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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 out, not ruled out, intestinal
lumbarspine OA, TLS OA TLS obstruction,
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 – Change in consistency
fiber diet – Rectal bleeding/ bloody
• Sedentary lifestyle stool
– Unexplained weight
• Smoking loss
• Alcohol use – Fatigue
• Family history – Persistent abdominal
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 mos Every 3-6 mos Every 6 mos

Tumor markers Every 3 mos Every 3 mos determined by


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