Diagnostic and Management Approach of Intestinal
Obstruction
Danny A. Portes , M.D.Department of Medicine
Veterans Memorial Medical Center
GENERAL OBJECTIVE :
To discuss a case of Adenocarcinoma of the colon presenting as intestinal obstruction
SPECIFIC OBJECTIVES :
1. To discuss diagnostic approach on intestinal obstruction.
2. To present differential diagnoses on intestinal obstruction.
3. To discuss the management approach of intestinal obstruction.
General data
• 82 y/o , male • Married , RPV • Roman Catholic• Pangasinan• Admitted for the 1st time on May 23,
2005
Chief Complaint
Abdominal Pain
History of Present Illness
1 MONTH PTA abdominal pain consultation done
1 WEEK PTA still with abdominal pain(+) vomiting(+) loss of appetite(+) weight lossno consultation normedication taken
1 DAY PTA persistence of above s/sxconsultation donemedication: Cotrimoxazole 800mg/tab Ranitidine 150 mg/tab tid Hyoscine N Butyl Bromidetransferred to our institution
ADMISSION
Past Medical History (+) Hypertension x 20 years - on
Amlodipine 5mg/tab, OD Hemorrhoidectomy - 1969
Personal / Social History 47 pack year smoker – stopped in 1969 alcoholic beverage drinker – stopped in
1969
Family History Hypertension – paternal side
Review of Systems
(+) generalized body weakness (-) fever(-) cough, hemoptysis, DOB(-) chest pain, orthopnea, PND(-) palpitations, dyspnea(-) dysuria, frequency, urgency(-) bleeding episode(-) polyuria, polydipsia, polyphagia
Physical Examination Conscious , coherent , not in distress BP: 130/70 CR: 72bpm RR: 20 T:37 pale palpebral conjunctivae, anicteric
sclerae,no nasoaural discharge, moist lips and buccal mucosa
supple, no CLAD, no neck vein engorgement
SCE, no lagging, nor retractions, resonant, no adventitious sounds
Adynamic precordium, PMI at 5th ICS, LMCL NRRR, (-) murmur
• Flat, (-)scars, normoactive bowel sounds, (-) bruit, soft, tympanitic, with slight tenderness at the epigastric and hypogastric area on deep palpation, (-) hepatosplenomegaly, (-) palpable mass, (-) rebound tenderness
• Abdominal circumference= 34 inches
Genitalia: no lesions no scrotal enlargement
Extremities: grossly normal, full and equal pulses, no edema, no cyanosis
Skin: dry skin, poor skin turgor, no active dermatoses, no jaundice
DRE: no skin tags, no lesions, no fissures, good sphincteric tone, full rectal vault, (+) brownish hard stool on examining finger
Salient Features 82yo, male abdominal pain vomiting anorexia weight loss pallor slight tenderness on deep palpation at
epigastric area and hypogastrium
Admitting Impression
T/C BPUD, Anemia 2° Hypertension, Stage 2, controlled
Differential Diagnosis
Biliary tract disease Chronic diverticulitis Colonic CA
Biliary Tract Disease
nausea, vomiting and epigastric or RUQ abdominal pain that is steady or colicky
post-prandial fullness, flatulence and fatty food intolerance jaundice
Complete Blood Count
5-23 5-28 5-30 6-15 7-7
Hgb 81 116 148 115 112
Hct 27 37 46 37 36
WBC 4.2 15.7 8.4
seg .78 .96 .85 .78
lymp .22 .04 .15 .22
retic 16
platelet 264
protime 264
Pro act 120
control 12.9
MCV 66
MCH 20
MCHC 30
Blood Chemistries 5-23 5-25 5-28 6-1 7-10
BUN 5.2 3.2
Crea 82 73
Na 141 145 137
Cl 100 101 100
K 4.2 3.4 3.9
FBS 6.0
BUA 151
HDL 1.0
LDL 3.9
Mg
Ca 2.0
Phos
sgot 38
sgpt 20
TC 5.1
TG 0.5
amylse 51
glob 26 25
alb 28 15 27
TP 54
5-26 6-15 7-15
color yellow D. yellow yellow
transprency sl turbid sl turbid clear
sp gravity 1.010 1.015 1.015
pH 7.0 6.5 7.5
albumin neg neg neg
sugar neg neg neg
RBC 0-1 0-1 2-4
PUS 0-3 0-4 2-3
bacteria few mod
epith cells few occ
CEA: 6-241.18ng/ml ( 2.10-6.20)
12-L ECG Results:5-23-05
- 1st degree AV block
- CRBBB
6-5-05
- CRBBB
Radiographic Report
5-24 5-25 5-26 5-27
Gen adynamic ileus, OA thoraco lumbarspine
Gen ileus, partial int obstruction not ruled out, OA, TLS
Gen ileus, partial int obstruction not ruled out, OA TLS
Finding consistent with partial intestinal obstruction, OA, TLS
Chest ( A-P)
5-27-05
- No significant cardiopulmonary problems
findings except for atheromatous aorta, OA, thoracis spine
Lumbo-sacral - spurs on the bodies of the lumbar spine with intact disc space consistent with degenerative changes, lumbar instability
Ultrasound Report Abdominal Aorta:
5-23-05- no sonographic evidence of
abdominal aortic aneurysm HBT, LGBPS, AA:
5-24-05- normal liver, biliary tree, spleen- consider cholecystitis- non visualized pancreas and AA - minimal ascites noted
HBT, LGBPS, PAN:
6-17-05
- diffuse parenchymal liver disease
- dilated intrahepatic duct- sonographically normal gall bladder- non visualized pancreas- negative para-aortic node
enlargement- incident note of ascites and right basal pleural effusion
Whole Abdomen CT Scan
5-27-05
- Generalized ileus. Possibility of chronic partial intestinal
obstruction likewise considered.- dilated gall bladder- OA changes of lumbar spine
Histopathological Diagnosis
Adenocarcinoma, low grade (Moderately Differentiated), 5x4 cm extending to the muscular and subserosal layerASTLER COLLER STAGING, STAGE B2T3MOMx, AJCC
Remarks: all (0/8) lymph node and lines of resection are NEGATIVE for malignant cells.
Course in the ward
Admission
Venoclysis done • diet : low salt , low cholesterol Dx : CBC – anemia
12 L ECG – complete RBBB, 1st degree AV block
Tx : Famotidine 20 mg IV q 8°Metoclopramide 10 mg IV prnAlMgOH 45 cc prnAmlodipine 5 mg/tabISDN prnPRBC 2 “u” requested
1st hospital day Vital signs were normal • Occasional epigastric pain radiating to the
hypogastric area • 2 episodes of vomiting • IMPRESSION: T/C Cholecystitis
Dx: Ultrasound unremarkable Tx/Plan: Gastro service
Surgery service
2nd hospital day Still with crampy abdominal pain, vomiting• Normal vital signs, abdominal girth= 36 inches• IMPRESSION: T/C Acute Intestinal Obstruction
Dx: Flat Plate of abdomen
- Generalized adynamic ileus Serum amylase normalSerum electrolytes - normalUTZ of LGBPS normal
Tx: NPO NGT insertedBlood transfusion 1 unit PRBC
3rd hospital day Still with the same complaints • Normal vital signs, abdominal girth = 36
inches
Repeat flat plate done – Generalized ileus – Intestinal obstruction not ruled out
GI service - continue decompression and start Empiric antibiotic therapy • Cefuroxime 750 mg IV q8°• Metronidazole 500 mg IV q8°
Surgery service Non surgical abdomen and concurred
with the plan Suggestions :
Endoscopy serum TPAG determination liquid diet if tolerated
4th hospital day Still with crampy abdominal pain (+) nausea (-) vomiting Stable vital signs AC = 36 inches
Repeat flat plate – Partial Intestinal obstruction– Post BT H & H
Continue empiric antibiotic treatment and decompression
BT of 2nd unit of PRBC referred back to Gastro service
5th hospital day Still with abdominal pain localized in left
hypogastrium (+) vomiting (-) fever– Increasing abdominal girth (37 inches)– Tenderness on deep palpation
CT scan of abdomen – Generalized ileus – Consider Chronic partial intestinal
obstruction– Dilated gallbladder– Osteoarthritic changes of lumbar spine
6th hospital day Transfer of
service– Surgery
“E” lap done – Left
hemicolectomy with Devine’s colostomy and biopsy done
Intraoperative findings • 5 x 4 cms firm ,
constricting mass at the splenic flexure , markedly dilated bowels from LOT to mid transverse colon
• With serosal tears at
80 cm and 110 cm from LOT
Histopathologic report • Adenocarcinoma , low grade
( Moderately Differentiated ) extending to the muscular and subserosal layer
• ASTLER COLLER STAGING , STAGE B2 T3N0Mx , AJCC
• All (0/8)LN and lines of resection are NEGATIVE of malignant cells
Course in the ward:
• He stayed at surgery service for two weeks. Antimicrobial coverage, hydration and nutritional build-up were provided.
Course in the ward:
• He was subsequently transferred to ONCOLOGY service.
• On his 39th hospital day, he was discharged clinically improved and stable.
DISCUSSION
By location – small bowel (proximal/distal) - large bowel
By mechanism – mechanical or non-mechanical ( adynamic, paralytic ileus, pseudo-obstruction)
By pathophysiology – simple, closed loop, strangulated
Intestinal Obstruction
Colonic Obstruction
Neoplasm (60%)
Volvulus (20%)
Diverticular stricture (10%) Others (10%)
Volvulus 20-50% of all intestinal obstruction abnormal twisting of a segment of
bowel on itself along its longitudinal axis
closed loop obstruction is often produced
sigmoid and cecum are the most frequent sites
transverse colon, splenic flexure
colicky abdominal pain, obstipation and abdominal distention
“ bent-inner tube” ( sigmoid volvulus) or omega loop sign
“ kidney-bean shaped” ( cecum) these “classical” radiographic findings
are seen in 40%-60% of cases operative distortion/colonoscopic
distortion
Diverticulitis
diverticula are small mucosal pockets in the wall of the colon
obstruction of the neck of the diverticulum may result in the distention secondary to mucus secretion and overgrowth of normal colonic bacteria ultimately leading to perforation.
pain maybe intermittent or constant frequently associated with a change in
bowel habits hematochezia is rare anorexia, nausea and vomiting may
occur recurrent attacks can result in the
formation of scar tissue, leading to narrowing and obstruction of the colonic lumen.
Management ofIntestinal Obstruction
Evaluations
History and Physical Examination Laboratory Examinations Chest/Abdominal Radiographs
- flat, upright and decubitus Contrast studies (single, double) Endoscopy
Computed Tomography MRI CT colonoscopy/
Virtual colonography
Colonoscopy
Indications for colonoscopy: evaluation of potentially significant
barium enema evaluation of lower GI bleed IBD therapeutic indications surveilance studies
removal of colon polyp work up of iron deficiency anemia discretionary follow-up of colonic lesions
of unknown significance diagnosis and localization of lower GI
bleed prior to possible electrocauterization or surgery
“These indications are not all-inclusive and are subject to physician discretion in individual cases”.
Contraindications: toxic, fulminant colitis perforation of abdominal viscus severe coagulopathy acute diverticulitis acute or recent MI patient refusal
American College of Physician
“ Although colonoscopy maybe useful in patients with partial colonic obstruction, it has little role in the initial evaluation of patients suspected of having complete obstruction. The insufflation of air or CO2 through endoscope may exacerbate colonic distention and precipitate perforation”
Sleisenger and Fordtran’s 7TH Edition 2002
Contrast Studies
Perform if the diagnosis of large bowel obstruction is suspected but not proven
If differentiation b/w obstipation and obstruction is required
If localization is required for surgical intervention
Contrast Studies
The reflux of barium above an obstructing colon may promote the development of complete obstruction
The use of water soluble contrast media obviates the risk of barium impaction at the site of obstruction and barium peritonitis in the case of unrecognized perforation.
Sleisenger & Fordtrans 7th Edition
Barium should be used cautiously or not at all because it may inspissate at the site of stricture and exacerbate the blockage
Cameron’s Current Surgical Therapy
7th Edition
“ CT scan has an overall sensitivity of 98 % and specificity of 87 % in detecting colon cancer “
Robinson P , Brunett H , Nicholson DA
Clinical Radiology Dec 2003
“ Overall sensitivity was 71.7% on plain film And 83.0% on CT.
Efficacy of abdominal plain film and CT in bowel obstruction
Nippon Igaku Hoshesen Gakkai Zasshi, Mar 2002Dept of Radiology, St Martin University
“ CT had high sensitivity (93%), specificity (99%) and accuracy (94%) in diagnosing
the presence of obstruction. The comparable
sensitivity, specificity and accuracy were, respectively, (83%), (98%), (84%) for US and (77%), (70%) and (80%) for plain radiography. The level of obstruction was correctly predicted in 93% on CT, 70% on US and 60% on plain films.
“Comparative evaluation of plain films, ultrasound and CTin the diagnosis of Intestinal obstruction”.
Suri, Gupta, Sudhakar, Venkataramu, Sood, WigDept of Radiodiagnosis, Post Grad Inst of Medical Education
And Research, Chandigarh, India ( 2001)
“ CT scan as a routine preoperative diagnostic exam could cause MISDIAGNOSIS due to the following :
Inadequate bowel preparation Flat lesions > 10 mm - misinterpreted
as feces Small polyps “
Barton JB , Langdale et alAm J of Surgey May 2004
“ MRI is superior to CT in staging Cancer and in differentiating between scarring tissue and recurrence “
“ It’s 91 % sensitive and 100 % specific ““ It has 100% positive predictive value
and 89% negative predictive value with an accuracy of 95 % “
Hock D. , Cancer Journal May 2003
“ MRI is superior in sensitivity , specificity and accuracy to CT scan in determining extent of tumor “
Pema PJ , Bennett WF Journal of Computer assisted Tomography March-April 2004
Treatment and Outcome
Resuscitation and Initial management
- restoration of intravascular volume- correction of electrolyte abnormalities- nasogastric decompression
Subsequent therapeutic decision depend primarily on the presence of complete or partial obstruction or evidenced of strangulation
Patients with partially obstructing benign or malignant strictures w/o evidenced of peritonitis may undergo semi-elective resection.
Complete colonic obstruction necessitates emergency operative decompression.
Self-expanding metallic endoprostheses or endoluminal colonic wall stents.
The goals of operative management in complete colonic obstruction are three-fold :(a) to quickly decompress the obstructed colon(b) to definitely treat the obstructing lesion(c) to re-established the intestinal continuity
“The competency of ileocecal valve is of great importance to the pathophysiology of colonic obstruction.
The necessity for emergency operation is dictated by the presence of complete colonic obstruction and not by the measurement of cecal diameter”.
Sleisenger & Fordtran’s GI and Liver Disease
7th Edition
“Operating in an urgent or emergent fashion is associated with high operative mortality/morbidity”. A thorough knowledge of the cause of colonic obstruction is important for optimal patient’s outcome”.
Cameron’s Current Surgical Therapy 7TH Edition
Current Concepts in Diagnoses and Management of Intestinal Obstruction
Virtual colonography/CT colonoscopy
•
Current concepts
“ CT colonography /Virtual colonoscopy promises to become a 1° screening method for colorectal Cancer “
“ New rapidly developing non invasive CT technique to detect polyps and cancers >/=10 mm in size “
Gluecher TM , Fletcher JG . Europe J Cancer Nov. 2003
“ CT colonography is 98 % sensitive and 96 % specificity in detecting Colorectal Cancer “
Neri E., Giusti P., Battolla L
Diagnostics and Interventional Radiology , Univ. Pisa , Rome June 2004
Angiography for diagnosis and treatment of colorectal
cancer Preoperative selective arterial
angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time arterial chemotherapy can be an important form of preoperative therapy.
Jin Gu, Ming Li, Guang Xu, Dept of Sx, Oncology School of Peking University, Beijing, Beijing China.
Zhai-Li Dept of Surgery, Beijing Chaoyang Hospital
Carcinoma of the Colon
•
Colonic Cancer• 5-year survival is 90%
when colorectal Ca is diagnosed at an early stage, less than 40% of cases are diagnosed when the cancer is still localized.
• 3rd most common Ca in men and women.
• about 60% present with obstructive symptoms
How is colon cancer diagnosed?
RISK FACTORS
• > 40 y/o• High fat and low
fiber diet• Sedentary lifestyle• Smoking • Alcohol use • Family history• IBD
SIGNS/SYMPTOMS • No obvious signs but
could include – Change in bowel
frequency– Change in consistency– Rectal bleeding/
bloody stool– Unexplained weight
loss– Fatigue– Persistent abdominal
discomfort – Unexplained anemia
Environmental Factors Potentially Influencing
Carcinogenesis in the Colon and Rectum
Probably Related- high fat and low fiber consumption
Possibly Related- beer and ale consumption (esp Rectal Ca)- environmental carcinogen and mutagens
Fecapentaenes ( from colonic bacteria )
Heterocyclic amines ( from charbroiled and fried meat and fish )
Probably Protective- high fiber consumption- physical activity and low body mass- Aspirin and NSAIDs- Calcium
Possibly Protective- yellow green cruciferous vegetable- Vitamin A, C, E- HRT ( estrogen )
Average-Risk Sreening Guidelines
FOBT Flexible sigmoidoscopy Colonoscopy Double-contrast enema CEA and Serologic Tumor Markers Genetic Testing
High-Risk Groups
IBD Previous colorectal cancer Previous adenomas Female genital cancer Familial polyposis HNPCC Familial colon cancer
Treatment
Surgery Chemotherapy Immunotargeted therapy and
Immunotherapy Radiation therapy
Summary
History & Physical Examination Symptomatology Diagnostics Management and Intervention Prognosis
Conclusion
“Prompt investigation of the cause of abdominal pain, watchful monitoring of the patient’s clinical status with adequate history and physical examination as well as collaboration with different specialties are of prime importance to the diagnosis and appropriate management of our patient”.
THANK YOU! &
GOOD MORNING
THANK YOU
Small Intestinal Disease
Periumbilical region crampy and maybe associated
with vomiting and changes in bowel movement
constipation and inability to pass flatus
high –pitched or musical bowel sounds
What is the most likely etiology of
his abdominal pain?
ABDOMINAL PAIN
A. PARIETAL
B. VISCERAL
A. ACUTE
B. CHRONIC
What happens after treatment ?Follow up care
Follow up care 1st year after treatment
2nd-3rd year after treatment
4th – 5th year
after treatment
Doctor’s visit Every 3- 6 mos
Every 3-6 mos
Every 6 mos
Tumor markers
Every 3 mos Every 3 mos determined by doctor
CT colonography
Yearly Yearly determined by doctor
Proctosigmoi-doscopy
Yearly yearly determined by doctor
What could have caused the misdiagnosis preoperatively ?
Differential Diagnosis of Colonic Obstruction
Acute Obstruction
- cecal volvulus- sigmoid volvulus- transverse volvulus
Subacute/Chronic onset- colon ca
- Rectal ca- Metastatic or extracolonic malignancy- IBD- Diverticulitis- Ischemic bowel
Others- colonic pseudo-obstruction- Imperforate anus