Large-Bowel Obstruction

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Large-bowel obstruction (LBO) is an emergency condition that requires early identification and intervention. It is important to distinguish colonic obstruction from ileus, as well as to distinguish true mechanical obstruction from pseudo-obstruction; treatment differs. See the image below. 

See Can’t-Miss Gastrointestinal Diagnoses, a Critical Images slideshow, to help diagnose the potentially life-threatening conditions that present with gastrointestinal symptoms.

A history of bowel movements, flatus, obstipation, and associated symptoms should be obtained. Complaints in patients with LBO may include the following:

Other symptoms that may be diagnostically significant include the following:

Assessment of symptoms should attempt to distinguish the following:

Although a complete physical examination is necessary, the examination should place special emphasis on the following key areas:

See Presentation for more detail.

The following laboratory studies may be helpful:

Imaging modalities that may be considered are as follows:

See Workup for more detail.

Initial therapy in patients with suspected LBO includes the following:

The following are emergencies that call for surgical intervention:

Ileus is treated as follows:

Acute colonic pseudo-obstruction is treated as follows:

Volvulus is treated as follows:

Intussusception is treated as follows:

Colonic masses and strictures are treated as follows:

Diverticular disease is treated as follows:

See Treatment and Medication for more detail.

Large-bowel obstruction (LBO) is an emergency condition that requires early identification and intervention. The etiology of this condition is age-dependent, and it can result either from mechanical interruption of the flow of intestinal contents (see the following image) or from dilation of the colon in the absence of an anatomic lesion (pseudo-obstruction). Causes include neoplasms, inflammatory processes (diverticulitis), strictures, fecal impaction or volvulus.

It is important to distinguish colonic obstruction from ileus and to differentiate between true mechanical obstruction and pseudo-obstruction. Treatment differs. ^[1]

Colonic obstruction is more common in elderly individuals as a consequence of the higher incidence of neoplasms and other causative diseases in this population. ^[2] In neonates, colonic obstruction may be caused by an imperforate anus or other anatomic abnormalities. Obstruction may also be secondary to meconium ileus. In the pediatric population, Hirschsprung disease can resemble colonic obstruction.

For patient education information, see Digestive Disorders Center as well as Constipation in Adults and Abdominal Pain in Adults.

See also Ogilvie Syndrome, Ileus, Constipation, Small Bowel Obstruction, and Intussusception.

The prevalence of mechanical large-bowel obstruction (LBO) increases with age, as does that of its main causes, colon cancer and diverticulitis. Sigmoid volvulus and cecal volvulus are also potential causes of this disorder. ^[3]

Mechanical LBO causes bowel dilatation above the obstruction, which in turn, causes mucosal edema and impaired venous and arterial blood flow to the bowel. Bowel edema and ischemia increase the mucosal permeability of the bowel, which can lead to bacterial translocation, systemic toxicity, dehydration, and electrolyte abnormalities. Bowel ischemia can lead to perforation, fecal soilage of the peritoneal cavity, and dead bowel.

In cases of closed loop obstructions, such as colonic obstruction in the presence of a closed ileocecal valve or incarcerated hernia, this process may be accelerated.

The pathophysiology of acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, is not clear, but it is thought to result from an autonomic imbalance, which results from decreased parasympathetic tone or excessive sympathetic output. ^{[1, 4]} This condition usually occurs in the setting of a wide range of medical or surgical illnesses. If it goes untreated, colonic ischemia or perforation can occur. ACPO is characterized by a loss of peristalsis and results in the accumulation of gas and fluid in the colon. The right colon and cecum are most commonly involved. The risk of perforation for ACPO ranges from 3% to 15%. ^[5]

The most common causes of  large-bowel obstructions (LBO) are colon carcinoma and volvulus. ^[6] Approximately 60% of mechanical LBOs are caused by malignancies, 20% are caused by diverticular disease, and 5% are the result of colonic volvulus. ^{[1, 7, 8]} The most common causes of adult large-bowel obstruction are as follows:

Obstructions caused by tumors tend to have a gradual onset and result from tumor growth narrowing the colonic lumen.

Diverticulitis is associated with muscular hypertrophy of the colonic wall. Repetitive episodes of inflammation cause the colonic wall to become fibrotic and thickened, leading to luminal narrowing.

A colonic volvulus results when the colon twists on its mesentery, which impairs the venous drainage and arterial inflow. Symptoms of this condition are usually abrupt. The cecum and sigmoid colon are most commonly affected.

Volvulus typically occurs in elderly, debilitated individuals; patients living in an institutionalized setting; or patients with a history of chronic constipation.Volvulus may also be seen during pregnancy, most commonly occurring in the third trimester when the gravid uterus displaces the colon. ^[9]

Intussusception is primarily a pediatric disease; however, it is estimated that 5-16% of all intussusceptions in the Western world occur in adults. Two thirds of adult intussusception cases are caused by tumors. Two main types of intussusception affect the large bowel: enterocolic and colocolic.

Enterocolic intussusceptions involve both the small bowel and the large bowel. These are composed of either ileocolic intussusceptions or ileocecal intussusceptions, depending on where the lead point is located.

Colocolic intussusceptions involve only the colon. They are classified as either colocolic or sigmoidorectal intussusceptions.

ACPO (Ogilvie syndrome) has many etiologies. ACPO is a functional obstruction; it is typically seen in elderly or debilitated patients who are hospitalized with severe medical or traumatic illnesses. Medications that decrease intestinal motility are also associated with this disorder. In a retrospective review of more than 1400 cases of ACPO, the most common predisposing conditions were operative and nonoperative trauma (11%), infections (10%), and cardiac disease (10-18%). ^{[10, 11]}

Mortality is determined by the patient’s overall medical condition and the presence of any comorbidities that may influence the patient’s surgical risk. If large bowel obstruction is treated early, the outcome is generally good. Mortality is higher in patients who have developed bowel ischemia or perforation. After surgical decompression, the prognosis is determined by the underlying disease. In general, overall mortality for large-bowel obstruction ( is 20%, which increases to 40% if there is colonic perforation.

Mortality for acute colonic pseudo-obstruction (ACPO; Ogilvie syndrome) is 15% with early care; it increases to 36% if colonic ischemia or perforation develops. ^[5]

In a retrospective study, long-term outcomes of self-expandable metallic stenting for malignant colorectal obstruction in 42 elderly patients were excellent (97.6%), with shorter stents yielding longer event-free survival. ^[12]

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Atukorale YN, Church JL, Hoggan BL, Lambert RS, Gurgacz SL, Goodall S, et al. Self-Expanding Metallic Stents for the Management of Emergency Malignant Large Bowel Obstruction: a Systematic Review. J Gastrointest Surg. 2016 Feb. 20 (2):455-62. [Medline].

Geraghty J, Sarkar S, Cox T, et al. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis. 2014 Jun. 16 (6):476-83. [Medline].

Kobborg M, Broholm M, Frostberg E, Jeppesen M, Gogenür I. Short-term results of self-expanding metal stents for acute malignant large bowel obstruction. Colorectal Dis. 2017 Oct. 19 (10):O365-71. [Medline].

Matsuda A, Miyashita M, Matsumoto S, et al. Comparison of long-term outcomes of colonic stent as “bridge to surgery” and emergency surgery for malignant large-bowel obstruction: a meta-analysis. Ann Surg Oncol. 2015 Feb. 22 (2):497-504. [Medline].

Xu YS, Song T, Guo YT, et al. Placement of the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. J Gastrointest Surg. 2015 Dec. 19 (12):2243-8. [Medline].

Trompetas V. Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl. 2008 Apr. 90(3):181-6. [Medline]. [Full Text].

Deen KI, Madoff RD, Goldberg SM, Rothenberger DA. Surgical management of left colon obstruction: the University of Minnesota experience. J Am Coll Surg. 1998 Dec. 187(6):573-6. [Medline].

Fan YB, Cheng YS, Chen NW, et al. Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction. World J Gastroenterol. 2006 Feb 7. 12(5):755-9. [Medline].

Young CJ, De-Loyde KJ, Young JM, et al. Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion. Dis Colon Rectum. 2015 Sep. 58 (9):838-49. [Medline].

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Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML. Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review. JAMA Surg. 2014 Apr. 149(4):383-92. [Medline].

Frago R, Ramirez E, Millan M, Kreisler E, del Valle E, Biondo S. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg. 2014 Jan. 207 (1):127-38. [Medline].

Boyle DJ, Thorn C, Saini A, et al. Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis. Dis Colon Rectum. 2015 Mar. 58 (3):358-62. [Medline].

Takeyama H, Kitani K, Wakasa T, Tsujie M, Fujiwara Y, Mizuno S, et al. Self-expanding metallic stent improves histopathologic edema compared with transanal drainage tube for malignant colorectal obstruction. Dig Endosc. 2015 Dec 3. [Medline].

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Young CJ, Zahid A. Randomised controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post-hoc cost analysis. Colorectal Dis. 2017 Nov 1. [Medline].

Christy Hopkins, MD, MPH Associate Professor, Department of Surgery, University of Utah School of Medicine; Medical Director, Division of Emergency Medicine, University Health Care

Christy Hopkins, MD, MPH is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Joseph J Sachter, MD, FACEP Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center

Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Large-Bowel Obstruction

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