This document discusses various causes of large bowel obstruction including cancer, inflammation, volvulus, and Ogilvie's syndrome. It provides details on the diagnostic evaluation, imaging findings, and treatment options for partial versus complete, simple versus strangulating obstructions. The most common mechanical cause is colorectal cancer while the most common adynamic cause is acute colonic pseudo-obstruction. Treatment depends on the etiology and includes resection, stenting, decompression, and creation of a stoma.

1. Colonic Obstruction
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2. Large bowel obstruction = intestinal obstruction
distal to ileocecal valve

3. Diagnostic Evaluation of
bowel obstruction
• Distinguish mechanical obstruction from ileus
• Determine etiology
• Discriminate partial from complete obstruction
• Discriminate simple from strangulating
obstruction

4. • Most common mechanical cause = CRC
• Common adynamic cause = acute colonic
pseudoobstruction

5. Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia: Elsevier, 2014.

6. IMAGING

7. Plain Abdomen
• Bowel obstruction
– Absent bowel gas distal to obstruction
– Different air-fluid level in the same loop
– String of pearl sign: small bubbles between
valvulae conniventes
– Distal large bowel obstruction, especially sigmoid
may be confused with generalized ileus if the
ileocecal valve is incompetent

8. Plain abdomen
• Ileus
– Diffusely gas-fill bowel including rectum
– Common causes of generalized ileus = abdominal
surgery, severe abdominal illness
– Localized ileus (sentinel loop): local inflammation

9. Fox JC. Clinical emergency radiology. Cambridge: Cambridge university press, 2008.

10. Fox JC. Clinical emergency radiology. Cambridge: Cambridge university press, 2008.

11. CANCER

12. • Most common symptom of a large bowel
obstruction from malignancy is abdominal
distention
• History: recent weight loss, bowel habit
change, change in stool consistency
• Vomiting is a late sign and can be
stercoraceous

13. Treatment
• Partial obstruction: NG decompression and
one-stage procedure
• For unresectable disease: stent or colostomy
• For resectable disease:
– Right side: right hemicolectomy

14. Treatment: Left Side
• Loop colostomy/ileostomy
• Primary resection with end colostomy (Hartmann’s
procedure)
• Primary resection and anastomosis
– Total or subtotal colectomy
– Segmental colectomy
• With intraoperative colonic irrigation
• With manual decompression
• Endoscopic colonic stenting (self-expanding metallic
stent)
– Palliation
– Bridge to surgery

15. • Colostomy with staged procedure VS
Hartmann’s procedure:
– Colostomy with staged procedure: no more
popular, only decompression, allow surgeon to
evaluate clinical staging, CA rectum
– Hartmann’ s procedure is recommended over the
previous

16. • Hartmann’s procedure VS primary resection
and anastomosis:
– Primary anastomosis is recommended BUT only in
experienced surgeons and be careful on
anastomotic leakage (2.2 – 12%)

17. • Total/subtotal colectomy VS segmental
colectomy with intraoperative colonic
irrigation:
– SCOTIA (subtotal colectomy versus on table
irrigation and anastomosis) trial: segmental
colectomy is better
– Intraoperative colonic irrigation: more SSI
– Subtotal colectomy indication:
• Right colon ischemia
• Synchronous proximal malignant

18. • Intraoperative colonic irrigation VS manual
decompression:
– Both no different morbidity and mortality
– Manual decompression takes less time

19. • Stent VS colostomy for palliation:
– Stent is recommended due to safe and high success
rate
– Avoid stent in patients with avastin
– Stent: bridge from emergency to elective surgery

20. • Stent for bridging to surgery VS emergency
surgery:
– Stent is recommended

21. Self-Expandable Metallic Stent
(SEMS)
• Ideally: 2 cm above and below the stricture
• The waist of the stent should be in the middle
• Fully recoil within 24 – 48 hrs
• Complications:
– Perforation: associated bevacizumab
– Stent migration
– Stent failure

22. INFLAMMATION

23. • May be secondary to:
– Acute: diverticulitis, Crohn’s disease, radiation
colitis
– Chronic: from previous diverticulitis, pelvic
radiation, prior bowel anastomosis

24. Acute Inflammation
• Inflammation of diverticulitis, Crohn’s disease,
radiation colitis
• Can be treated with nonoperative management
if absent of peritonitis: NG, IV resusctitation,
antibiotics
• Surgery: Hartmann’s procedure or loop
colostomy for difficult cases
• Malignancy must always be a concern:
colonoscope

25. Chronic Stricture
• From stricture, inflammation, and fibrosis
• Previous diverticulitis, pelvic radiation, prior
bowel anastomosis
• Present with chronic constipation and partial
obstructive symptoms
• Should be evaluated for malignancy
• Treatment: elective one-stage resection or stent

26. COLONIC VOLVULUS

27. • Volvulus: a torsion on the organ pedicle
• Volvulus of the large bowel results from the
colon’s twisting on its mesentery  producing
symptoms by narrowing of the bowel lumen and
strangulation of the blood vessels
• Third most common
– Sigmoid
– Ileosigmoid
– Cecum
– Transverse colon
– Splenic flexure

28. Sigmoid Volvulus

29. • Most common volvulus
• Etiology:
– Sigmoid must be long, floppy, narrow mesenteric
root
– Disproportion between antimesenteric and
mesenteric sites when bowel becomes distended
and elongated
– Antimesenteric border elongates 30% whereas
mesenteric site 10%

30. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

31. Pathogenesis
• Torsion clockwise or counterclockwise
• Torsion at least 180 degree (asymtomatic and
physiologic if less than this)
• Closed-loop type of obstruction

32. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

33. Clinical Presentation
• Acute fulminating type
– Younger
– Sudden onset and rapid course: early vomiting, diffuse
abdominal pain, signs of gangrene, minimal abdominal
distention
• Subacute progressive type
– More common
– History of chronic constipation
– Abdominal distention is extreme

34. Diagnosis
• Plain film
• Gastrograffin enema
• CT abdomen: identify strangulation

35. Coffee bean sign
Fox JC. Clinical emergency
radiology. Cambridge: Cambridge
university press, 2008.

37. Treatment
• Nonstrangulated
• Strangulated

38. Strangulated Sigmoid Volvulus
• Sigmoid resection with colostomy and
Hartmann’s procedure is safest

39. Management of Nonstrangulated
Sigmoid Volvulus
• Decompression
– Rigid sigmoidoscopic
– Colonoscopic and flexible sigmoidoscopic
• Surgical management
– Sigmoidectomy
– Nonresective
• Sigmoid decompression and colopexy
• Mesosigmoidoplasty
• Foley catheter sigmoidostomy
• T-fastener sigmoidopexy

40. Rigid Sigmoidoscopic Decompression
• Jackknife position
• Lateral decubitus is acceptable
• Carefully insert sigmoidoscope and inspect for
ischemic mucosa or until torsion site is seen
• 40 to 60 cm rectal tube is gently passed and
fixed for 48 hrs

41. Colonoscopic and Flexible
Sigmoidoscopic Decompression
• Largely replace rigid sigmoidoscope
• Colonoscope itself can pass torsion site

42. Sigmoidectomy
• Primary anastomosis is safe after successful
decompression

43. Sigmoid Decompression and Colopexy
• First deflate sigmoid by needle
• Insert rectal tube
• 4 -5 days after: colopexy
– 6 to 8 Strips of Gore-Tex band encircle the bowel
and are sutured to abdominal wall

44. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

45. Mesosigmoidoplasty
Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

46. Foley Catheter Sigmoidostomy
• Fix redundant sigmoid to anterior abdominal
wall
• Foley catheter is removed 2 weeks later

47. T-Fasteners Sigmoidopexy
• Fix sigmoid to anterior abdominal wall with the
aid of colonoscopy
• 3 to 4 T-fastener pulls the sigmoid colon up
against the abdominal wall and is tightened on the
skin over the cotton pledget .These fasteners are
cut at the skin level after 28 days and pass with
stool. By this time, the sigmoid colon should
adhere to the anterior abdominal wall.
• The procedure is performed under mild sedation

48. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

49. Ileosigmoid Knotting

50. • Loop of sigmoid and ileum wrap each other
• Initiated by hyperactive ileum that winds itself
around the pedicle of a passive sigmoid loop
• Majority of patients present with peritonitis

51. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

52. Treatment
• Emergency condition
• It cannot reduce via endoscopy
• Viable bowel: untie the knot and resection may
be primary anastomosis
• Gangrenous bowel: En bloc resection with no
anastomosis

53. Cecal Volvulus

54. • Younger
• Congenital anatomic variant: incomplete
peritoneal fixation of right colon
• Clinical presentation
– Acute fulminating: acute abdomen
– Acute obstruction: bowel obstruction
– Intermittent or recurrent: subside spontaneously

55. • Reversed C
• Bird’s beak
• Whirl sign
Fox JC. Clinical emergency
radiology. Cambridge: Cambridge
university press, 2008.

56. Treatment
• Nonoperative reduction is generally
unsuccessful and hazardous
• Right hemicolectomy with ileostomy for
gangrenous
• Cecostomy with colopexy with peritoneal flap
• Last resort: CT-guided percutaneous
decompression and using SPC set

57. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

58. Volvulus of Transverse Colon

59. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york:
Informa healthcare USA, 2007.

60. OGILVIE’S SYNDROME

61. • Colonic distension in the absence of
mechanical obstruction
• Complication: ischemia and perforation
• Clinical features:
– Abdominal distension
– Abdominal pain 80%
– Nausea and vomiting 60%
– Presence of bowel sound

62. • ACPO occurs in hospitalized patients with
significant comorbidity and may occurs
postoperative day 4
• Mechanical obstruction should be ruled out by
water-soluble enema

63. Fox JC. Clinical emergency
radiology. Cambridge: Cambridge
university press, 2008.

64. Management
• Supportive treatment
• Neostigmine
• Colonoscopy
• Tube cecostomy
• surgery

65. Supportive Treatment
• NPO
• Correct fluid and electrolyte imbalance: K, Mg,
Ca
• Treat systemic illness
• Stop exacerbating medications: opiates,
anticholinergics, antidiarrheal medication
(loperamide), TCA, antipsychotics, CCB, BB
• NG and rectal tubes
• Ambulation
• Avoid laxatives and enema

66. Neostigmine
• Acetylcholinesterase inhibitor
• Side effects: abdominal pain, nausea,
excessive salivation, bradyarrhythmia, renal
failure, exacerbate bronchoconstriction
• 2 mg IV with atropine

67. Colonoscopy
• Should be consider:
– Not improve after 24 hrs
– Mark cecal distention (>12cm) with significant
duration (>6days)
– Cannot tolerate neostigmine
• Colon should NOT be prepped with enema
• After successful colonoscopy, decompression
tube should be placed, flush q4-6hr with
saline, and remove after 72 hrs

68. Tube Cecostomy
• Can be considered:
– Do not respond to pharmacologic or endoscopic
decompression
– No evidence of ischemia
– Poor surgical candidate

69. Surgery
• Should only be considered when others
unsuccessful
• Colonic resection
• colostomy

70. Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia: Elsevier, 2014.

71. INTUSSUSCEPTION

72. • Present with melena or guaiac positive stool
• Less with abdominal pain, nausea, and
vomiting
• Mass may be palpated
• Most useful diagnostic test: CT
– target-shaped area of colon that represents the
intussusceptum in the center surrounded by the
intussuscipiens

73. Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia: Elsevier, 2014.

74. • Unlike children, adult intussusception cause by
malignant focus: 43%
• Treatment: surgical resection along lymphatic
drainage without reduction
– Rt side  Rt hemicolectomy
– Lt side  Hartmann procedure

75. References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill
Education, 2015.
Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia:
Elsevier, 2014.
Fox JC. Clinical emergency radiology. Cambridge: Cambridge university
press, 2008.
Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon,
rectum, and anus. 3rd ed. New york: Informa healthcare USA, 2007.
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