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Small-bowel obstruction
Imminence of risk dictates treatment
BY George Miller, MD and Philip H.
Gordon, MD
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Jane A., 57 years old and previously
healthy, presents in the office because she developed progressive
crampy abdominal pain the previous evening, accompanied by nausea
and two episodes of bilious emesis. Her symptoms began 4 days prior
to presentation with mild bloating and severe constipation. She hasn't
passed flatus or had a bowel movement since yesterday afternoon. On
examination, she's afebrile and her heart rate is 90 beats per minute.
The treating physician sends her to the emergency room for further
testing.
Presentation
History and physical examination
- appendectomy as a child
- transabdominal hysterectomy for fibroids
11 years ago
- chest clear
- abdomen distended
- high-pitched bowel sounds
- mild tenderness on palpation in the
periumbilical region
- no palpable hernias
- rectal exam is unremarkable
Investigations
- lab results
- white blood cell count (WBC)
9 x 109/L, 82% neutrophils
- liver function tests, amylase
and lipase are normal
- abdominal x-ray: multiple dilated
loops of small bowel with air-fluid levels and no gas in
the colon
Diagnosis
and treatment
Jane is admitted to the surgical service with the diagnosis
of small-bowel obstruction (SBO). She is taken off food and
drink (NPO), placed on intravenous fluids, and a nasogastric
tube is inserted, which immediately returns 800 mL of bilious
fluid. Serial abdominal exams are performed every few hours.
On rounds the next morning, the
patient still hasn't passed flatus. She now has a temperature
of 38.6°C and is tachycardic (heart rate of 110). The pain
is worse in her abdomen, which is also more distended and
exquisitely tender. Morning lab tests reveal worsening leukocytosis
(WBC 13 x 109/L,
91% neutrophils). Jane is taken urgently to the operating
room, where she's found to have a very dilated proximal small
bowel, with an abrupt transition to collapsed bowel at the
point of an adhesive band deep in the pelvis. The proximal
bowel is congested but still appears viable. Upon lysis of
the adhesive band, air and effluent are seen passing into
the distal small bowel. Jane has an unremarkable recovery
from surgery. She passes flatus on day 7 after the surgery,
at which time she's started on a clear liquid diet and quickly
advanced to regular food.
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Making the case
About 75% of SBOs are the result of adhesions that form after abdominal
surgery. Most commonly, adhesive obstructions follow gynecologic
or colorectal operations. The timing of an obstructive episode can
vary widely from the immediate post-operative period to decades
after the index operation. Other less common causes of bowel obstruction
include Crohn's disease, incarcerated hernias, primary or metastatic
neoplasms to the small bowel, and radiation enteritis.
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