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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

SMALL BOWEL OBSTRUCTION


D Fölscher, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary


Over 90% of patients who have undergone at least one previous abdominal operation have post-surgical adhesions accounting for more than 40% of all cases of intestinal obstruction. In 1988, admissions for adhesiolysis in the US accounted for nearly 950,000 days of inpatient care. Intestinal obstruction accounted for about 1% of all admissions in emergency surgery and 4% of major laparotomies. Risk factors, such as type of surgery and site of adhesions, as well as timing and recurrence rate of adhesive obstruction, remain unpredictable. Laparoscopy does not seem to eliminate the risk of adhesions and adhesive obstruction. Mortality rates escalate from 3% for simple obstructions to 30% when the bowel becomes necrotic or perforated.

2. Keywords


Small bowel, obstruction, surgery

3. Patient


75-year-old female patient

4. Past history


- rheumatoid arthritis requiring chronic methotrexate and steroid therapy;
- multiple fractures (hips, shoulders);
- perforated gastric ulcer two years ago treated surgically;
- chronic septic arthritis of right knee.

5. History of the present illness


Patient presents with a 5-day history of crampy abdominal pain followed by onset of abdominal distension, nausea and bilious vomiting.

6. Examinations


6.1. Physical exams

- T: 37.5°C;
- BP: 162/95;
- pulse: 125;
- distended abdomen with hypoactive bowel sounds;
- diffuse tympany;
- no tenderness or guarding;
- rectal exam: empty vault.

6.2. Laboratory values

- WBC: 15200/mm3 (N = 3900-10500/mm3);
- 89% neutrophils;
- CRP: 34.9 mg/dL (N<10).

6.3. Flat abdominal plate

Multiple air fluid levels with distended bowel loops

6.4. CT scan

Distended loops of small bowel with no passage of contrast

7. Treatment


Because of the duration and complete nature of the obstruction, after nasogastric decompression and resuscitation, a laparotomy is performed with the finding of a small bowel obstruction secondary to adhesions.
A lysis of adhesions is performed uneventfully and the patient makes a complete recovery.

8. Discussion


Small bowel obstruction is an extremely common and vexing problem. Postoperative adhesions occur after almost every abdominal surgical procedure and are the leading cause of intestinal obstruction, accounting for more than 40% of all cases and 60% to 70% of those involving the small bowel. Problems resulting from post-surgical adhesions create a considerable workload. Over 24 years at Westminster Hospital (UK), intestinal obstruction accounted for 0.9% of all admissions, 3.3% of major laparotomies and 28.8% of cases of large or small bowel obstructions. A 1992 British survey reported an annual total of 12,000 to 14,400 cases of adhesive intestinal obstruction. In 1988, admissions for adhesiolysis in the US accounted for nearly 950,000 days of inpatient care.
While the clinical diagnosis is often evident, the management of SBO can be a dilemma. The main issue at hand is the early identification of patients at risk for bowel strangulation. Mortality rates escalate from 3% for simple obstructions to 30% when the bowel becomes necrotic or perforated. Unfortunately, little progress has been made to enable physicians to detect early, reversible strangulation, and therefore the surgical management of small bowel obstruction has changed very little over the past 10 years. Because of the inability to detect reversible ischemia, there is a substantial risk of progression to irreversible ischemia (and an inherent rise in morbidity and mortality) when surgery is delayed for an extended period of time, especially in the setting of suspected complete obstruction. However, almost all patients do benefit from an initial 12 to 24 hours of resuscitation and decompression in cases of complete obstruction; resuscitation and decompression can usually be extended for a longer period of time in patients with partial obstruction who exhibit no signs of progression, with resolution in 50% to 60% of cases.
Newer imaging modalities (CT) have allowed a more accurate diagnosis with increased sensitivity (>90%). The use of water-soluble contrast imaging has been advocated to help differentiate complete obstructions from partial obstructions. The laparoscopic approach to SBO appears to be promising in expert hands. In the majority of cases (60-80%), a laparotomy can be avoided.

9. References


  1. Agresta F, Piazza A, Michelet I, Bedin N, Sartori CA. Small bowel obstruction. Laparoscopic approach. Surg Endosc 2000 Feb;14:154-6.
  2. Bass KN, Jones B, Bulkley GB. Current management of small-bowel obstruction. Adv Surg 1997;31:1-34.
  3. Daneshmand S, Hedley CG, Stain SC. The utility and reliability of computed tomography scan in the diagnosis of small bowel obstruction. Am Surg 1999;65:922-6.
  4. Fevang BT, Jensen D, Fevang J, Sondenaa K, Ovrebo K, Rokke O, Gislasson H, Svanes K, Viste A. Upper gastrointestinal contrast study in the management of small bowel obstruction - a prospective randomised study. Eur J Surg 2000;166:39-43.
  5. Joyce WP, Delaney PV, Gorey TF, Fitzpatrick JM. The value of water-soluble contrast radiology in the management of acute small bowel obstruction. Ann R Coll Surg Engl 1992;74:422-5.