Intestinal Obstruction

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Questions Received:

  1. My brother's operation for colon cancer a month ago was a success. However he then developed a blockage in his small intestines. They are now thinking of doing a second operation. How successful is this, does it pose great danger to the patient to have another operation so soon, and is it not dangerous to operate on the small intestines?

  2. What is the pathophysiology of small bowel obstruction?

  3. I have a daughter that is 11 years old that has just been released from the hospital for the eighth time. She has had several surgeries. It all started in 1996 when she was suspected to have a Appendicitis. They performed an Appendectomy, her Appendix was fine, but she continued to be ill. After three weeks in the hospital she started having Sydenham’s Chorea seizures. At that time the doctors realized that she had Rheumatic Fever. She could not walk for a while and spent 8 mths in a wheelchair because her Aortic and Mitral valves were damaged and weak. Now she is having several problems with intestinal obstructions. She just had her 3rd intestinal operation on 04/16/99. Will the obstructions caused by adhesions ever end? She has missed so much of her childhood and school being in the hospital. Is there anything that can help stop the adhesions from forming? Will she continue to have surgeries the rest of her life?

  4. My brother was given a barium swallow a month ago. The barium is still stuck in his system. He is obstructed by it and is vomiting everything. The doctor tried all kinds of enemas to get it out with no success. He cannot use laxatives at this point, because my brother underwent surgery just two weeks ago to bypass two small intestine tumors. The surgey was supposed to relieve the vomiting, but we are back to square one, because of the stuck barium, according to the doctor. Any suggestions would be very appreciated. The barium is stuck at the end of the small intestine at the entrance to the colon.

  5. I received an injury to my right side about 2 months ago and have not had a BM (bowel movement) since. I have seen a Dr and he states it is just constipation. Even after a prep for a barium enema I had no BM and the test continued which set up because I could not get rid of it. There is little or no real bowel sounds and I am miserable. I have a history of Crohn's disease and was wondering if a blow to the transverse/ascending area would cause a paralytic ileus?

  6. I am about to under go a resection or a total colectomy. I cannot find any information on the nutritional problems associated with this surgery. Also what are the long term problems associated with these types of surgery? I do not have cancer, it is the result of an adynamic bowel due to an injury sustained. How long before I can return to work and any limitations I may have. I am an RN.

  7. Previously, I've been treated for IBS. Symptoms are pain in lower left abdomen, retention and difficulty in having a BM. I keep an inflamation (mucus and foul odor in stool) and the pain/pressure is relieved once I am able to have a BM. The great news is that I do not have nausea. I had a baruim enema several years ago that revealed IBS/lazy ileus. MD rec'mnds extra fiber and avoid certain foods. In the past year symptoms are worse and quality of life is poor. I sought second opinions from specialists to no avail. The gastrologist I was seeing several months ago ordered colorectal cancer test, stool testings and CT scan. All were ok including the CT scan which was read without dye due to vein blowing at beginning of scan. Again, diet recomended.

Responses:

My brother's operation for colon cancer a month ago was a success. However he then developed a blockage in his small intestines. They are now thinking of doing a second operation. How successful is this, does it pose great danger to the patient to have another operation so soon, and is it not dangerous to operate on the small intestines?

2nd March 1999

It is likely that because this gentleman's post operative intestinal obstruction has failed to respond to conservative measures that the surgical team have decided to investigate further. The results of these investigations will enable the team to decide whether further surgery is warranted. If it is, it will be carried out in order to either resect or bypass the section of small bowel that is involved e.g. resection and end-to-end anastamosis.

Any operation carries with it a risk. The decision to commit this gentleman to further surgery will therefore not be entered into lightly. The surgical team will have taken into account the risks and the benefits to the patient, their aim will be to completely resolve the underlying problem, or, if this is not possible, to achieve symptomatic relief. It is now common practice to discuss these aims/options with the patient concerned, and if necessary their relatives also.

Please keep in mind that the surgical, anaesthetic and nursing teams will be aiming to act in the patient's best interest. Anxiety and uncertainty by the patient and close relatives is a natural response and is unlikely to resolve until the operation and the immediate post operative period has passed. Hopefully, the underlying problem will be amenable to surgery, as is normally the case, if an operation is planned.

What is the pathophysiology of small bowel obstruction?

16th March 1999

Approximately 6 - 8 litres of fluid enters the small bowel every 24hours. Most of this fluid is absorbed through the microvilli in the small intestine. The wall of the small bowel contains layers of smooth muscle and the nerve supply to this smooth muscle is from both the parasympathetic (vagus nerve - the 10th. cranial) and the sympathetic divisions of the autonomic nervous system. Parasympathetic stimulation increases movement through the lumen of the gut wall (motility). This is achieved through pendular contractions and waves of peristalsis. Sympathetic activity has the opposite effect, it brings about a reduction in intestinal motility and peristalsis.

In small bowel obstruction these normal physiological functions are disrupted. Peristalsis is either severely reduced or absent. As a result, fluid, gas and intestinal contents accumulate and abdominal distention with nausea and vomiting occurs. This leads to fluid loss, dehydration and electrolyte imbalances involving sodium, potassium and chloride. These disturbances contribute further to the existing intestinal obstuction.

Distention of the bowel wall brings about an increase in capillary permeability, and intestinal fluid and electrolytes leak (extravasation) into the peritoneal cavity causing peritonitis. Peritonitis is a major cause of paralytic ileus and together with fluid loss and electrolyte disturbances rapidly places the patient, unless treated correctly, in a state of hypovolaemic shock.

< A loop of small intestine has herniated along the inguinal canal and become constricted, obstructing the normal flow of food materials through its lumen.

 

 

 

 

In intussusception a segment of small intestine slips inside the next segment, causing narrowing and obstruction. (Diagrams modified from Price, S.A., and Wilson, L.Mc. (1992) Pathophysiology: clinical concepts of disease processes. St Louis: Mosby-Year Book Inc. Page 318.)

 

 

 

 

I have a daughter that is 11 years old that has just been released from the hospital for the eighth time. She has had several surgeries. It all started in 1996 when she was suspected to have a Appendicitis. They performed an Appendectomy, her Appendix was fine, but she continued to be ill. After three weeks in the hospital she started having Sydenham’s Chorea seizures.

At that time the doctors realized that she had Rheumatic Fever. She could not walk for a while and spent 8 mths in a wheelchair because her Aortic and Mitral valves were damaged and weak. Now she is having several problems with intestinal obstructions. She just had her 3rd intestinal operation on 04/16/99. Will the obstructions caused by adhesions ever end? She has missed so much of her childhood and school being in the hospital. Is there anything that can help stop the adhesions from forming? Will she continue to have surgeries the rest of her life?

29th April 1999

Adhesions develop when the smooth, delicate peritoneal lining within the abdomen is damaged and becomes inflamed and sticky. The damage can be caused by infection or by events during surgery such as handling, instrument contact, suturing, entry of glove dusting powder, drying or overheating during the operation. Adhesions occur in 50-95% of all patients who undergo abdominal or gynaecological surgery (diZerega, 1997), and produce numerous problems for the patient such as intestinal obstruction, infertility, and pain. Follow-up care creates a continuing stress on surgical facilities and other hospital resources. Appendicitis and appendicectomy are the commonest cause of intra-abdominal adhesion formation (Thompson, 1998). The problem is that follow-up surgery to correct problems created by adhesions can create new adhesions.

Adhesions result from the way that the peritoneum heals during the first five to seven days after injury. Chemical messengers released by cells at the site of injury bring about a cascade of events: a fibrin matrix forms where there is contact between the damaged peritoneum and neighbouring peritoneum and serves as the basis for subsequent development of an adhesion (Holmdahl, 1997). White blood cells called neutrophils and macrophages are attracted to the region of damaged peritoneal cells as part of an inflammatory response. The macrophages recruit new peritoneal cells which form small islands throughout the injured area and proliferate to cover the deficiency.

Protective fibrinolytic enzyme systems of the peritoneum, such as the tissue plasminogen activator system, can under some circumstances remove the fibrin matrix at an early stage allowing adhesion-free healing, but unfortunately surgery dramatically diminishes fibrinolytic activity by causing the release of plasminogen activator inhibitors (Ivarsson et al, 1998). This results in the development of permanent fibrous adhesions. It was hoped that application of tissue plasminogen activator to the peritoneum during surgery would help to prevent adhesion formation, but unfortunately this treatment also inhibited general wound healing (Evans et al, 1993).

Preventive measures include limitation of peritoneal injury, inhibition of the inflammatory response, prevention of coagulation of fibrinogen, removal of fibrin and mechanical separation of injured mesothelial surfaces (Pijlman et al, 1994). The development of suitable resorbable barriers that are put in place at the end of the operation hold the promise of substantial progress in the prevention of adhesions (diZerega, 1994). The risk of adhesions can be reduced by minimising trauma during operation, and there is increasing evidence that laparoscopic surgery is less likely to result in adhesions (Thompson, 1998; Schafer, Krahenbhl, and Buchler, 1998).

References

A useful article by Dr diZerega about adhesion prevention can be found at:

www.centerforendo.com/news/adhesions/adhesions.htm

Further information can be found at:

www.ethiconinc.com/womens_health/product/adhesions/prev_con.htm

My brother was given a barium swallow a month ago. The barium is still stuck in his system. He is obstructed by it and is vomiting everything. The doctor tried all kinds of enemas to get it out with no success. He cannot use laxatives at this point, because my brother underwent surgery just two weeks ago to bypass two small intestine tumors. The surgey was supposed to relieve the vomiting, but we are back to square one, because of the stuck barium, according to the doctor. Any suggestions would be very appreciated. The barium is stuck at the end of the small intestine at the entrance to the colon.

16th June 1999

Barium does not normally get stuck within the alimentary tract. It seems more likely in this case that the movement of the barium along the digestive tract has become obstructed close to the ileo-caecal junction, in the same way that the passage of food is being obstructed. Thus the barium is not a cause of the problem but an indicator of where the problem is located. Usually barium which is used for a swallow, meal or enema has left the digestive tract after 36-72 hours, and certainly after 7 to 10 days any remaining traces of barium will have been evacuated. It is possible that in someone with diverticular disease (a disease of the large bowel) barium from a barium enema may remain in diverticula for several days after the examination. Barium is, as far as we are aware, an inert substance and one which does not get absorbed. Nor does it behave like a commercial filler - it does not set or harden although it can cause constipation if it is not fully evacuated.

The surgical team are the best people to give advice here. It may mean that conservative management along the lines of periodic observation and reassessment is required, or, that further surgery is required to relieve the obstruction.

I received an injury to my right side about 2 months ago and have not had a BM (bowel movement) since. I have seen a Dr and he states it is just constipation. Even after a prep for a barium enema I had no BM and the test continued which set up because I could not get rid of it. There is little or no real bowel sounds and I am miserable. I have a history of Crohn's disease and was wondering if a blow to the transverse/ascending area would cause a paralytic ileus?

29th July 1999

We are concerned that this problem has persisted for 2 months - are you managing to maintain good nutrition? It sounds as if you have some form of bowel obstruction, although it is not clear whether the injury to your right side is implicated or whether it is due to the progression of Crohn's disease. (The inflammatory process underlying Crohn's disease can lead to obstruction.) Either way, it will be necessary to locate the site of the problem and then determine the best clinical strategy. We hope your doctor will be able to help you overcome this problem.

I am about to under go a resection or a total colectomy. I cannot find any information on the nutritional problems associated with this surgery. Also what are the long term problems associated with these types of surgery? I do not have cancer, it is the result of an adynamic bowel due to an injury sustained. How long before I can return to work and any limitations I may have. I am an RN.

27th August 1999

The nutritional implications associated with surgery of the large bowel will depend upon the type of operation performed. In the immediate post operative period the alimentary tract is rested and oral fluids are restricted. Initially nothing is given by mouth, or, sips of water only may be taken. Gradually, as peristalsis and intestinal absorption returns, the amount of fluid is increased and after a period, which can vary between 5 - 7 days, a soft, low residue diet may be tolerated. From that point the kind of diet which can be consumed will depend upon the type of operation that has been performed.

For someone who has had a large bowel resection a return to their previous dietary pattern should be possible. Sometimes people find they have to "fine tune" their diet and this is often done with the help and guidance of a dietician.

For someone who has had a total colectomy attention to the diet is very important as the homeostatic functions of the large bowel (storage, absorption of water, salts & some vitamins, consolidation of faeces) are no longer available.

There are two types of operation performed:

It is common practice for a person who has to undergo operations of this kind to be seen by both the dietician and the colorectal nurse specialist during the pre-operative period. A person with a stoma and who has a positive outlook can also make an important contribution at this stage and during the rehabilitation period. Dietary restriction normally involves limiting roughage and avoiding foods which produce flatus and malodour. The following "Guide to Food Selection for the Client with an Ostomy" by Barbara Henzel provides valuable information on foods that may need to be avoided.

Odour Producing Diarrhoea Producing
eggs
Garlic
Onions
Fish
Asparagus
Cabbage
Broccoli
Alcohol		 Alcohol
Beer
Cabbage Family
Spinach
Green Beans
Coffee
Spicy Foods
Raw Fruits
Gas Forming Constipating
Beans
Cabbage Family
Onions
Carbonated Beverages
Strong Cheese
Sprouts
Corn		 Nuts
Raisins
Popcorn
Seeds
Raw Vegetables
Celery

From:- Nursing Role in Management. Problems of Absorption and Elimination by Barbara Henzel. Chapter 37 in - Medical Surgical Nursing Assessment and Management of Clinical Problems (3rd edition), edited by Sharon Mantik Lewis and Idolia Cox Collier. 1987, Mosby - Year Book, Inc.

It can take up to six months for the body to adjust following major surgery of this kind. The amount of time that a person may need to take off work following the surgery is variable and will largely depend upon whether there are post-operative complications and how positive a person's views are towards the operation and any alterations that have been made to their body image. The age of the person and the type of work that they are engaged upon will also play an important part. Anything that involves lifting and the possibility of straining the abdominal and pelvic muscles must be avoided for at least the first three months.

Useful Address

The Ileostomy and Internal Pouch Support Group. UK National Office: Amblehurst House, PO BOX 23, Mansfield, Nottinghamshire. NG18 4TT.

We should like to thank Rosemary Baker, Colorectal Nurse Specialist, Royal Devon & Exeter Healthcare N.H.S.Trust, Wonford, Exeter, Devon. EX2 5DW for her help with this response.

Previously, I've been treated for IBS. Symptoms are pain in lower left abdomen, retention and difficulty in having a BM. I keep an inflamation (mucus and foul odor in stool) and the pain/pressure is relieved once I am able to have a BM. The great news is that I do not have nausea. I had a barium enema several years ago that revealed IBS/lazy ileus. MD rec'mnds extra fiber and avoid certain foods. In the past year symptoms are worse and quality of life is poor. I sought second opinions from specialists to no avail. The gastrologist I was seeing several months ago ordered colorectal cancer test, stool testings and CT scan. All were ok including the CT scan which was read without dye due to vein blowing at beginning of scan. Again, diet recomended.

Constipation IS NOT the problem. Even after taking laxatives, I am having to strain to pass a loose stool. Occassionally, when I must resort to enemas for relief only "what goes in does not come back out." Recently, I was ref'rd to a colorectal surgeon by family MD due to an abcessed cyst just inside anal opening. I also experienced bleeding and the usual lower left quad ab' pain with much retention. The surgeon ordered a Colonoscopy. The bowel prep was a nightmare. It took all evening/night and next morning to empty. My ab' swole to a new record. I also bled, more. I had the worse headache from straining and weak from boodloss. Small/benigned cluster of polps (pathology=lymph-type matter) were removed. There was evidence of ulceration and in some areas lack of sufficient blood supply. Dr. rx'd asachol and rfer'd me back to Gen' MD to determine if Gastrologist should advise. I feel like the "hot potato" being passed about and continue to suffer. The only meds rx'd were sulfasalizine, asachol, cipro and fiber. I can't believe there are no meds available (even temporary)to give the smallest relief. I advised all MDs of the chronic ENDO/PID I had prior to HYSTO' which right ovary was attached to bladder ect. I wondered if adhesions were a contributing factor. They all agreed to some extent but understandably, did not want to "go there." Meanwhile, I am left to suffer the swelling, pain, discomfort, financial and mental agony without any human medical hope except in the "Great Physician" to which I pray, fervently! Can you shed light? Also, the psuedo intestinal obstruction really sounds like me! Can this type obstruction be treated with medication? If so, what are they? My GEN' MD is open for suggestions.

27th December 1999

It is reassuring that the tests so far have not revealed any evidence of cancer or a physical obstruction, and it is also encouraging that your doctor is willing to discuss your problem and to consider suggestions to follow up. You have already explored dietary factors that might help to resolve your problem, and it will be well worth continuing to identify foods that facilitate digestive function and minimise the distressing symptoms. Other conservative measures that may be helpful include regular moderate exercise to encourage digestive movements, and the reduction of stress to an acceptable level. This includes the need to remain calm when attempting bowel movements, and trying to avoid excessive straining.

The symptoms you describe - pain in the lower abdomen, straining to produce bowel movements (tenesmus), bloating, rectal bleeding - can be generated by several conditions, and it is extremely difficult to differentiate between them clinically. As you have already experienced, some of the exploratory tests can be very unpleasant - for example purgatives given prior to a colonoscopy can be extremely distressing, particularly when the intestines are inflamed, sensitive and dysfunctional - so there will be a limit to how many tests can be undertaken.

In such circumstances, irritable bowel syndrome is a diagnosis often reached. The problem then is to find an effective treatment. It is worth remembering that the walls of the digestive tract contain an extensive network of neurons which helps to regulate digestive activities and provide a degree of autonomy from control by the brain. In fact, there are as many neurons in the digestive tract as there are in the spinal cord. This means that some patterns of digestive activity are ‘learned’ as we grow up and can then become modified by a variety of factors such as lifestyle and ill-health. This complexity of digestive activity means that simple medications are unlikely to produce long-lasting or completely appropriate changes in digestive behaviour when things go wrong. Medications can be useful, but sometimes a ‘re-training’ of the digestive tract is also required. It may be worth discussing this possibility with your doctor.

You mention "chronic ENDO/PID" that you had "prior to HYSTO". We have to be careful here that we are interpreting your abbreviations correctly, since they can be used differently in different countries, but we read into this that you had an episode of endometriosis and pelvic inflammatory disease, followed by a hysterectomy. (Please correct us if we are in error here.) As you are aware, adhesions can occur after abdominal surgery and may indeed be contributing to your present problem. Interestingly, though, the various tests which you have undergone did not reveal clear evidence of obstruction, whether caused by adhesions or some other mechanism, so there is a possibility that something else is responsible for your symptoms. As you suggest yourself, some kind of pseudo-obstruction may be at work, a possibility that will be worth following up.

Have your doctors considered the possibility of intestinal endometriosis? Endometriosis tends to be more of a problem during the fertile years between puberty and menopause, but problems can occasionally arise post-menopausally too. (We do not know your age.) The symptoms you describe can be produced by intestinal endometriosis, but unfortunately there will be difficulty in confirming the diagnosis. A helpful indicator is when the symptoms and signs coincide in some way with the menstrual cycle. Thus, the rectal bleeding may become most apparent during menstruation. This is because the ectopic endometrial tissue is responding to the hormonal cycles in the same way as the normal endometrium. Although endoscopic ultrasound can be helpful, usually the diagnosis can only be made securely by laparoscopy ("keyhole" surgery) or laparotomy (opening up the abdomen in the conventional way). If confirmed, it would then be necessary to remove the affected tissues surgically. It may be worth discussing the possibility of endometriosis with your doctor if this has not been done already. (In case it may be of help, we have appended a few notes about intestinal endometriosis.)

Intestinal Endometriosis

The endometrium is a specialised tissue lining the inside of the uterus. The term endometriosis means the presence of endometrial tissue outside the uterus. This ectopic endometrial tissue responds to circulating hormones in just the same way as normal endometrium, undergoing the same proliferative and functional changes during the menstrual cycle. Generally endometriosis is a benign disorder and without symptoms, occurring in up to 10% of women of child-bearing age, but occasionally it becomes more active and invades neighbouring tissues such as the intestines to produce a variety of symptoms (Girona et al, 1998).

Intestinal involvement occurs in up to a third of cases of endometriosis (Higgs et al, 1995; de Bree et al, 1998). The commonest sites of ectopic endometrial tissue are the rectosigmoid region, appendix, and ileocaecal region. Generally only the outer serosa is affected, although endometrial tissue may in some cases extend through the thickness of the intestinal wall (Higgs et al, 1995; Insabato and Pettinato, 1996).

If symptoms arise, abdominal pain is the most common symptom, associated with changed bowel habits, rectal bleeding, abdominal bloating and tenesmus (Cameron et al, 1995). Intestinal endometriosis mimics a wide variety of inflammatory, infectious, or neoplastic digestive diseases (Langlois et al, 1994; Cameron et al, 1995; Shah et al, 1995), thus making diagnosis difficult. Occasionally rectal bleeding coincides with the menstrual cycle, enabling a tentative diagnosis of intestinal endometriosis to be made (Higgs et al, 1995). Rectal endoscopic ultrasonography has been shown to be effective in the identification of deep bowel infiltration (Kameyama et al, 1997; Chapron et al, 1998). Endometriosis is an important differential diagnosis of Crohn's disease in young females (Gladisch et al, 1992; Korber et al, 1997).

Intestinal resection can be performed safely in most women with severe endometriosis and bowel involvement (Urbach et al, 1998). In recent years there has been growing confidence that laparoscopy can be beneficial in both the diagnosis and treatment of patients with intestinal endometriosis (Nezhat et al, 1995; Redwine et al, 1996; Garcha et al, 1996; Jerby et al, 1999).

(There is an Endometriosis Institute located in Oregon, St Charles Medical Center, Bend 97701, USA.)

References

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