Bowel obstruction vexed medical practitioners as long ago as 350 BC, and it continues to do so today.1 The management of patients with bowel obstruction is challenging because decision-making is complicated in many patient care scenarios. First, the diagnosis of bowel obstruction may be difficult in a patient who recently underwent surgery. That is, does this lack of gastrointestinal function represent an ileus or a true bowel obstruction? Second, the timing of surgical intervention may not be obvious. When is an operation appropriate in a patient who underwent recent surgery? Finally, what is the appropriate operation in patients who have had multiple, chronic intestinal obstructions? All of these scenarios represent high-risk decisions, and thus management of bowel obstruction requires critical analysis and decision-making. The goal of this review is to provide a contemporary summary of the epidemiology, diagnosis, and management of bowel obstruction in a broad context of impaired gastrointestinal function.
Bowel obstruction is defined by the lack of aborad transit of intestinal contents, regardless of etiology. Bowel obstruction may involve only the small intestine (small bowel obstruction), the large intestine (large bowel obstruction), or both via systemic alterations in metabolism, electrolyte balance, or neuroregulatory mechanisms (generalized ileus). Traditionally, the surgeon’s perspective of a bowel obstruction represents a mechanical obstruction that is due to physical stenosis or occlusion of the intestinal lumen. In the broader context, however, ineffective motility, without any physical obstruction, causes a functional obstruction or ileus of the intestine. Furthermore, intestinal obstruction can be classified based on duration of presence (acute vs chronic obstruction), extent (partial vs complete), type of obstruction (simple vs closed-loop), and risk of bowel compromise (incarcerated vs strangulated).
Bowel obstruction continues to be one of the most common intra-abdominal problems faced by general surgeons. In a 2010 global burden of disease study, bowel obstruction and ileus were responsible for 2.1 deaths, 54 years of life lost, and 54 disability-adjusted life-years per 100,000 population, respectively, second only to peptic ulcer disease for all abdominal conditions for each of these parameters.2 Independent of the underlying etiology, bowel obstruction remains a major cause of morbidity and mortality. Early recognition and aggressive treatment are crucial in preventing irreversible ischemia and transmural necrosis, thereby decreasing mortality and long-term morbidity. Despite multiple recent advances in diagnostic imaging and marked advances in our treatment armamentarium, intestinal obstruction will remain a significant surgical problem given the lack of treatment options to manage adhesions, hernias, and malignancies.
Mechanical Bowel Obstruction
Mechanical bowel obstruction is defined as a physical narrowing or occlusion of the intestinal lumen. This blockage may be intrinsic or extrinsic to the wall of the intestine or secondary to luminal obstruction arising from intraluminal contents (eg, an intraluminal gallstone or other foreign body) (Table 38-1). Partial obstruction implies that the intestinal lumen is narrowed, and some ...