Intestinal obstruction: a practical guide for doctors

Intestinal obstruction is a complex of symptoms that develop against the background of a complete or partial disruption of the movement of food through the intestines. Intestinal obstruction is a dangerous condition, which, if left untreated, is inevitably complicated by peritonitis, intestinal necrosis and leads to the death of the patient. Therefore, you need to start treating this disease as early as possible. [1,2]

• Causes and types of acute intestinal obstruction
• Consequences of intestinal obstruction
• Symptoms of intestinal obstruction
• Diagnosis of intestinal obstruction
• Treatment of intestinal obstruction and first aid

Causes and types of acute intestinal obstruction

Depending on what caused its development, there are:

1. Dynamic or functional obstruction. It develops due to a violation of intestinal motility - its spasm or paralysis.
2. Mechanical intestinal obstruction. It develops due to the closure of the intestinal lumen and the impossibility of transit of its contents. Here they distinguish:
   Strangulated intestinal obstruction, from the Latin strangulatio - strangulation. It develops due to compression of the intestine or its mesentery, as a result of which the blood supply to the intestine is disrupted. This is a very dangerous condition as it can lead to necrosis of the intestinal wall.
3. Obstructive intestinal obstruction. Develops due to blockage (obstruction) of the intestinal lumen by foreign bodies (calculi, parasites), tumor or scar deformation. [1]

Depending on the site of development, colonic and small intestinal obstruction are distinguished.

In oncology, intestinal obstruction most often has an obstructive nature and develops as a complication of colorectal cancer, when the tumor blocks the lumen of the colon, usually in its terminal stages. Obstruction can also develop as a result of compression of the intestine by a tumor of another organ, for example, the uterus or prostate gland. [3]

Small intestinal obstruction occurs less frequently. As a rule, its cause is carcinomatosis of the visceral peritoneum. Primary tumors in this region are extremely rare. [4,5]

Preoperative testing

If you have symptoms of a bowel obstruction, your doctor will do a physical exam to check your stomach and bowel sounds.

Diagnostic evaluation may include an abdominal x-ray, computed tomography (ultrasound) scan, or ultrasound. These tests may or may not include a barium enema, which involves injecting a small amount of contrast material into the rectum to better visualize the structures.

If you have a blockage, you may also need a sigmoidoscopy or colonoscopy, which are invasive diagnostic procedures in which a camera is inserted into the colon to visualize the blockage.

Consequences of intestinal obstruction

The development of obstruction triggers a cascade of pathological processes that affect the body systemically. With tumor obturation, the onset, as a rule, is blurred due to incomplete occlusion of the intestinal lumen, but as the tumor grows, the situation worsens. Acute obstruction, as a rule, develops due to complete obstruction of dense feces in the area of ​​the intestine narrowed by the tumor.

In the first time after the development of obstruction, there is an increase in intestinal peristalsis. It's as if he wants to overcome an obstacle. As intestinal contents accumulate, the intestinal wall becomes overstretched, water-electrolyte and metabolic disturbances occur, motor function sharply weakens, and then intestinal paralysis occurs.

At the second stage, disturbances in the secretory-resorptive activity of the intestine and disturbances in parietal digestion develop, the enzymatic activity of enterocytes is blocked, as they are rejected, and the regenerative activity of the crypts is first inhibited and then completely stopped.

Under such conditions, the activity of intestinal bacteria and the so-called symbiont digestion is activated. It is not physiological and is inferior in efficiency to normal, parietal digestion. As a result, rotting and fermentation occurs, as well as the accumulation of a large number of products of incomplete breakdown of proteins, some of which have a toxic effect. [9]

As the process progresses, the immune defense mechanisms are disrupted, which leads to the active proliferation of anaerobic bacteria that secrete exo- and endotoxins. They act systemically on the body - they disrupt tissue microcirculation, lead to central nervous system disorder, and disrupt cellular metabolism. Due to these effects, the permeability of the intestinal wall to bacteria increases, and they can spread into the abdominal cavity, blood and lymph flow, causing peritonitis and even sepsis.

Water and electrolyte disturbances also progress. Due to disruption of the intestine, increased filtration of fluid occurs; it is not absorbed back and accumulates in the afferent loop of the intestine. Under normal conditions, about 10 liters of liquid enter the gastrointestinal tract per day (including food, drink, saliva and secretions of the digestive glands). About 8-9 liters should be absorbed back, but this does not happen due to impaired reabsorption. Fluid accumulates in the adductor section of the intestine, causing it to expand. This, in turn, leads to reflex vomiting, which further worsens dehydration. Against this background, electrolyte disturbances quickly develop, which ultimately lead to renal and heart failure. [1.10]

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Symptoms of intestinal obstruction

• Pain. This is one of the very first signs of intestinal obstruction. It is observed in absolutely all patients. With tumor obstruction, pain occurs suddenly, for no apparent reason, and may even be one of the first signs of cancer. It has a cramping character. The greatest pain occurs at the time of peristaltic contractions, after which it subsides a little for a couple of minutes. Gradually, the intensity of the pain increases and after a few hours it becomes unbearable. They subside only on the 2-3rd day, when paralysis of the intestine already develops - “noise at the beginning, silence at the end”, a symptom of “grave silence”, when there are no sounds of peristalsis at all.
• Vomit. If the obstruction is located at the level of the small intestine or the right part of the large intestine, vomiting will be present in the early stages, as a sign of reflex irritation of the gastrointestinal tract. If there is obstruction of the terminal sections, vomiting will most likely not occur at first, or it will occur at large intervals. During breaks, patients may suffer from nausea, hiccups or belching. If intestinal obstruction persists, vomiting becomes indomitable, first the stagnant contents of the stomach and then the intestines are released, up to vomiting of feces. This is a bad sign, because it indicates that vomiting is a symptom of toxic cerebral edema, and it cannot be eliminated by draining the gastrointestinal tract.
• Retention of stool. This symptom is observed with obstruction at the level of the sigmoid and rectum. If there is high obstruction at first, the stool may persist.
• Bloating. There are 4 signs here: asymmetry of the abdomen, palpable bulge of the intestine, peristaltic contractions of the intestine that can be seen with the naked eye, tympanic sound upon percussion.
• Bloody or mucous discharge from the rectum. They usually occur with cancer of the terminal sections of the intestine and are associated with the secretion of mucus by the tumor, its disintegration, or injury from feces. [1,4,6]

In the process of developing the clinical picture of intestinal obstruction, three periods are distinguished (see Table).

Table 1 - Clinical picture of intestinal obstruction.

Preventive actions

The effectiveness of treatment depends on the etiology of the disease and the qualifications of the surgeon, because accurate diagnosis and timely and correct treatment measures minimize the likelihood of complications. It is also necessary to take into account the age of the patient: older patients have an increased risk of complications.

Prevention is aimed at treating diseases that cause intestinal obstruction:

• control of helminthiasis;
• timely diagnosis and removal of tumors;
• prevention of adhesions;
• preventing traumatic injuries;
• healthy eating;
• the right way of life.

The multidisciplinary clinic CELT has a powerful diagnostic and treatment base and experienced specialists of the highest level.

Diagnosis of intestinal obstruction

The diagnosis of intestinal obstruction can be suspected based on the patient’s characteristic complaints. Confirmation is made using instrumental examination. [eleven]

The simplest, fastest and most accessible diagnostic method is a survey radiography of the abdominal organs. The photographs reveal characteristic features:

• Kloiber's cup - dilated intestinal loops in the form of domes are visible, and there is a horizontal level of liquid in them. This painting resembles a bowl turned upside down. There may be several bowls; in the picture they are layered on top of each other.
• Intestinal arcades - arise due to swelling of the loops of the small intestine with gases; a horizontal level of fluid is visualized in the lower knees of the intestine.
• Kerking's folds - due to stretching of the jejunum on radiographs, it takes on the appearance of an extended spring.
• X-ray studies with contrast can also be used, for example, a study of the passage of barium suspension through the gastrointestinal tract, or irrigoscopy. However, these methods take a lot of time and delay the decision on the need for surgery.

Other diagnostic methods used:

• Endoscopic examination, such as colonoscopy or sigmoidoscopy. Such a study helps determine the localization of the tumor and the level of stenosis in the obstructed intestinal segment. In some cases, it is possible to pass a probe through the stenotic area and drain the afferent intestine. Colonoscopy is not performed if the patient’s condition is severe, there are symptoms of peritonitis and there is a risk of tumor perforation.
• CT. Using this study, it is possible to visualize the tumor, its size and the extent of stenosis (narrowing). In addition, the relationship of the cancer with surrounding tissues can be assessed and the presence of metastases can be determined.
• Ultrasound. In case of obstruction, an increase in the intestinal lumen, accumulation of air (gases) in it, and thickening of the intestinal wall due to inflammation are visualized. With the development of systemic inflammatory processes, free fluid may be detected in the abdominal cavity. [1,7,8]

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Lutsevich Oleg Emmanuilovich

Chief Surgeon of CELT, Honored Doctor of the Russian Federation, Chief Specialist of the Moscow Department of Health in Endosurgery and Endoscopy, Corresponding Member of the Russian Academy of Sciences, Head of the Department of Faculty Surgery No. 1 of the State Budgetary Educational Institution BPO MGMSU, Doctor of Medical Sciences, Doctor of the Highest Category, Professor

42 years of experience

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Gordeev Sergey Alexandrovich

Surgeon, Candidate of Medical Sciences, doctor of the highest category

41 years of experience

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Prokhorov Yuri Anatolievich

Surgeon, head of the surgical service of CELT, candidate of medical sciences, doctor of the highest category

32 years of experience

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Grossman Stanislav Sergeevich

Surgeon, Candidate of Medical Sciences

Experience 26 years

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Treatment of intestinal obstruction and first aid

If a patient is suspected of intestinal obstruction, he is immediately hospitalized in a hospital, since the timing of treatment directly affects the prognosis. Both conservative and surgical methods are used.

As part of conservative therapy, the following procedures are used:

• Bowel decompression. For this purpose, removal of intestinal contents above the site of obstruction using probe aspiration or enemas can be used.
• Correction of water and electrolyte disturbances, replenishment of fluid loss. For this purpose, infusions of crystalloid solutions are prescribed.
• Pain relief. Antispasmodics and analgesics are prescribed, for example, atropine, platyphylline, etc.
• Replenishment of protein loss - infusion of protein drugs.
• To prevent infectious complications, broad-spectrum antibiotics are prescribed.
• Stenting of the intestinal lumen. Using an endoscope, a self-expanding stent is inserted into the site of intestinal obstruction. It pushes tumor tissue apart and maintains the intestine in a straightened state, ensuring the free passage of its contents. This way, time is gained for more thorough preparation for the planned intervention. [7,9]

This is especially important for cancer patients, since extensive tumor damage leads to the need for a colostomy. Placement of a stent for tumor obstruction allows time for neoadjuvant or perioperative chemotherapy. This will reduce the volume of the tumor mass and, possibly, even perform radical surgery. In other cases, this provides a chance to perform bypass anastomoses. For patients with end-stage colorectal cancer, who have a high risk of complications from surgery and anesthesia, stenting is the mainstay of treatment for intestinal obstruction. After the procedure, the patient continues to be monitored and surgical treatment is resorted to only in case of life-threatening complications. [1]

In all other cases, surgery is indicated, since the tumor will continue to grow and sooner or later a relapse of obstruction will occur.

In a compensated condition, surgical intervention can be delayed for up to 10 days; in a subcompensated condition, it is performed as early as possible, after the patient has stabilized. And if there are symptoms of peritonitis, emergency surgery is performed.

In any case, during surgery for intestinal obstruction, the abdominal cavity is opened (laparotomy) and revised. The location of the tumor, its relationship with surrounding tissues, and the presence of visible metastases are determined. An assessment of the viability of the intestinal wall is also performed to determine the extent of resection.

Ideally, radical removal of the tumor is performed through resection of the affected part of the intestine and restoration of intestinal continuity through anastomosis. Unfortunately, when obstruction develops against the background of a malignant process, it is very difficult and risky to perform such a volume of surgery in one stage, since there are extensive tumor lesions.

As a rule, in such cases palliative operations are performed:

• Performing a bypass anastomosis around a fragment of intestine with a tumor. Thus, the impassable (obstructed) section is excluded from the digestive chain.
• Stoma removal - a section of the intestine located above the site of obstruction is brought out onto the anterior abdominal wall in the form of an opening. Through it, the intestinal contents will be drained into a special bag - a colostomy bag.

Ostomy is a mutilating operation and is difficult for patients to endure morally. But in this situation, saving the patient’s life comes first. If possible, after stabilizing his condition and eliminating the consequences of intestinal obstruction, further treatment is carried out, for example, chemotherapy, radiation therapy, and, if the results are satisfactory, reconstructive interventions are performed to restore the integrity of the intestine. [1,5,7]

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Bibliography:

1. Clinical recommendations: Acute intestinal obstruction of tumor etiology in adults. — Ministry of Health of the Russian Federation. — 2021.
2. Methodological development for the practical lesson “Acute intestinal obstruction” Ed. USMA, Yekaterinburg, 2011 - 25 p.
3. Clinical recommendations: Acute intestinal obstruction of tumor etiology. - Moscow, 2014.
4. B. O. Kabeshev, S. L. Zyblev. Acute intestinal obstruction. — A practical guide for doctors. — Gomel, 2021.
5. M.Yu. Kabanov, I.A. Solovyov, O.V. Balura. — Results of complex treatment of patients with acute intestinal obstruction of carcinomatous origin. - Bulletin of the Russian Military Medical Academy, 1(37)-2012.
6. A.V. Pugaev, E.E. Achkasov, M.G. Negrebov. — Intussusception intestinal obstruction in adults. — Surgery, 5 — 2021.
7. National clinical guidelines “Acute non-tumor intestinal obstruction”. — Russian Society of Surgeons. — 2015.
8. Abdukarimova M.K. — X-ray diagnosis of intestinal obstruction. — Bulletin of AGIUV. — 2008, No. 5(8).
9. Patrick Jackson, and Mariana Vigiola Cruz. — Intestinal Obstruction: Evaluation and Management, Am Fam Physician. 2021 Sep 15;98(6):362-367.
10. Bertrand Trilling, Edouard Girard. — Intestinal obstruction, an overview — Rev Infirm. 2021 Jan;(217):16-8. doi: 10.1016/j.revinf.2015.10.028
11. Thévy Hor, François Paye. — Diagnosis and treatment of an intestinal obstruction. — Rev Infirm. 2021 Jan;(217):19-21. doi: 10.1016/j.revinf.2015.10.030.

Patients with contraindications to surgery - is it possible to help?

As for weakened patients, in cancer patients with severe exhaustion, the absence of stool for a couple of days is acceptable. All other patients, including those with neurological pathologies, for example, those suffering from Alzheimer's or Parkinson's disease, require urgent hospitalization; in case of intestinal obstruction, such patients should be under constant medical supervision. In this situation, surgery is prescribed as a last resort - if it was not possible to alleviate the patient’s condition within 2-3 days, as well as if there is a risk of developing coprostasis. If surgery is contraindicated, then colon stenting using endoscopic equipment is possible as palliative treatment. All manipulations are carried out through a natural opening: a balloon is inserted into the intestinal lumen, expanding the narrowed section of the intestine, after which a stent is installed. In this way, it is possible to avoid or postpone abdominal surgery in an inoperable patient, improving his quality of life.

Intestinal obstruction is a dangerous condition, the outcome of which depends on timely medical care. But complete recovery, even in severe cases, is possible if the patient is urgently hospitalized in the surgical department. Therefore, when the first symptoms appear, contact us immediately - this way you can avoid serious consequences, or even save your life; everything depends on you!