Malignant Large Bowel Obstruction

Abstract

Large bowel obstruction is a serious and potentially life-threatening surgical emergency which is associated with high morbidity and mortality rate. The most common etiology is colorectal cancer which accounts for over 60% of all large bowel obstructions. Proper assessment, thoughtful decision-making and prompt treatment is necessary to decrease the high morbidity and mortality which is associated with this entity. Knowledge of the key elements regarding the presentation of a patient with a large bowel obstruction will help the surgeon in formulating an appropriate treatment plan for the patient. Comprehensive knowledge and understanding of the various treatment options available is necessary when caring for these patients. This chapter will review the presentation of patients with malignant large bowel obstruction, discuss the various diagnostic modalities available, as well as discuss treatment options and the various clinical scenarios in which they are most appropriately utilized.

Large Bowel Obstruction: Etiologies, Diagnosis, and Management

“…[34][35][36] Of note, in the cases in which only proximal diversion is used, if the ileocecal valve is competent, a loop ileostomy will not relieve the obstruction and a loop colostomy or end colostomy with mucus fistula should be used instead. 10 If resection of the obstructing segment of the colon is pursued, the decision to perform primary anastomosis or to divert proximally should be carefully considered. 8,25,37 The decision to perform an anastomosis depends on the location of the obstruction, preoperative steroids or immunosuppression, the patient's nutrition and hemodynamic status, and the presence of perforation or fecal contamination.…”

“…For patients with rectal cancer, proximal diversion for low cancers should be considered so that neoadjuvant therapy may be completed prior to definitive resection. 10,50,51 Patients with obstructing cancers have worse long-term outcomes (16 vs. 37% for 5-year survival), although this appears to be related to age and stage, rather than obstruction or emergency surgery in itself. [52][53][54][55] For elderly patients and those who have poor functional status preoperatively and/or have evidence of metastatic or peritoneal disease, goals of care discussions and consultation with palliative care services should be considered, as palliative surgery is associated with high rates of complications, readmission, and re-obstruction and limited life expectancy.…”

“…Prior episodes of left lower quadrant pain may indicate diverticular disease, while constitutional symptoms such as fatigue and weight loss may indicate malignancy. 10…”

“…34 35 36 Of note, in the cases in which only proximal diversion is used, if the ileocecal valve is competent, a loop ileostomy will not relieve the obstruction and a loop colostomy or end colostomy with mucus fistula should be used instead. 10…”

“…Prior episodes of left lower quadrant pain may indicate diverticular disease, while constitutional symptoms such as fatigue and weight loss may indicate malignancy. 10 Digital rectal examination can help identify distal masses or fecal impaction. In addition, physical examination…”