Intestinal Obstruction and Pseudo‐obstruction

Abstract

Identifying the etiology of abdominal pain, nausea, and vomiting often remains a challenge for clinicians. A laundry list of etiologies exists for these symptoms including acute gastroenteritis, peptic ulcer disease, metabolic etiologies, medication effects, gastroparesis, mechanical obstruction, and pseudo -obstruction. This review focuses on the diagnosis and management of intestinal mechanical obstruction, intestinal pseudoobstruction, and differentiating the two. Early identifi cation of complete mechanical obstruction and/or the presence of intestinal ischemia or peritonitis is paramount, as these patients benefi t from early surgical intervention. Most patients with partial bowel obstruction may be managed medically. Clinical recognition of intestinal pseudo -obstruction avoids unnecessary surgery and directs treatment towards symptomatic management. The role of newer imaging techniques, CT and MR radiography and other, newer diagnostic techniques in intestinal pseudo -obstruction is also reviewed. mechanical obstruction is partial (incomplete). Acute intestinal mechanical obstruction may be subdivided into three broad categories with the obstruction the result of: (i) abnormalities of the bowel wall; (ii) extrinsic compression; or (iii) intraluminal process. Abnormalities of the bowel wall include infl ammatory or fi brotic strictures as in Crohn disease. The most common extrinsic etiology remains fi brous adhesions. Hernias would also fall in this category. Intraluminal causes of bowel obstruction include ingested foreign bodies, gall stones, parasites, and tumors. Adhesions, the most common cause of bowel obstruction, occur commonly following abdominal surgery. Adhesions develop in up to 93% of individuals with prior intra -abdominal surgery versus a prevalence of only 10% in patients without prior abdominal surgery [1] . Acute intestinal mechanical obstruction must further be subdivided into simple obstruction, without vascular compromise, versus obstruction complicated by vascular comprise and/or peritonitis, the latter requiring urgent surgical intervention.The medical management of complete bowel obstruction remains relatively straight forward with management responsibilities most often falling to the surgeon. 290 CaseA 65 -year -old, long -time smoker presents to the Emergency Department with a 2 -day history of worsening abdominal pain, distension, diarrhea, nausea, and vomiting. This is her third visit in the past several months, and she has been hospitalized each time for conservative treatment. She has responded each time to nasogastric suction and intravenous fl uids. CT imaging reveals diffusely dilated loops of small bowel without evidence of a transition point or mass lesion. The dilation is noted to be worse than on previous fi lms. She again responds symptomatically with decompression and bowel rest, but is noted to have a 4.5 kg (10 lb) weight loss since her last admission.