IS Case 391: High grade mechanical large bowel obstruction

David Tuttle, MD


2009 URMC Imaging Sciences
Publication Date: 2010-03-09

History

Patient is a 59-year-old man status post esophago-gastrectomy for adenocarcinoma with Roux-en-Y esophagojejunostomy, now with increased J-tube drainage. Bowel obstruction is suspected.

Findings

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Diagnosis

High grade mechanical large bowel obstruction

Discussion

Large bowel obstruction can be mechanical (due to blockage) or adynamic (absence of intestinal contractility). Obstruction may be intraluminal (fecal impaction, inspissated barium, foreign bodies), intramural (carcinoma, inflammatory conditions, Hirschsprung’s disease, ischemia, radiation, intussusceptions, anastomotic stricture), and extraluminal (adhesions, hernias, tumors in adjacent organs, abscesses, volvulus). Colorectal cancer is the most common cause of large bowel obstruction.

Clinical presentation includes abdominal distention and pain, and failure to pass stool and flatus. Clues to diagnosis are found in the history and physical exam. Plain films may aid in the location of the obstruction and in some situations may be diagnostic of a volvulus. CT is helpful in revealing underlying inflammatory processes such as a diverticular abscess. If a volvulus or distal sigmoid cancer is suspected, a contrast enema may establish the diagnosis. In patients with known malignancy who have symptoms indicative of bowel obstruction, gadolinium-enhanced MR imaging can help distinguish benign from malignant causes of bowel obstruction.

Treatment depends on the cause of obstruction. Metallic stents has been shown to be effective in the treatment of malignant colorectal obstruction before surgery and for palliation.

References

  1. Townsend CM Jr, Beauchamp DR, Evers MB, Mattox KL(Eds.) Sabiston Textbook of Surgery, 18th ed., Elsevier, 2009.
  2. Camúñez F, Echenagusia A, Simó G, Turégano F, Vázquez J, Barreiro-Meiro I. Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology. 2000 Aug;216(2):492-7. PMID: 10924576
  3. Low RN, Chen SC, Barone R. Distinguishing benign from malignant bowel obstruction in patients with malignancy: findings at MR imaging. Radiology. 2003 Jul;228(1):157-65. PMID: 12832579

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