Diagnostic and Management

Approach of Intestinal Obstruction

Danny A. Portes , M.D.

Department of Medicine
Veterans Memorial Medical Center
GENERAL OBJECTIVE :

 To discuss a case of Adenocarcinoma

of the colon presenting as intestinal
obstruction
SPECIFIC OBJECTIVES :

1. To discuss diagnostic approach on

intestinal obstruction.
2. To present differential diagnoses on
intestinal obstruction.
3. To discuss the management approach
of intestinal obstruction.
 General data
• 82 y/o , male
• Married , RPV
• Roman Catholic
• Pangasinan
• Admitted for the 1st time on May 23, 2005
Chief Complaint

Abdominal Pain
History of Present Illness
1 MONTH PTA abdominal pain
consultation done

1 WEEK PTA still with abdominal pain

(+) vomiting
(+) loss of appetite
(+) weight loss
no consultation nor
medication taken
1 DAY PTA persistence of above s/sx
consultation done
medication:
Cotrimoxazole 800mg/tab
Ranitidine 150 mg/tab tid
Hyoscine N Butyl Bromide
transferred to our institution

ADMISSION
Past Medical History
 (+) Hypertension x 20 years - on Amlodipine
5mg/tab, OD
 Hemorrhoidectomy - 1969

Personal / Social History

 47 pack year smoker – stopped in 1969
 alcoholic beverage drinker – stopped in 1969

Family History
 Hypertension – paternal side
 Review of Systems
 (+) generalized body weakness (-) fever
 (-) cough, hemoptysis, DOB
 (-) chest pain, orthopnea, PND
 (-) palpitations, dyspnea
 (-) dysuria, frequency, urgency
 (-) bleeding episode
 (-) polyuria, polydipsia, polyphagia
 Physical Examination
 Conscious , coherent , not in distress
BP: 130/70 CR: 72bpm RR: 20 T:37
 pale palpebral conjunctivae, anicteric
sclerae,no nasoaural discharge, moist lips and
buccal mucosa
 supple, no CLAD, no neck vein engorgement
 SCE, no lagging, nor retractions, resonant,
no adventitious sounds
 Adynamic precordium, PMI at 5th ICS, LMCL
NRRR, (-) murmur
• Flat, (-)scars, normoactive bowel
sounds, (-) bruit, soft, tympanitic, with
slight tenderness at the epigastric and
hypogastric area on deep palpation,
(-) hepatosplenomegaly, (-) palpable
mass, (-) rebound tenderness
• Abdominal circumference= 34 inches
 Genitalia: no lesions no scrotal enlargement
 Extremities: grossly normal, full and equal
pulses, no edema, no cyanosis
 Skin: dry skin, poor skin turgor, no active
dermatoses, no jaundice
DRE: no skin tags, no lesions, no
fissures, good sphincteric tone, full
rectal vault, (+) brownish hard stool on
examining finger
 Salient Features
 82yo, male
 abdominal pain
 vomiting
 anorexia
 weight loss
 pallor
 slight tenderness on deep palpation at
epigastric area and hypogastrium
 Admitting Impression
 T/C BPUD, Anemia 2°
 Hypertension, Stage 2, controlled
 Differential Diagnosis
 Biliary tract disease
 Chronic diverticulitis
 Colonic CA
 Biliary Tract Disease
 nausea, vomiting and epigastric or
RUQ abdominal pain that is steady or
colicky
 post-prandial fullness, flatulence
and fatty food intolerance
 jaundice
 Complete Blood Count
5-23 5-28 5-30 6-15 7-7
Hgb 81 116 148 115 112
Hct 27 37 46 37 36
WBC 4.2 15.7 8.4

seg .78 .96 .85 .78

lymp .22 .04 .15 .22
retic 16
platelet 264
protime 264
Pro act 120
control 12.9
MCV 66
MCH 20
MCHC 30
 Blood Chemistries
5-23 5-25 5-28 6-1 7-10
BUN 5.2 3.2
Crea 82 73
Na 141 145 137
Cl 100 101 100
K 4.2 3.4 3.9
FBS 6.0
BUA 151
HDL 1.0
LDL 3.9
Mg
Ca 2.0
Phos
sgot 38
sgpt 20
TC 5.1
TG 0.5
amylse 51
glob 26 25
alb 28 15 27
TP 54
 5-26 6-15 7-15
color yellow D. yellow yellow
transprency sl turbid sl turbid clear
sp gravity 1.010 1.015 1.015
pH 7.0 6.5 7.5
albumin neg neg neg
sugar neg neg neg
RBC 0-1 0-1 2-4
PUS 0-3 0-4 2-3
bacteria few mod
epith cells few occ
 CEA: 6-24
1.18ng/ml ( 2.10-6.20)

12-L ECG Results:

5-23-05
- 1st degree AV block
- CRBBB
6-5-05
- CRBBB
 Radiographic Report
5-24 5-25 5-26 5-27

Gen Gen ileus, Gen ileus, Finding

adynamic partial int partial int consistent
ileus, OA obstruction obstruction with partial
thoraco not ruled not ruled intestinal
lumbarspine out, OA, out, OA obstruction,
TLS TLS OA, TLS
 Chest ( A-P)
5-27-05
- No significant cardiopulmonary problems
findings except for atheromatous aorta,
OA, thoracis spine
 Lumbo-sacral
- spurs on the bodies of the lumbar spine
with intact disc space consistent with
degenerative changes, lumbar instability
 Ultrasound Report
 Abdominal Aorta:
5-23-05
- no sonographic evidence of abdominal
aortic aneurysm
 HBT, LGBPS, AA:
5-24-05
- normal liver, biliary tree, spleen
- consider cholecystitis
- non visualized pancreas and AA
- minimal ascites noted
 HBT, LGBPS, PAN:
6-17-05
- diffuse parenchymal liver disease
- dilated intrahepatic duct
- sonographically normal gall bladder
- non visualized pancreas
- negative para-aortic node enlargement
- incident note of ascites and right
basal pleural effusion
 Whole Abdomen CT Scan
 5-27-05
- Generalized ileus. Possibility of
chronic partial intestinal obstruction
likewise considered.
- dilated gall bladder
- OA changes of lumbar spine
 Histopathological Diagnosis
 Adenocarcinoma, low grade (Moderately
Differentiated), 5x4 cm extending to the
muscular and subserosal layer
ASTLER COLLER STAGING, STAGE B2
T3MOMx, AJCC
Remarks: all (0/8) lymph node and lines of
resection are NEGATIVE for malignant cells.
Course in the ward
 Admission
 Venoclysis done
• diet : low salt , low cholesterol
 Dx : CBC – anemia
12 L ECG – complete RBBB, 1st degree AV block
 Tx : Famotidine 20 mg IV q 8°
Metoclopramide 10 mg IV prn
AlMgOH 45 cc prn
Amlodipine 5 mg/tab
ISDN prn
PRBC 2 “u” requested
 1st hospital day
 Vital signs were normal
• Occasional epigastric pain radiating to the hypogastric
area
• 2 episodes of vomiting
• IMPRESSION: T/C Cholecystitis

 Dx: Ultrasound  unremarkable

 Tx/Plan: Gastro service
Surgery service
 2 nd
hospital day
 Still with crampy abdominal pain, vomiting
• Normal vital signs, abdominal girth= 36 inches
• IMPRESSION: T/C Acute Intestinal Obstruction

 Dx: Flat Plate of abdomen

- Generalized adynamic ileus
Serum amylase  normal
Serum electrolytes - normal
UTZ of LGBPS  normal
 Tx: NPO
NGT inserted
Blood transfusion 1 unit PRBC
 3rd hospital day
 Still with the same complaints
• Normal vital signs, abdominal girth = 36 inches

 Repeat flat plate done

– Generalized ileus
– Intestinal obstruction not ruled out

 GI service - continue decompression and start

Empiric antibiotic therapy
• Cefuroxime 750 mg IV q8°
• Metronidazole 500 mg IV q8°
 Surgery service
 Non surgical abdomen and concurred
with the plan
Suggestions :
 Endoscopy
 serum TPAG determination
 liquid diet if tolerated
 4th hospital day
 Still with crampy abdominal pain
(+) nausea (-) vomiting
Stable vital signs AC = 36 inches

 Repeat flat plate

– Partial Intestinal obstruction
– Post BT H & H

 Continue empiric antibiotic treatment and

decompression
 BT of 2nd unit of PRBC
 referred back to Gastro service
 5th hospital day
 Still with abdominal pain localized in left
hypogastrium (+) vomiting (-) fever
– Increasing abdominal girth (37 inches)
– Tenderness on deep palpation
CT scan of abdomen
– Generalized ileus
– Consider Chronic partial intestinal obstruction
– Dilated gallbladder
– Osteoarthritic changes of lumbar spine
 6th hospital day
 Transfer of service
– Surgery

 “E” lap done

– Left hemicolectomy
with Devine’s
colostomy and
biopsy done
 Intraoperative findings
• 5 x 4 cms firm ,
constricting mass at the
splenic flexure ,
markedly dilated bowels
from LOT to mid
transverse colon

• With serosal tears at 80

cm and 110 cm from
LOT
 Histopathologic report
• Adenocarcinoma , low grade
( Moderately Differentiated )
extending to the muscular
and subserosal layer

• ASTLER COLLER STAGING ,

STAGE B2 T3N0Mx , AJCC

• All (0/8)LN and lines of

resection are NEGATIVE of
malignant cells
 Course in the ward:
• He stayed at surgery service for two
weeks. Antimicrobial coverage,
hydration and nutritional build-up were
provided.
 Course in the ward:
• He was subsequently transferred to
ONCOLOGY service.
• On his 39th hospital day, he was
discharged clinically improved and
stable.
DISCUSSION
 Intestinal Obstruction
 By location – small bowel (proximal/distal)
- large bowel

 By mechanism – mechanical or non-

mechanical ( adynamic, paralytic ileus,
pseudo-obstruction)

 By pathophysiology – simple, closed loop,

strangulated
 Colonic Obstruction
 Neoplasm (60%)

 Volvulus (20%)

 Diverticular stricture (10%)

 Others (10%)
 Volvulus
 20-50% of all intestinal obstruction
 abnormal twisting of a segment of bowel on
itself along its longitudinal axis
 closed loop obstruction is often produced
 sigmoid and cecum are the most frequent
sites
 transverse colon, splenic flexure
 colicky abdominal pain, obstipation and
abdominal distention
 “ bent-inner tube” ( sigmoid volvulus) or
omega loop sign
 “ kidney-bean shaped” ( cecum)
 these “classical” radiographic findings are
seen in 40%-60% of cases
 operative distortion/colonoscopic distortion
 Diverticulitis
 diverticula are small mucosal pockets in the
wall of the colon
 obstruction of the neck of the diverticulum
may result in the distention secondary to
mucus secretion and overgrowth of normal
colonic bacteria ultimately leading to
perforation.
 pain maybe intermittent or constant
 frequently associated with a change in bowel
habits
 hematochezia is rare
 anorexia, nausea and vomiting may occur
 recurrent attacks can result in the formation
of scar tissue, leading to narrowing and
obstruction of the colonic lumen.
 Management of
Intestinal Obstruction
 Evaluations
 History and Physical Examination
 Laboratory Examinations
 Chest/Abdominal Radiographs
- flat, upright and decubitus
 Contrast studies (single, double)
 Endoscopy
 Computed Tomography
 MRI
 CT colonoscopy/
Virtual colonography
 Colonoscopy
Indications for colonoscopy:
 evaluation of potentially significant barium
enema
 evaluation of lower GI bleed
 IBD
 therapeutic indications
 surveilance studies
 removal of colon polyp
 work up of iron deficiency anemia
 discretionary follow-up of colonic lesions of
unknown significance
 diagnosis and localization of lower GI bleed
prior to possible electrocauterization or
surgery

“These indications are not all-inclusive and are

subject to physician discretion in individual cases”.
Contraindications:
 toxic, fulminant colitis
 perforation of abdominal viscus
 severe coagulopathy
 acute diverticulitis
 acute or recent MI
 patient refusal

American College of Physician

“ Although colonoscopy maybe useful in
patients with partial colonic obstruction, it has
little role in the initial evaluation of patients
suspected of having complete obstruction.
The insufflation of air or CO2 through
endoscope may exacerbate colonic distention
and precipitate perforation”

Sleisenger and Fordtran’s

7TH Edition 2002
 Contrast Studies
 Perform if the diagnosis of large bowel
obstruction is suspected but not proven
 If differentiation b/w obstipation and
obstruction is required
 If localization is required for surgical
intervention
 Contrast Studies
 The reflux of barium above an obstructing
colon may promote the development of
complete obstruction
 The use of water soluble contrast media
obviates the risk of barium impaction at the
site of obstruction and barium peritonitis in
the case of unrecognized perforation.

Sleisenger & Fordtrans

7th Edition
 Barium should be used cautiously or not at
all because it may inspissate at the site of
stricture and exacerbate the blockage

Cameron’s Current Surgical Therapy

7th Edition
“ CT scan has an overall sensitivity of 98 % and
specificity of 87 % in detecting colon cancer “

Robinson P , Brunett H , Nicholson DA

Clinical Radiology Dec 2003
“ Overall sensitivity was 71.7% on plain
film And 83.0% on CT.

Efficacy of abdominal plain film and CT in bowel obstruction

Nippon Igaku Hoshesen Gakkai Zasshi, Mar 2002
Dept of Radiology, St Martin University
“ CT had high sensitivity (93%), specificity
(99%) and accuracy (94%) in diagnosing the
presence of obstruction. The comparable
sensitivity, specificity and accuracy were,
respectively, (83%), (98%), (84%) for US
and (77%), (70%) and (80%) for plain
radiography. The level of obstruction was
correctly predicted in 93% on CT, 70% on US
and 60% on plain films.

“Comparative evaluation of plain films, ultrasound and CT

in the diagnosis of Intestinal obstruction”.
Suri, Gupta, Sudhakar, Venkataramu, Sood, Wig
Dept of Radiodiagnosis, Post Grad Inst of Medical Education
And Research, Chandigarh, India ( 2001)
“ CT scan as a routine preoperative
diagnostic exam could cause
MISDIAGNOSIS due to the following :
 Inadequate bowel preparation
 Flat lesions > 10 mm - misinterpreted as
feces
 Small polyps “

Barton JB , Langdale et al
Am J of Surgey May 2004
“ MRI is superior to CT in staging Cancer and
in differentiating between scarring tissue and
recurrence “
“ It’s 91 % sensitive and 100 % specific “
“ It has 100% positive predictive value and
89% negative predictive value with an
accuracy of 95 % “

Hock D. , Cancer Journal May 2003

“ MRI is superior in sensitivity , specificity
and accuracy to CT scan in determining
extent of tumor “

Pema PJ , Bennett WF
Journal of Computer assisted Tomography March-April 2004
 Treatment and Outcome
 Resuscitation and Initial management
- restoration of intravascular volume
- correction of electrolyte abnormalities
- nasogastric decompression
 Subsequent therapeutic decision depend
primarily on the presence of complete or
partial obstruction or evidenced of
strangulation
 Patients with partially obstructing benign or
malignant strictures w/o evidenced of
peritonitis may undergo semi-elective
resection.
 Complete colonic obstruction necessitates
emergency operative decompression.
 Self-expanding metallic endoprostheses or
endoluminal colonic wall stents.
The goals of operative management in
complete colonic obstruction are three-fold :
(a) to quickly decompress the obstructed
colon
(b) to definitely treat the obstructing lesion
(c) to re-established the intestinal continuity
“The competency of ileocecal valve is of
great importance to the
pathophysiology of colonic obstruction.
The necessity for emergency operation is
dictated by the presence of complete
colonic obstruction and not by the
measurement of cecal diameter”.

Sleisenger & Fordtran’s GI and Liver Disease

7th Edition
“Operating in an urgent or emergent
fashion is associated with high operative
mortality/morbidity”. A thorough
knowledge of the cause of colonic
obstruction is important for optimal
patient’s outcome”.

Cameron’s Current Surgical Therapy

7TH Edition
Current Concepts in
Diagnoses and
Management of
Intestinal Obstruction
 Virtual colonography/CT
•
colonoscopy
 Current concepts
“ CT colonography /Virtual colonoscopy 
promises to become a 1° screening method
for colorectal Cancer “

“ New rapidly developing non invasive CT

technique to detect polyps and cancers
>/=10 mm in size “

Gluecher TM , Fletcher JG .
Europe J Cancer Nov. 2003
“ CT colonography is 98 % sensitive and 96
% specificity in detecting Colorectal
Cancer “

Neri E., Giusti P., Battolla L

Diagnostics and Interventional Radiology , Univ. Pisa , Rome
June 2004
 Angiography for diagnosis and
treatment of colorectal cancer
 Preoperative selective arterial angiography
can help the diagnosis and locate primary
tumors and to detect liver metastasis. At the
same time arterial chemotherapy can be an
important form of preoperative therapy.

Jin Gu, Ming Li, Guang Xu, Dept of Sx, Oncology School of Peking
University, Beijing, Beijing China.
Zhai-Li Dept of Surgery, Beijing Chaoyang Hospital
 Carcinoma of the Colon
•
 Colonic Cancer
• 5-year survival is 90%
when colorectal Ca is
diagnosed at an early
stage, less than 40% of
cases are diagnosed
when the cancer is still
localized.
• 3rd most common Ca in
men and women.
• about 60% present
with obstructive
symptoms
 How is colon cancer
diagnosed?
SIGNS/SYMPTOMS
RISK FACTORS • No obvious signs but
could include
• > 40 y/o – Change in bowel
frequency
• High fat and low fiber
– Change in consistency
diet
– Rectal bleeding/ bloody
• Sedentary lifestyle stool
• Smoking – Unexplained weight loss
• Alcohol use – Fatigue
– Persistent abdominal
• Family history discomfort
• IBD – Unexplained anemia
 Environmental Factors Potentially
Influencing Carcinogenesis in the
Colon and Rectum
 Probably Related
- high fat and low fiber consumption
 Possibly Related
- beer and ale consumption (esp Rectal Ca)
- environmental carcinogen and mutagens
Fecapentaenes ( from colonic bacteria )
Heterocyclic amines ( from charbroiled
and fried meat and fish )
 Probably Protective
- high fiber consumption
- physical activity and low body mass
- Aspirin and NSAIDs
- Calcium

 Possibly Protective
- yellow green cruciferous vegetable
- Vitamin A, C, E
- HRT ( estrogen )
 Average-Risk Sreening
Guidelines
 FOBT
 Flexible sigmoidoscopy
 Colonoscopy
 Double-contrast enema
 CEA and Serologic Tumor Markers
 Genetic Testing
 High-Risk Groups
 IBD
 Previous colorectal cancer
 Previous adenomas
 Female genital cancer
 Familial polyposis
 HNPCC
 Familial colon cancer
 Treatment
 Surgery
 Chemotherapy
 Immunotargeted therapy and
Immunotherapy
 Radiation therapy
 Summary
 History & Physical Examination
 Symptomatology
 Diagnostics
 Management and Intervention
 Prognosis
 Conclusion
“Prompt investigation of the cause of
abdominal pain, watchful monitoring of
the patient’s clinical status with
adequate history and physical
examination as well as collaboration
with different specialties are of prime
importance to the diagnosis and
appropriate management of our
patient”.
 THANK YOU!
&
GOOD MORNING
THANK YOU
 Small Intestinal Disease
 Periumbilical region
 crampy and maybe associated with
vomiting and changes in bowel
movement
 constipation and inability to pass flatus
 high –pitched or musical bowel sounds
 What is the most
likely etiology of his
abdominal pain?
 ABDOMINAL PAIN
A. PARIETAL A. ACUTE

B. VISCERAL B. CHRONIC
 What happens after treatment ?
Follow up care
Follow up care 1st year after 2nd-3rd year after 4th – 5th year
treatment treatment after treatment
Doctor’s visit Every 3- 6 Every 3-6 Every 6 mos
mos mos
Tumor Every 3 mos Every 3 mos determined by
markers doctor
CT Yearly Yearly determined by
colonography doctor
Proctosigmoi- Yearly yearly determined by
doscopy doctor
What could have caused
the misdiagnosis
preoperatively ?
 Differential Diagnosis of
Colonic Obstruction
 Acute Obstruction
- cecal volvulus
- sigmoid volvulus
- transverse volvulus

 Subacute/Chronic onset
- colon ca
 - Rectal ca
- Metastatic or extracolonic malignancy
- IBD
- Diverticulitis
- Ischemic bowel

 Others
- colonic pseudo-obstruction
- Imperforate anus