Large bowel obstruction

Question 1

An 82 year old woman presents to the Emergency Department with a four day history of cramping supra-pubic abdominal pain, abdominal distension and complete constipation. She has not previously had any abdominal surgery. Clinical examination reveals evidence of right iliac fossa tenderness. Can you outline your management plan?

Answer 1

Impression
Given the pertinent clinical features of complete constipation, abdominal distension and pain, I am concerned about a large bowel obstruction and would be worried about complications of perforation and sepsis. In particular, given the patients age and lack of previous abdominal surgery I would be concerned about malignancy being the most likely cause of this presentation.

DDx
- LBO: volvulus, hernia, malignancy, ileus, strictures
- SBO: hernia, adhesions
- appendicitis (wrong demographic)
- gynae pathology (ovarian torsion, malignancies)
- genitourinary: suprapubic pain; urinary retention, cystitis

Question 2

LBO - History

Answer 2

History
- Sx: constipation, nausea/vomiting (?contents; faecolent), pain (SOCRATES), characterise constipation
- REDS: fevers, night-sweats, weight loss
- RISKS: age, fam Hx, past abdo surgeries,
- complications: peritonitis, HD instability,
- PSHx, any procedures (colonoscopy, findings of),
- PMHx, medications, allergies, SNAP

Question 3

LBO - Examination

Answer 3

Examination
- General appearance + vitals (Cachexia, etc)
- Abdo examination: masses, peritonitis, bowel sounds (absent, high-pitched tinkling), tenderness location, shifting dullness
- systems review: metastasis, systemic illness.

Question 4

LBO - Investigations

Answer 4

Investigations
Key/diagnostic:
- abdominal imaging; CT abdo w IV contrast, MRI

• Bedside: Vitals, urine for infection
• Bloods: FBC, UEC, LFT, CRP/ESR, CMP, tumor markers (CEA, AFP, ca125, etc), G+H (pre-op)
• Imaging: staging imaging if malignancy

Question 5

LBO - Management

Answer 5

Management
Whilst SBO can be managed conservatively/expectantly, LBO usually requires surgical intervention for definitive mx.

Definitive
- Gen surg consult for management input
- Laparoscopy/laparotomy depending on underlying cause of LBO identified from investigations
- may require colectomy +/- stoma, flexible sigmoidoscopy for sigmoid volv.

Supportive
- analgesia, antipyretics
- antiemetics
- NBM
- monitoring for complications
- fluids and electrolytes
- PPI given risk of ulcers when NBM
- NGT for gastric decompression