Download PDF
Clin Colon Rectal Surg
DOI: 10.1055/s-0043-1777452
Review Article

Large Bowel Obstruction: Etiologies, Diagnosis, and Management

Kevin A. Chen
1   Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
,
Muneera R. Kapadia
1   Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
› Author Affiliations Funding None.
› Further Information
   Permissions and Reprints

Abstract

Large bowel obstructions (LBOs) often require urgent surgical intervention. Diagnosis relies on astute history and physical examination, as well as imaging with computed tomography (CT) scan for stable patients. Because of the high mortality associated with colonic perforation in patients with LBOs, decisive surgical decision-making is needed for optimal outcomes. This review seeks to provide an overview of the etiologies of LBO, diagnosis, and general management principles, as well as specific management for the most common etiologies, including colorectal cancer and strictures.

Keywords

large bowel obstruction - colorectal cancer - colonic stent


Publication History

Article published online:
29 December 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Moghadamyeghaneh Z, Talus H, Ballantyne G, Stamos MJ, Pigazzi A. Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer. Surg Endosc 2021; 35 (06) 2986-2996
    CrossrefPubMedGoogle Scholar
  • 2 Aslar AK, Özdemir S, Mahmoudi H, Kuzu MA. Analysis of 230 cases of emergent surgery for obstructing colon cancer: lessons learned. J Gastrointest Surg 2011; 15 (01) 110-119
    CrossrefPubMedGoogle Scholar
  • 3 Markogiannakis H, Messaris E, Dardamanis D. et al. Acute mechanical bowel obstruction: clinical presentation, etiology, management and outcome. World J Gastroenterol 2007; 13 (03) 432-437
    CrossrefPubMedGoogle Scholar
  • 4 Byrne JJ. Large bowel obstruction. Am J Surg 1960; 99 (02) 168-178
    CrossrefPubMedGoogle Scholar
  • 5 Farkas NG, Welman TJP, Ross T, Brown S, Smith JJ, Pawa N. Unusual causes of large bowel obstruction. Curr Probl Surg 2019; 56 (02) 49-90
    CrossrefPubMedGoogle Scholar
  • 6 Jaffe T, Thompson WM. Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology 2015; 275 (03) 651-663
    CrossrefPubMedGoogle Scholar
  • 7 Lopez-Kostner F, Hool GR, Lavery IC. Management and causes of acute large-bowel obstruction. Surg Clin North Am 1997; 77 (06) 1265-1290
    CrossrefPubMedGoogle Scholar
  • 8 Yeo HL, Lee SW. Colorectal emergencies: review and controversies in the management of large bowel obstruction. J Gastrointest Surg 2013; 17 (11) 2007-2012
    CrossrefPubMedGoogle Scholar
  • 9 Buechter KJ, Boustany C, Caillouette R, Cohn Jr I. Surgical management of the acutely obstructed colon. A review of 127 cases. Am J Surg 1988; 156 (3, Pt 1): 163-168
    CrossrefPubMedGoogle Scholar
  • 10 Muldoon RL. Malignant Large Bowel Obstruction. Clin Colon Rectal Surg 2021; 34 (04) 251-261
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Telem DA, Chin EH, Nguyen SQ, Divino CM. Risk factors for anastomotic leak following colorectal surgery: a case-control study. Arch Surg 2010; 145 (04) 371-376 , discussion 376
    CrossrefPubMedGoogle Scholar
  • 12 Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients. Colorectal Dis 2017; 19 (03) 288-298
    CrossrefPubMedGoogle Scholar
  • 13 Chapman AH, McNamara M, Porter G. The acute contrast enema in suspected large bowel obstruction: value and technique. Clin Radiol 1992; 46 (04) 273-278
    CrossrefPubMedGoogle Scholar
  • 14 Frager D. Intestinal obstruction role of CT. Gastroenterol Clin North Am 2002; 31 (03) 777-799
    CrossrefPubMedGoogle Scholar
  • 15 Frager D, Rovno HDS, Baer JW, Bashist B, Friedman M. Prospective evaluation of colonic obstruction with computed tomography. Abdom Imaging 1998; 23 (02) 141-146
    CrossrefPubMedGoogle Scholar
  • 16 Ramanathan S, Ojili V, Vassa R, Nagar A. Large bowel obstruction in the emergency department: imaging spectrum of common and uncommon causes. J Clin Imaging Sci 2017; 7 (01) 15
    CrossrefPubMedGoogle Scholar
  • 17 Sabbagh C, Siembida N, Yzet T. et al. What are the predictive factors of caecal perforation in patients with obstructing distal colon cancer?. Colorectal Dis 2018; 20 (08) 688-695
    CrossrefPubMedGoogle Scholar
  • 18 Kwaan MR, Ren Y, Wu Y, Xirasagar S. Colonic stent use by indication and patient outcomes: a nationwide inpatient sample study. J Surg Res 2021; 265: 168-179
    CrossrefPubMedGoogle Scholar
  • 19 Meisner S, Hensler M, Knop FK, West F, Wille-Jørgensen P. Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center. Dis Colon Rectum 2004; 47 (04) 444-450
    CrossrefPubMedGoogle Scholar
  • 20 Tilney HS, Lovegrove RE, Purkayastha S. et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 2007; 21 (02) 225-233
    CrossrefPubMedGoogle Scholar
  • 21 Huang X, Lv B, Zhang S, Meng L. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg 2014; 18 (03) 584-591
    CrossrefPubMedGoogle Scholar
  • 22 Zhang Y, Shi J, Shi B, Song CY, Xie WF, Chen YX. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc 2012; 26 (01) 110-119
    CrossrefPubMedGoogle Scholar
  • 23 Vogel JD, Felder SI, Bhama AR. et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of colon cancer. Dis Colon Rectum 2022; 65 (02) 148-177
    CrossrefPubMedGoogle Scholar
  • 24 Tan CJ, Dasari BVM, Gardiner K. Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg 2012; 99 (04) 469-476
    CrossrefPubMedGoogle Scholar
  • 25 Schwartzberg DM, Valente MA. Surgical dilemmas associated with malignant large bowel obstructions. Clin Colon Rectal Surg 2022; 35 (03) 197-203
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Matsuda A, Yamada T, Yokoyama Y, Takahashi G, Yoshida H. Long-term outcomes between self-expandable metallic stent and transanal decompression tube for malignant large bowel obstruction: a multicenter retrospective study and meta-analysis. Ann Gastroenterol Surg 2023; 7 (04) 583-593
    CrossrefPubMedGoogle Scholar
  • 27 Skelton IV WP, Franke AJ, Iqbal A, George TJ. Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer. J Gastrointest Oncol 2020; 11 (04) 790-802
    CrossrefPubMedGoogle Scholar
  • 28 Carraro PG, Segala M, Orlotti C, Tiberio G. Outcome of large-bowel perforation in patients with colorectal cancer. Dis Colon Rectum 1998; 41 (11) 1421-1426
    CrossrefPubMedGoogle Scholar
  • 29 Nozawa H, Sasaki S, Hayashi C. et al. Preoperative stoma site marking reduces postoperative stoma-related complications in emergency surgery: a single center retrospective cohort study. Scand J Surg 2023; 14 574969231186282
    PubMedGoogle Scholar
  • 30 Yeo H, Park H. Benefits of a single-session, in-hospital preoperative education program for patients undergoing ostomy surgery: a randomized controlled trial. J Wound Ostomy Continence Nurs 2023; 50 (04) 313-318
    CrossrefPubMedGoogle Scholar
  • 31 Awotar GK, Guan G, Sun W. et al. Reviewing the management of obstructive left colon cancer: assessing the feasibility of the one-stage resection and anastomosis after intraoperative colonic irrigation. Clin Colorectal Cancer 2017; 16 (02) e89-e103
    CrossrefPubMedGoogle Scholar
  • 32 Hsu TC. Comparison of one-stage resection and anastomosis of acute complete obstruction of left and right colon. Am J Surg 2005; 189 (04) 384-387
    CrossrefPubMedGoogle Scholar
  • 33 Allen-Mersh TG. Should primary anastomosis and on-table colonic lavage be standard treatment for left colon emergencies?. Ann R Coll Surg Engl 1993; 75 (03) 195-198
    PubMedGoogle Scholar
  • 34 Amelung FJ, Mulder CLJ, Verheijen PM, Draaisma WA, Siersema PD, Consten ECJ. Acute resection versus bridge to surgery with diverting colostomy for patients with acute malignant left sided colonic obstruction: systematic review and meta-analysis. Surg Oncol 2015; 24 (04) 313-321
    CrossrefPubMedGoogle Scholar
  • 35 Amelung FJ, Ter Borg F, Consten ECJ, Siersema PD, Draaisma WA. Deviating colostomy construction versus stent placement as bridge to surgery for malignant left-sided colonic obstruction. Surg Endosc 2016; 30 (12) 5345-5355
    CrossrefPubMedGoogle Scholar
  • 36 Amelung FJ, Mulder CLJ, Broeders IAMJ, Consten ECJ, Draaisma WA. Efficacy of loop colostomy construction for acute left-sided colonic obstructions: a cohort analysis. Int J Colorectal Dis 2017; 32 (03) 383-390
    CrossrefPubMedGoogle Scholar
  • 37 Johnson WR, Hawkins AT. Large bowel obstruction. Clin Colon Rectal Surg 2021; 34 (04) 233-241
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Frago R, Biondo S, Millan M. et al. Differences between proximal and distal obstructing colonic cancer after curative surgery. Colorectal Dis 2011; 13 (06) e116-e122
    CrossrefPubMedGoogle Scholar
  • 39 Lee YM, Law WL, Chu KW, Poon RTP. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions. J Am Coll Surg 2001; 192 (06) 719-725
    CrossrefPubMedGoogle Scholar
  • 40 Caulfield H, Hyman NH. Anastomotic leak after low anterior resection: a spectrum of clinical entities. JAMA Surg 2013; 148 (02) 177-182
    CrossrefPubMedGoogle Scholar
  • 41 Midura EF, Hanseman D, Davis BR. et al. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum 2015; 58 (03) 333-338
    CrossrefPubMedGoogle Scholar
  • 42 Nikolian VC, Kamdar NS, Regenbogen SE. et al. Anastomotic leak after colorectal resection: a population-based study of risk factors and hospital variation. Surgery 2017; 161 (06) 1619-1627
    CrossrefPubMedGoogle Scholar
  • 43 Boccola MA, Buettner PG, Rozen WM. et al. Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients. World J Surg 2011; 35 (01) 186-195
    CrossrefPubMedGoogle Scholar
  • 44 Kamal T, Pai A, Velchuru VR. et al. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection?. Colorectal Dis 2015; 17 (02) 160-164
    CrossrefPubMedGoogle Scholar
  • 45 Deidda S, Elmore U, Rosati R. et al. Association of delayed surgery with oncologic long-term outcomes in patients with locally advanced rectal cancer not responding to preoperative chemoradiation. JAMA Surg 2021; 156 (12) 1141-1149
    CrossrefPubMedGoogle Scholar
  • 46 Allaix ME, Lena A, Degiuli M. et al. Intraoperative air leak test reduces the rate of postoperative anastomotic leak: analysis of 777 laparoscopic left-sided colon resections. Surg Endosc 2019; 33 (05) 1592-1599
    CrossrefPubMedGoogle Scholar
  • 47 Leichtle SW, Mouawad NJ, Welch KB, Lampman RM, Cleary RK. Risk factors for anastomotic leakage after colectomy. Dis Colon Rectum 2012; 55 (05) 569-575
    CrossrefPubMedGoogle Scholar
  • 48 Gash K, Chambers W, Ghosh A, Dixon AR. The role of laparoscopic surgery for the management of acute large bowel obstruction. Colorectal Dis 2011; 13 (03) 263-266
    CrossrefPubMedGoogle Scholar
  • 49 Pisano M, Zorcolo L, Merli C. et al. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018; 13: 36
    CrossrefPubMedGoogle Scholar
  • 50 Petrelli F, Trevisan F, Cabiddu M. et al. Total neoadjuvant therapy in rectal cancer: a systematic review and meta-analysis of treatment outcomes. Ann Surg 2020; 271 (03) 440-448
    CrossrefPubMedGoogle Scholar
  • 51 Malakorn S, Stein SL, Lee JH, You YN. Urgent management of obstructing colorectal cancer: divert, stent, or resect?. J Gastrointest Surg 2019; 23 (02) 425-432
    CrossrefPubMedGoogle Scholar
  • 52 Öhman U. Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982; 143 (06) 742-747
    CrossrefPubMedGoogle Scholar
  • 53 Lavanchy JL, Vaisnora L, Haltmeier T. et al. Oncologic long-term outcomes of emergency versus elective resection for colorectal cancer. Int J Colorectal Dis 2019; 34 (12) 2091-2099
    CrossrefPubMedGoogle Scholar
  • 54 Manceau G, Voron T, Mege D. et al; AFC (French Surgical Association) Working Group. Prognostic factors and patterns of recurrence after emergency management for obstructing colon cancer: multivariate analysis from a series of 2120 patients. Langenbecks Arch Surg 2019; 404 (06) 717-729
    CrossrefPubMedGoogle Scholar
  • 55 Carraro PG, Segala M, Cesana BM, Tiberio G. Obstructing colonic cancer: failure and survival patterns over a ten-year follow-up after one-stage curative surgery. Dis Colon Rectum 2001; 44 (02) 243-250
    CrossrefPubMedGoogle Scholar
  • 56 de Boer NL, Hagemans JAW, Schultze BTA. et al. Acute malignant obstruction in patients with peritoneal carcinomatosis: the role of palliative surgery. Eur J Surg Oncol 2019; 45 (03) 389-393
    CrossrefPubMedGoogle Scholar
  • 57 van Hooft JE, Veld JV, Arnold D. et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) guideline—update 2020. Endoscopy 2020; 52 (05) 389-407
    Article in Thieme ConnectPubMedGoogle Scholar
  • 58 Imbulgoda A, MacLean A, Heine J, Drolet S, Vickers MM. Colonic perforation with intraluminal stents and bevacizumab in advanced colorectal cancer: retrospective case series and literature review. Can J Surg 2015; 58 (03) 167-171
    CrossrefPubMedGoogle Scholar
  • 59 Thaler K, Baig MK, Berho M. et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003; 46 (03) 385-388
    CrossrefPubMedGoogle Scholar
  • 60 Paúl L, Pinto I, Gómez H, Fernández-Lobato R, Moyano E. Metallic stents in the treatment of benign diseases of the colon: preliminary experience in 10 cases. Radiology 2002; 223 (03) 715-722
    CrossrefPubMedGoogle Scholar
  • 61 Rieder F, Zimmermann EM, Remzi FH, Sandborn WJ. Crohn's disease complicated by strictures: a systematic review. Gut 2013; 62 (07) 1072-1084
    CrossrefPubMedGoogle Scholar
  • 62 Morar PS, Faiz O, Warusavitarne J. et al; Crohn's Stricture Study (CroSS) Group. Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures. Aliment Pharmacol Ther 2015; 42 (10) 1137-1148
    CrossrefPubMedGoogle Scholar
  • 63 Lian L, Stocchi L, Remzi FH, Shen B. Comparison of endoscopic dilation vs surgery for anastomotic stricture in patients with Crohn's disease following ileocolonic resection. Clin Gastroenterol Hepatol 2017; 15 (08) 1226-1231
    CrossrefPubMedGoogle Scholar