Avoid

• Do not delay surgery in patients with peritonitis, ischemia, or perforation while attempting conservative management 1, 2
• Do not perform routine surgery on patients with poor prognostic criteria such as intra-abdominal carcinomatosis, poor performance status, and massive ascites 5
• Do not use endoscopic detorsion alone as definitive treatment for sigmoid volvulus in surgical candidates—recurrence rates are prohibitively high 1
• Do not miss the competent ileocecal valve on imaging, which converts the proximal colon into a second "closed loop" requiring more urgent intervention 4
• Monitor closely for clinical deterioration with serial exams, white blood cell counts, and lactate levels—immediate surgery is necessary if deterioration develops 1