Bowel obstruction refers to a blockage in the intestines, which can occur anywhere from the beginning to the end, including the small or large intestine and rectum. Causes include twisting of the bowel, kinking or blockage from scar tissue after previous surgery, mass or tumor (benign or malignant), bowel stuck in a hernia, or even hard stool that cannot be evacuated. Whatever the cause, the patient may have had symptoms of the primary process leading up to the perforation before it happens, or not. Crampy abdominal pain and progressive bloating, or distention of the abdomen, are common symptoms of obstruction. Sometimes, ongoing pain may actually be relieved when the bowel that has been stretching and “blowing up” finally “pops open,” or perforates, which then requires emergency surgery. The pain may be felt anywhere in the abdomen, depending on the part that is blocked, though there are certain associations to pain patterns. Pain coming from the foregut, or stomach and first part of the small intestine, may be felt just under the bottom of the breastbone, high in the midline. Midgut pain, from the rest of the small intestine all the way to the start of the colon, is frequently felt around the belly button. And pain from the hindgut, or large intestine and rectum, tends to occur down in the middle just above the pubic bone in the pelvis. With intestinal blockage, nausea and vomiting are common, though they may not occur until late in the process. Constipation or not passing stool or gas are also frequent symptoms, though it is possible to pass both even if the small intestine is blocked, until the colon is empty. Patients may feel hot with temperatures higher than normal. Some patients experience chills instead, and feel cold or have shivers, when others around them do not. Sometimes, it is possible to feel chilled and have a fever at the same time.
Diagnosis of Bowel Obstruction
The doctor will take a careful history, asking about when and how your symptoms started, like pain, fever, bloating, constipation or vomiting, and whether there have been changes since they started. A physical examination enables your doctor to evaluate for abdominal distention, presence, location and degree of tenderness; and blood is drawn to check labs related to infection, dehydration and other possible causes of your symptoms. Imaging will be performed, X-rays and/or a CT scan, which can show the doctor whether the intestines appear blocked, and possibly where and why. If the site of obstruction can be identified based on the imaging, the cause may also be suspected. If you have ever had abdominal surgery before, the most common cause is scar tissue. If you have never had abdominal surgery before, in most cases surgery will be necessary to relieve the obstruction, whatever the cause.
Treatment for Bowel Obstruction
Intravenous fluids, decompression of the stomach and bowel with a nasogastric (NG) tube, and bowel rest are all mainstays of treatment for bowel obstruction. Pain medications will be used carefully as needed, though following your response to treatment, and whether your pain is increasing or decreasing, is important for the doctor to know. A small-caliber tube will be inserted through the nose, down the back of the throat and into the stomach, to drain fluid and gas, and keep it from moving forward toward the blockage. This is called decompression, and in cases of scar tissue causing obstruction, it frequently allows the bowels to deflate slowly, unkink themselves, and relieve the blockage without surgery. The patient is followed with daily X-rays, and when the obstruction has resolved, the NG tube will be removed, and the patient slowly allowed to resume drinking and eating.
When surgery is performed for bowel obstruction, it is to identify the cause and relieve it. An anesthesiologist puts the patient to sleep for the operation, and wakes them up afterward. An incision is made in the abdomen for the surgeon to look inside. Once the blockage is identified, the treatment becomes apparent. Sometimes, there are only bands of tissue causing the obstruction that can be divided and the bowel freed up without taking any part of it. If the blockage is from a hernia, the hernia will be fixed. If part of the small bowel is compromised, it may be removed and the ends reconnected. If the bowel is twisted, it will be untwisted. If it is a mass or tumor, part of the intestine or colon will be removed as well. If the colon is affected, and the ends cannot be reconnected right away, a colostomy may be created. This is an opening in the abdominal wall, where the free upper end of the colon is brought through and sutured to the skin. A special bag is placed over the opening, or stoma, for stool to collect in. In any case, the surgeon will do what is necessary and discuss it with you afterward. In any case, the abdominal incision may be closed or left open or partly open, with gauze packing tucked into the wound, which will be changed daily. This is because the wound may get infected if it is closed up tightly; the open areas will heal over time, from the inside out, with dressing changes. The patient will learn how to care for the colostomy, if they have one, and a visiting nurse may come to the patient’s home to help with wound and/or colostomy care.
Once the patient has recovered from their operation, a colostomy may be reversed at some point in the future, depending on that patient’s individual circumstances and operative risks. Most surgeons will wait at least 3 months to allow healing inside the abdomen before considering reversal, but each patient’s case is unique. This requires another operation to reconnect the ends of the bowel, and a period of time in the hospital for recovery. At that time, the surgeon will leave open a smaller wound, where the ostomy was, to heal with dressing changes. This time, though, the main incision will be closed, and the surgeon might even be able to revise the old scar, leaving less of a scar in its place.