Obstruction of the Large and Small Intestine

The Acute Abdomen

0039-6109/88 $0.00

+ .20

Obstruction of the Large and Small Intestine

William 0. Richards, M.D.,* and Lester F. Williams, Jr., M.D.t

Obstruction of the small and large intestine continues to be a major health problem in the United States. Since this review will address new refinements and developments, emphasis will be on obstruction of the small bowel and intestinal pseudo-obstruction, an ever-increasing clinical problem.

SMALL BOWEL OBSTRUCTION EPIDEMIOLOGY

In the first third of this century, the most common cause of small bowel obstruction in the United States was external hernia. Now, postoperative adhesions comprise 64 per cent to 79 per cent of the total number of small bowel obstructions in the United States. 5• 8 • 72 This shift in etiology can be attributed to the increasing number of elective abdominal operations and to the effectiveness of elective hernia repair in reducing the number of patients with incarcerated external hernias.

DIAGNOSIS

Identification of the Patient with Gangrenous Bowel Preoperative recognition of gangrene is essential if patients with small bowel obstruction are treated nonoperatively with tube decompression, *Assistant Professor of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee tProfessor of Surgery, Vanderbilt University School of Medicine, and Chief, Surgical Service, Veterans Administration Medical Center, Nashville, Tennessee

Surgical Clinics of North America-Vol. 68, No. 2, April 1988

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Table 1. Preoperation Evaluation of Strangulation in Patients with Small Bowel Obstruction*

STUDY

Sarr et al62 Snyder et al68 Silen et al66

NO. OF PATIENTS NO. OF PATIENTS WITH WITHOUT STRANGULATION STRANGULATION

30 78 368

21 31 112

NO. (%) OF PATIENTS WITHOUT STRANGULATION BUT WITH 2:1 SIGNS OF GANGRENOUS BOWEL

30 (100) 337 (91.6)

NO. (%)OF PATIENTS WITH STRANGULATION BUT WITHOUT ANY CLINICAL SIGNS PREOPERATIVELY

1 (5) 4 (13) 11 (10)

*Patients were evaluated by clinical criteria, including continuous pain, fever, tachycardia, leukocytosis, palpable mass, or peritoneal signs. These studies demonstrate the inability of clinical findings to differentiate simple from strangulated small bowel obstruction.

because if there is a significant risk of gangrene, or if the presence of gangrene cannot be excluded reliably, the risk of nonoperative management becomes prohibitive. A number of studies have reaffirmed the observation that even experienced clinicians cannot confidently diagnose nonviable intestine preoperatively. The classic findings of nonviable bowel-leukocytosis, tachycardia, localized abdominal pain, and fever-were evaluated in three separate studies (Table 1). 62 • 66 • 68 Experienced clinicians at these centers were unable to diagnose strangulation obstruction preoperatively with any accuracy. Although increasing numbers of clinical factors indicating strangulation are associated with gangrenous bowel, there were a number of patients in each study with no clinical findings of strangulation, yet at laparotomy, strangulation obstruction was identified. However, Stewardson and associates found that the absence of the four classic indicators of gangrene predicted a safe situation in which the patient could be managed nonoperatively, whereas if any of these factors developed, they recommended immediate operation. 72 Although clinical prediction of gangrene in the patient with bowel obstruction has not been successful, an experimental study using intraperitoneal injection of xenon-133 promises utility in the evaluation of the patient with suspected gangrene. Bulkley and associates noted serendipitously that fluorescein injected intravenously to detect nonviable areas of intestine remains in ischemic areas of bowel after the dye has washed out from well-perfused segments of bowel. 9 They hypothesized that dye diffusing across the serosal surface of the intestine would preferentially remain in the poorly perfused segment. Intraperitoneal injection of xenon-133 in experimental animals with strangulated bowel obstruction produced concentrations of the isotope magnitudes. higher than animals with bowel obstruction but without ischemia: the xenon-133 simply did not wash out of the ischemic sections of intestine. Thus, this simple study could differentiate ischemic from viable yet obstructed bowel. There remain a number of unanswered questions, including the amount of ischemic bowel necessary to obtain positive results and the effect intraperitoneal adhesions have on the diffusion of xenon and uptake of radioactive material. So far, there have

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Figure 1. Upper gastrointestinal and small bowel series in a patient with persistent nausea and vomiting. Plain abdominal radiographs were nondiagnostic and the patient was thought to have an adynamic ileus from pancreatitis. The patient had had near total gastrectomy and Billroth II gastrojejunostomy for adenocarcinoma 2 months previously. Radiographs show complete obstruction in proximal small bowel, illustrating the usefulness of barium studies in differentiating small bowel obstruction from what was thought to be adynamic ileus and pancreatitis in this patient.

been no reports of clinical use of xenon-133 in the diagnosis of ischemic bowel. Radiologic Studies The use of barium studies for the diagnosis of small bowel obstruction is becoming increasingly helpful, especially in cases where the plain films or clinical picture is nondiagnostic. Use of barium in either a small bowel series or enteroclysis can distinguish adynamic ileus from mechanical bowel obstruction. In a patient with adynamic ileus, barium will take 4 to 6 hours to move through the gastrointestinal tract to the colon. 25 Mechanical obstruction will produce dilated proximal intestine and progression of the barium to the site of obstruction in 1 hour or less (Fig. 1) Brolin was able to make a diagnosis in all 13 patients who had barium studies. 8 The use of enteroclysis is advocated by Maglinte and associates 44 because of its greater diagnostic yield. In this procedure, barium is infused through a tube inserted into the duodenum, instilling air and contrast medium directly into the small intestine. This procedure has at least two advantages over the routine small bowel series in which the patient ingests contrast. First, the radiologist is able to examine the mucosal surface of the small bowel more thoroughly because more contrast medium is inserted into the intestine and, second, the radiologist can evaluate the distensibility of the bowel. In patients with partial obstruction, the routine upper gastrointestinal series with a small bowel series will be unable to detect subtle dilation of the bowel proximal to the obstruction. Determination of the distensibility

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of the bowel and identification of dilated segments makes enteroclysis more sensitive and specific. In 32 examinations with enteroclysis, there was only one false-positive and no false-negative results, whereas the routine small bowel series produced three false-negative and two false-positive results in six patients.

TREATMENT

Use of Tube Decompression in Place of Operation Surgeons have heeded the adage "Never let the sun set or rise on a bowel obstruction" for years, largely because of the difficulty in differentiating simple obstruction from strangulation obstruction. However, there are an increasing number of reports indicating that certain patients can be treated with nasogastric or long tube decompression of the gastrointestinal tract, thus reducing the number of laparotomies. Patients with early postoperative obstruction, 27• 41 · 58 small bowel obstruction secondary to adhesions, 5 • 7• 8• 55 • 84 or obstruction associated with Crohn' s disease 5 are less likely to progress to strangulation than those with other types of obstruction and are more likely to resolve with nonoperative treatment. The ideal patient to treat with tube decompression of the gastrointestinal tract is one suspected of having adhesive small bowel obstruction from a previous laparotomy admitted without clinical signs of gangrenous bowel. Table 2 lists the experience using nasogastric and long intestinal tube decompression in treatment. All these authors stress the need for repeated evaluations of the patient by an experienced surgeon to treat the patient with obstruction successfully in this manner. Insecure diagnosis of small bowel obstruction is not a good reason to resort to tube decompression but should lead to early diagqostic studies--contrast enema, enteroclysis, small bowel manometry. Occurrence of any of the clinical signs of gangreneleukocytosis, fever, localized abdominal tenderness, tachycardia, and, Wolfson and associates would add, 84 radiologic evidence of necrosis (fixed loop with loss of mucosal markings)-should lead to immediate laparotomy. Patients who will respond to tube decompression of the gastrointestinal tract usually do so in the first 48 hours. Failure to improve with nonoperative treatment during this period of time should lead to operation. There is no convincing evidence that long intestinal tubes (Cantor, Kaslow, Miller-Abbott, or Dennis) are more efficacious than nasogastric tubes in the decompression of small bowel obstruction. Gallick and associates reviewed 45 patients with 54 episodes of small bowel obstruction. 19 Long intestinal tubes in 11 patients and nasogastric tubes in 27 patients produced no statistical difference in the frequency of resolution of obstruction. Brolin also found that there was no difference in the number of patients who responded to long intestinal tubes compared with nasogastric tubes. 7• 8 Eighty-two per cent of the patients with partial obstruction were treated successfully with long intestinal tubes, whereas 90 per cent of such patients treated with nasogastric tubes responded favorably. Another review of 196 patients revealed a 47 per cent success rate with nasogastric

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OBSTRUCTION OF THE LARGE AND SMALL INTESTINE

Thble 2. Outcome of Tube Decompression of Small Bowel Obstruction STUDY

Brolin7

Peetz et al55

TYPES OF TUBES USED*

Gallick et al 19 (patients with history of abdominal cancer)

COMMENTS

No difference in resolution between LIT and NG

47 LIT complete

15

28 LIT partial 37 NG complete 63 N G partial

82 19 90

76 LIT partial 24 LIT complete

65 25

Failure of LIT to pass beyond ligament of Treitz was a major factor in failure of nonoperative therapy Failure to improve in 24-48 hours should lead to operation

95

Use of tube decompression with steroids and intravenous alimentation very effective in active Crohn's disease

91 NG 105 LIT

47 50

Initial treatment with tube decompression indicated and likely to be successful when adhesions cause obstruction Patient should improve within 48 hours of initiation of treatment

11 LIT 27 NG

27

NG tube appeared more effective than LIT

Bizer et al5 (12 patients with Crohn's) Bizer et al5

PER CENT WITH RESOLUTION

Delay in operation in patients not responding to tube decompression leads to increased morbidity and mortality rates

Surgically treated patients had better palliation Wolfson et al84

113 Kazlow tubes 5NG

Helmkamp and KimmeP7 (pelvic malignancies)

69 Cantor tubes 33 radiation 22 recurrent tumor 14 early postop

Turner and Croom79

36 LIT

*LIT NG

= long intestinal tube = nasogastric tube

64

36

Two thirds of patients with partial obstruction had resolution without surgery Absence of risk factors suggests safety in nonoperative management Cantor tubes very effective in early postop period

32 86 53

No clear clinical criteria on which to base use of tube decompression Emphasize that failure to improve in 24 hours should lead to surgery

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decompression and a 50 per cent resolution rate with long intestinal tube decompression. 5 Failure of the long intestinal tube to progress beyond the ligament of Treitz may be a major factor in the success rate of tube decompression; 16 of the 45 patients requiring surgery failed tube decompression because the long intestinal tube never progressed beyond the ligament of Treitz. 55 The long tubes are sometimes difficult to place into position. The fiberoptic gastroscope can be used to position the tube in the small bowel in an expeditious fashion, 15 but the nasogastric tube is still easier and quicker to place. What happens to the patient with partial small bowel obstruction secondary to adhesions who is treated nonoperatively? The natural history of this patient is not known, but there may be a significant incidence of recurrent obstructions. More than a third (7 of 19) of patients treated nonoperatively with tube decompression returned with recurrent small bowel obstruction, but only three of these patients came to laparotomy to relieve their obstruction. Compared to the group undergoing immediate laparotomy (3 of 23 patients required a second laparotomy for recurrent obstruction), the chance of laparotomy after initial treatment (operative lysis of adhesions or nonoperative tube decompression) was not substantially different. 79 The number of patients returning for recurrent bowel obstruction was indeed higher among those initially treated nonoperatively; however, many of these patients could be successfully retreated with tube decompression rather than laparotomy. Early Postoperative Treatment The long intestinal tubes can treat intestinal obstruction successfully during the early postoperative period. Quatromoni and associates were able to treat 30 or 41 such patients using long intestinal tubes for long-term decompression. 58 Helmkemp and Kimmel successfully treated 86 per cent of their patients early after operations for pelvic malignancy with or without residual cancer with tube decompression of the gastrointestinal tract. 27 Treatment of the Patient with Cancer and Small Bowel Obstruction Some surgeons have been reluctant to reoperate on patients after any previous surgery (curative or palliative) for abdominal malignancy because they have attributed obstruction to recurrence or spread of cancer. Gallick and associates found 13 of 50 patients with malignancies and small bowel obstruction had benign adhesions as the cause of their obstruction. 19 More than a third of these patients (35 per cent) were able to leave the hospital eating normally after operation to lyse adhesions or to resect metastatic tumor causing obstruction. They also found that 41 per cent of the patients with initial resolution of obstruction by tube decompression were readmitted with recurrent obstructions within 30 days of discharge. The patients in the operative group were more effectively palliated and had better survival. Other studies on the outcome of patients undergoing treatment of bowel obstruction who have had previously treated malignancies are listed in Table 3; generally, they come to the same conclusions as Gallick's group. 19 Operation in this group of patients should be vigorously pursued,

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Table 3. Treatment of Small Bowel Obstruction in Patients with Previously Treated Intra-abdominal Malignancies

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STUDY

Gallick et al19

Krebs and Goplerud39 (ovarian cancer)

OUTCOME OF NONOPERATIVE TREATMENT

PER CENT OF BENIGN CAUSES OF OBSTRUCTION

27% resolved, but 41% of these had recurrence within 30 days

26 benign

10% resolved; 12 of 14 readmitted for recurrence

None

OUTCOME OF OPERATIVE TREATMENT

62% resolved

87% palliated

g 0 COMMENTS

Poor outcome when carcinomatosis present; otherwise, operative intervention cured or significantly palliated patients Surgery indicated for palliation in patients with ovarian carcinoma

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82

81% palliated

Surgery identified large number of obstructions secondary to benign causes and effectively palliated patients with malignant causes

Tunca et al

Only terminally ill patients treated nonoperatively

9.4

86% palliated

Surgical bypass indicated if small bowel motility normal

Osteen et al53

23% resolved, but 6 of 15 readmitted with recurrence

38

89% palliated

Patients without proven carcinomatosis will benefit from operation

Gizer et al5

14% resolution

?

87% palliated

Tube decompression unlikely to relieve malignant obstruction. Patients with previously treated malignancy should undergo surgery

Pathak et al54

64% mortality rate

12

61% palliated

Surgery associated with lower mortality and prolonged survival

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as nonoperative means are generally unsuccessful in alleviating the obstruction. Patients with previously treated ovarian carcinoma are more likely to present with small and large bowel obstruction caused by recurrent tumor than are patients with other abdominal malignancies. In a review of 208 patients with ovarian cancer, 46 per cent had 165 episodes of small bowel obstruction requiring hospitalization, and tumor recurrence caused all the episodes. 39 The outcome of tube decompression in patients with ovarian carcinoma is similar to that in patients with intestinal tumors, 19 as only 10 per cent of the patients with recurrent ovarian cancer were treated successfully without operation. Operative intervention should not be withheld from patients with previous laparotomy for ovarian cancer, as a significant number can be effectively palliated by operation unless they have known carcinomatosis. 78 Chemotherapy in the Treatment of Malignant Small Bowel Obstruction Most chemotherapy for cancers obstructing the gastrointestinal tract have been disappointing, except for the multiagent treatment of ovarian carcinoma. Tunca demonstrated complete resolution of intestinal obstructions in patients with advanced ovarian cancer with cisplatin/doxorubicin/ cyclophosphamide therapy. 77 Six of the seven patients treated had resolution of their obstruction and were able to be discharged. Although three of the patients died (4, 9, and 11 months after treatment), they received significant palliation from this regimen, made even more significant because all seven were deemed to be inoperable because of encasement of the peritoneal cavity with tumor prior to initiation of chemotherapy. Combination of chemotherapy (cis-plastin) and surgery was successful in palliating 17 per cent who responded to chemotherapy in a series from Roswell Park. 57 A chemotherapeutic protocol can give significant palliation to patients with advanced ovarian carcinoma. 38 Treatment of Small Bowel Obstruction Caused by Inflammatory Bowel Disease Analysis of a subgroup of patients treated by Bizer and coworkers showed that conservative therapy was very successful in the treatment of small bowel obstruction secondary to active Crohn' s disease. 5 All but 1 of 21 patients treated with steroids, parenteral alimentation, and long tube decompression of the intestine had resolution of bowel obstruction. During the acute inflammation of Crohn' s disease, there is swelling and edema of the tissues causing obstruction that will resolve with appropriate therapy to reduce inflammation. Obstruction persisting longer than 3 weeks despite adequate therapy most likely represents formation of scar that will need surgical treatment to resolve. Even though tube decompression and medical therapy can relieve obstruction in many patients with Crohn' s disease, the most common indication for operation in 135 patients undergoing 214 operations for complications ofCrohn's disease was obstruction (31.3 per cent). 13 Resection with anastomosis has become more popular than simple bypass of involved

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segments because it removes the possibility of cancer, fistula, and abscess developing in the bypassed segment. Strictureplasty of the strictured segment of bowel is advocated by Kendall and Haynes and their colleagues for patients with strictured segments of the small intestine in Crohn' s disease that cause partial obstruction. 26• 32 The strictured segment is incised along the longitudinal axis and then sutured like a Reineke-Mikulicz pyloroplasty so that the lumen is enlarged. The advantages of this type of operation are the simplicity of the technique, conservation of bowel, and the low rate of complications, especially when used in the patient with inactive disease. The average follow-up reported by Kendall and associates is only 20 months, so strictureplasty cannot be wholeheartedly recommended until long-term followup is obtained. Prevention of Recurrent Adhesive Small Bowel Obstruction The patient with multiple dense adhesions of the peritoneal cavity poses a serious problem for the surgeon. A number of techniques have been devised to reduce the recurrence of intestinal obstruction after laparotomy to lyse adhesions. These were first employed on patients with at least one previous episode of adhesive small bowel obstruction. When reoperation for adhesive small bowel obstruction was necessary, the various plications 11 • 51 or tube intubation of the small bowel was carried out. 2 With longer follow-up, McCarthy, 46 Close and Christensen, 12 and Jones and Munro31 have advocated extension of these techniques in patients undergoing their first laparotomy for small bowel obstruction but with extensive dense intraperitoneal adhesions. Close and Christensen 12 and McCarthy46 also advocate Childs-Phillips plication in patients without obstruction who are deemed to be at high risk for subsequent bowel obstruction from dense adhesions found at laparotomy. The bulk of information suggests that Baker tube intubation is safe and may reduce the incidence of subsequent small bowel obstruction (Table 4). Pharmacologic Manipulation of Adhesions If, as Jones and Munro estimate, 5 per cent of laparotomies will be complicated by small bowel obstruction, 31 adhesive bowel obstruction is a problem that will continue to grow. Extensive animal experiments during the 1960s and 1970s showed that several medications reduce the formation of intraperitoneal adhesions after laparotomy. Promethazine, an antihistamine, reduces the number of intraperitoneal adhesions in rats and dogs after laparotomy and trauma to serosal and peritoneal surfaces, presumably by reducing the protein-rich exudate from the injured peritoneum. 20 By reducing this exudate and fibroblast proliferation, scarring and adhesions were reduced. Promethazine has been used most commonly with steroids (dexamethasone) that theoretically will reduce inflammation at the site of injury and act synergistically with antihistamine. Repogle and associates studied 90 dogs subjected to laparotomy and trauma to the distal ileum (the serosal surface was rubbed with a stiff nylon brush); 63 of the 70 animals in the control group developed moderate to severe adhesions, whereas none of the 20 animals treated with

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Table 4. Use of Baker Tube to Prevent Recurrent Small Bowel Obstruction in Patients with Dense Intraperitoneal Adhesions Who Are at Increased Risk for Recurrent Obstruction

STUDY

Close and Christensen 12 Weigelt et al83

Baker

COMPLICATIONS

RECURRENT

NO. OF

ASSOCIATED WITH

EPISODES OF

PATIENTS

BAKER TUBE

OBSTRUCTION (%)

37 154

52

Pelvic abscess (1) Prolonged jejunostomy drainage (5) Tubes difficult to remove (3) Tubes caused ternporary obstruction at ileocecal valve (2) Intussusception requiring operative reduction (1) Prolonged drainage from jejunostomy (1) Obstruction at site of jejunostomy that required operation (1)

1 (3) related to a pelvic abscess 12 (8)

2 (4)

FOLLOW-UP

6 months to 12 years 3 weeks to 8 years

2 to 5 years

dexamethasone and promethazine developed moderate or severe adhesions. 60 Grosfeld and coworkers showed that rats treated with high doses of steroids and antihistamines developed many complications, and 38 per cent died. 24 Subsequent concern for increased infections and delayed wound healing resulting from use of high-dose steroids has been one reason why these medications have not achieved widespread acceptance. Intraperitoneal instillation of dextran-70 was able to reduce the formation of adhesions after laparotomy and abrasion of the peritoneum or intestinal anastomosis. 17 Although it reduced the number of adhesions significantly, dextran also allowed the development of peritonitis, with early death of the experimental animals. The exact mechanism of death was not determined; however, the authors hypothesize that reduction of intraperitoneal adhesions was accompanied by a defect in the normal defenses of the peritoneal cavity to wall off leaks from the bowel, thus leading to the disastrous consequences found in the study. As yet, there is no clinically useful method to reduce intraperitoneal adhesions except for the prevention of starch granulomas through non-use of gloves with starch powder and thorough cleansing of the gloves prior to opening the abdomen.

SMALL BOWEL PSEUDO-OBSTRUCTION

Pseudo-obstruction of the small bowel is one instance in which repeated laparotomies lead to more adhesions and greater likelihood of mechanical

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Table 5. Diseases Associated with Pseudo-obstruction Diseases involving intestinal smooth muscle Collagen vascular diseases Scleroderma Progressive systemic sclerosis Dermatomyositis, polymyositis Systemic lupus erythematosus Infiltrative muscle disorders Amyloidosis Miscellaneous Ceroidosis Nontropical sprue Endocrine disorders Hypothyroidism Diabetes mellitus Hypoparathyroidism Pheochromocytoma Neurologic disorders Parkinson's disease Familial autonomic dysfunction (ShyDrager syndrome) Hirshsprung' s disease Chagas' disease Psychosis

Pharmacologically induced disorders Toxic compounds Lead poisoning Amanita (mushroom) poisoning Drug side effect Phenotbiazines Tricyclic antidepressants Antiparkinsonian medications Ganglionic blockers Clonidine Carthartic abuse Electrolyte disturbances Hypokalemia Hypocalcemia Hypomagnesemia Uremia Miscellaneous J ejunoileal bypass Jejunal diverticulosis Spinal cord trauma

obstruction, thus increasing the need for future laparotomies to exclude adhesive bowel obstruction.

ETIOLOGY

Table 5 shows the wide range of reported associations and disease entities related to pseudo-obstruction. Many cases still have no demonstrable pathologic features on routine microscopic sections of bowel. The etiology of pseudo-obstruction can be divided into two basic groups: (1) degeneration of the smooth muscle of the intestine and (2) the degeneration of the myenteric and submucosal plexes of nerves. Nervous degeneration leads to incoordination of smooth muscle contraction and disordered, ineffective peristalsis.

DIAGNOSIS

Clinical Presentation Differentiation between partial mechanical small bowel obstruction and the numerous syndromes of pseudo-obstruction can be very difficult. Both groups of patients present with recurrent attacks of obstruction characterized by nausea, vomiting, crampy abdominal pain, and distention. With pseudo-obstruction, these attacks are highly variable in frequency, severity, and duration but tend to worsen to a point where the syndrome never fully resolves and the patient has constant symptoms. Obstipation

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and constipation are uncommon complaints. More likely, they will have diarrhea associated with the attacks. 18• 65· 71 The diagnosis is often made only after repeated laparotomies fail to disclose a mechanical cause of obstruction. Radiologic Diagnosis Radiologic examination in the patient with small bowel obstruction or pseudo-obstruction is aimed at differentiating a mechanical cause of obstruction from a pseudo-obstruction. An upper gastrointestinal series with enteroclysis should be used to identifY areas of dysmotility and to suggest the differential diagnosis. A barium small bowel series or enteroclysis will show mechanical obstruction usually within 1 hour of barium ingestion. Patients with pseudo-obstruction, like those with adynamic ileus, will have a prolonged transit time of barium to the colon (4 to 5 hours) and will not have an identifiable mechanical cause of obstruction. 61 Manometric Evaluation Intubation of the small bowel with multilumen long intestinal tubes for the purpose of recording contractions is a relatively new and productive method of studying intestinal pseudo-obstruction. Manometry is performed in the same manner as esophageal manometry, with a multilumen polyvinyl tube introduced into the lumen of the small bowel. The holes of the tubes are located at intervals and are perfused with sterile water at a slow rate powered by a pneumatic perfusion machine. Pressure transducers attached to the column of water are monitored by a chart recorder, thus identifYing peristaltic waves in the small intestine. Both fasting and fed states can be identified. Two manometric patterns of pseudo-obstruction can be identified: (1) infrequent low-amplitude contractions characteristic of smooth muscle degeneration (Fig. 2) and (2) multiple disordered clustered contractions characteristic of nervous degeneration of the myenteric plexus (Fig. 3). Characterization of the manometric patterns in health and disease is beyond the scope of this article, and the reader is referred to the literature. 45 • 75 • 76 Radionuclide Evaluation Several new methods of radioactive labeling have allowed accurate measurement of intestinal transit time. Radionuclide motility studies have not been used to differentiate mechanical obstruction from pseudo-obstruction but rather are useful tools to confirm motility problems and to evaluate the effects of medication on small bowel motility -in patients with pseudoobstruction. Camilleri and associates describe the use of nondigestible 1131-fiber for evaluating small bowel transit. 10 As predicted, the patients with manometric disturbances of intestinal motility had prolonged transit times. Others have used technetium-99-labeled pellets to determine small bowel transit time. These investigators were also able to identifY small bowel dysmotility in patients with pseudo-obstruction. 49 These studies deliver a very low dose of radiation to the patient, thus allowing repeated use to evaluate the efficacy of treatment.

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OBSTRUCTION OF THE LARGE AND SMALL INTESTINE

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Figure 2. Tracing of small bowel manometry in a 56-year-old woman with scleroderma and symptoms of small bowel obstruction. There is near-complete absence of phasic pressure activity in the antrum, duodenum, and proximal jejunum--all consistent with pseudoobstruction caused by scleroderma and diseased smooth muscle of the gut. (From Malagelada JR, Camilleri M, Stanghellini V: Manometric Diagnosis of Gastrointestinal Motility Disorders. New York, Thieme, Inc, 1986; with permission.)

Postprandial nausea and vomiting but no intestinal symptoms Proximal duodenum

Age: 6 yrs

(12111/80) Proximal jejunum

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Intestinal obstructive symptoms after a total gastrectomy Proximal •mall bowel

Age: 8yrs (7 I 14/82)

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Figure 3. Progression of abnormal intestinal activity characteristic ot pseudo-obstruction secondary to neurologic degeneration of the myenteric plexus. Top tracing at age 6 shows normal fasting pattern of motility with a propagated peristaltic wave. Bottom tracing at age 8 shows multiple disorganized non peristaltic bursts of intestinal contractions. (From Malagelada JR, Camilleri M, Stanghellini V: Manometric Diagnosis of Gastrointestinal Motility Disorders. New York, Thieme, Inc, 1986; with permission.)

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·SURGERY

Often, patients with pseudo-obstruction are operated on with a preoperative diagnosis of mechanical obstruction. Once no mechanical cause for obstruction is identified, what should be done surgically? A full-thickness biopsy of the affected segment of intestine is highly recommended. Histologic study may be able to identify smooth muscle degeneration or, with the help of special silver stains of the myenteric plexus, nerve degeneration as a cause of pseudo-obstruction. The special techniques used for the silver staining are described by Schuffier and associates. 64 The biopsy should be full thickness and at least 2 X 2 em to allow adequate study. Although it is generally undesirable to open obstructed segments of bowel, these types of full-thickness biopsies have been performed by a number of surgeons without excess mortality or morbidity rates. Schuffier and Deitch identify four categories of pseudo-obstruction that have different treatments: (1) esophageal-predominant, treated with balloon dilation; (2) gastroduodenal-predominant, usually treated with vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy although if limited to the duodenum duodenojejunostomy may be apropriate; and (3) small bowelpredominant, treated with venting gastrostomies and long-term intravenous alimentation when necessary. 63 Repeated laparotomies are to be avoided because inadvertent damage to the small bowel ensues, necessitating resection that can lead to short gut syndrome. Patients should be treated with tube decompression of the gastrointestinal tract and intraveous alimentation during exacerbation of pseudo-obstruction. The fourth type, recurrent colonic-predominant pseudo-obstruction, is treated with colectomy and ileorectal anastomosis at the peritoneal reflection. There also have been scattered reports of segmental secretions of small bowel that have resolved completely the syndrome of pseudo-obstruction. 64 These reports are rare and are not the exp{lcted situation for most of the pseudoobstructions where there is widespread pathology throughout the gastrointestinal tract. 65 Pitt and associates have advocated the use of venting gastrostomies combined with the use of parenteral nutrition at home to allow patients with frequent episodes of pseudo-obstruction to manage their care without hospitalization. 56 When patients develop acute pseudo-obstruction, they open the venting gastrostomy to decompress the gastrointestinal tract. Intravenous alimentation can then be used to provide adequate fluids and calories, allowing the patient to treat multiple episodes of pseudo-obstruction at home. The use of venting gastrostomy also has the advantage of avoiding the use of nasogastric tubes that are uncomfortable and can cause recurrent aspiration when left in place for long periods of time.

MEDICAL TREATMENT

Although laparotomy is common prior to the diagnosis of pseudoobstruction, it is avoided after confirmation of pseudo-obstruction so medical treatment promises to be utilized more frequently. Occasional reports of

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cure using medications surface in the medical literature. Luderer and associates report the case of a 53-year-old woman with pseudo-obstruction and elevated prostaglandin E levels (1216 pgm/ml), and impaired platelet aggregation with ADP. 43 Treatment with indomethacin, an inhibitor of prostaglandin synthesis, reduced prostaglandin E levels to normal and reversed the pseudo-obstruction. Cisapride, a new prokinetic agent not yet available for clinical use in the United States, may prove useful in the treatment of intestinal pseudoobstruction. Cisapride has prokinetic activity in the esophagus, stomach, and small intestine that acts to release acetylcholine in the myenteric plexus of the intestine, thus increasing muscle activity. One child with duodenalpredominant pseudo-obstruction and cystic fibrosis had a good response to cisapride administration. Motility studies done before and after drug administration showed resumption of some irregular contractile activity in the fed state that had previously been absent. 28 Administration of cisapride to normal volunteers has increased lower esophageal sphincter pressures, 67 decreased reflux of bile salts into the stomach, 47 and reversed dopamine-induced gastric stasis. 48 It also induces prolonged peristaltic phase activity in fasting humans, 69 and it has been effective in increasing gastric emptying in patients with a demonstrable delay of gastric emptying and dyspepsia. 30 Early reports also suggest that cisapride can decrease intestinal transit time in patients with chronic idiopathic pseudo-obstruction. 10 Cholinergic drugs such as prostigmine have been used with various degrees of success in the treatment of chronic idiopathic pseudo-obstruction. One recent report relates a good response to intravenous prostigmine and cholecystokinin in two brothers for 3 years before the effects of these drugs dissipated. 40 So far, there are no hard and true guidelines for using these drugs, but the future holds promise for pharmacologic manipulation of intestinal motility.

LARGE BOWEL OBSTRUCTION The most important new development in large bowel obstruction has been the use of endoscopic equipment in the diagnosis and treatment not only of the mechanical obstruction but also of pseudo-obstruction. There have been a number of reports reconfirming long-held beliefs about the treatment of volvulus. Over the past 20 years, there has been a significant drop in morbidity and mortality rates for elective colon operation, but the mortality rate for emergency colon operations is still two to four times higher than that for elective operation. 22 • 29

DIAGNOSIS OF MALIGNANT OBSTRUCTION

Dudley and Brown note that large bowel obstruction is rarely a true emergency requiring immediate surgery, 16 so evaluation of the nature and level of suspected obstruction with a contrast enema or diagnostic colon-

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oscopy is desirable. 74 Koruth and associates identified 29 of 79 patients suspected of having colonic obstruction as having no obstruction by contrast enema. 36 These patients were saved from possible inappropriate laparotomy for mechanical bowel obstruction that did not exist. In 12 patients suspected of having colonic pseudo-obstruction, the contrast enema identified two with mechanical obstruction. Similarly, in 99 patients thought to have mechanical large bowel obstruction, 35 were found to have no obstruction by contrast enema. 73 Contrast enema also identified two of 18 patients suspected of having pseudo-obstruction as having mechanical large bowel obstruction. It could be argued that colonoscopy should be attempted rather than contrast enema in suspected cases of pseudo-obstruction because colonoscopy could be both diagnostic and therapeutic. However, these series point out the great value of careful evaluation of suspected mechanical obstruction before operation is undertaken.

TREATMENT

Endoscopic Treatment More revolutionary is the concept of using endoscopic techniques to treat malignant bowel obstruction. Two techniques have been described: (1) the obstructing tumor is identified endoscopically and a guide wire is passed through the narrowed lumen to permit successively large tubes to be inserted to decompress the colon, 42 or (2) photocoagulation of the tumor with a laser is used to recanalize the intestinal lumen. 33 Lelcuk and associates were able to decompress three of four patients preoperatively using the guide wire technique, 42 and Kiefhaber and colleagues were able to relieve obstruction in 54 of 57 cases of cancerous obstruction of the colon by laser photocoagulation. 33 The degree of obstruction in these series is not described but was probably partial. Changes in Treatment of Volvulus Sigmoid volvulus caused 6.1 per cent of the intestinal obstructions reported in 16 series. 3 • 4 Sigmoidoscopic decompression of the volvulus with insertion of a rectal tube in the patient without signs of gangrene or perforation can be expected to relieve the obstruction in the majority of cases (84 per cent to 91 per cent). 1• 3 • 4 Most investigators have used the rigid sigmoidoscope when treating sigmoid volvulus, but one series reports the successful use of the colonoscope in three patients for detorsion of the volvulus when rigid sigmoidoscopy was unsuccessful. 70 Since the recurrence rate of volvulus is 40 per cent to 90 per cent, definitive operation is recommended in patients with reasonable operative risk. Resection of the involved colon has been the most successful operation in preventing recurrent volvulus. Operative Treatment of Malignant Obstruction A number of surgeons have advocated primary resection of obstructing lesions with immediate anastomosis. Klatt and associates reported the use

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Figure 4. Technique of intraoperative antegrade irrigation of the large intestine for bowel preparation prior to resection at obstructing colon lesions and then primary anastomosis. (From Radcliffe AG, Dudley HAF: Intraoperative antegrade irrigation of the large intestine. Surg Gynecol Obstet 156:721-723, 1983; with permission.)

of a chest tube attached to suction inserted into the colon to evacuate stool from the obstructed colon, thus allowing immediate anastomosis. 34 They had no operative deaths in the five patients reported. A means of intraoperative colonic irrigation has been devised and advocated by Radcliffe and Dudley. 59 In 50 patients with obstructing colon lesions, they had one operative death and only two clinically apparent anastomotic leaks. Their technique of intraoperative bowel preparation (Fig. 4) 37 has been used by other investigators with good results. Koruth and associates reviewed 47 patients with obstructing left-sided colon cancers that had intraoperative irrigation of the bowel. 35 The mortality rate was 8.5 per cent, the rate of clinically significant anastomotic leak was 8.5 per cent, and the wound infection rate was 2.1 per cent (all the incisions were closed primarily after antibiotic irrigation). Still, the decision for resection and primary anastomosis rests with the surgeon, and some factors may dissuade the surgeon from this course of action. Advanced malignancy and signs of peritonitis are relative contraindications to primary anastomosis. An alternative is primary resection with colostomy. 14 This procedure gave effective palliation in 80 per cent of the patients in the series reported by Day and Bates, with a low mortality rate (5 per cent). The primary resection also has the benefit of removing the malignancy so that the disease process that brought the patient to the hospital has been treated. Comparison of the 5-year survival rates of patients with obstructing colon carcinomas treated with primary resection and anastomosis and those treated with staged operations shows a significantly better outcome (47.5 per cent versus 20.8 per cent) for the patients with primary resection. 81 This result is attributed to the delay in curative resection in the patients undergoing staged operations and to spread of tumor within the veins draining the lesion during the multiple manipulations of staged surgeries. However, although the patients with primary resections and anastomosis had higher 5-year survival rates, the mortality rate related to the operative procedure (primarily frorn anastomotic leak

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and sepsis) was 16.6 per cent compared with 10 per cep.t for those patients undergoing staged operations. For patients with obstructing cancers, primary resection of the tumor may have advantages and may result in a higher long-term survival, but fecal contamination of the abdominal cavity should be viewed as a contraindication to primary anastomosis.

COLONIC PSEUDO-OBSTRUCTION This subject has been a big story in recent years with a proliferation of reports from around the world. Many of the clinical features are indistinguishable from those of mechanical colon obstruction. Progressive abdominal distention over 3 to 4 days is the predominant and ubiquitous finding. The patient may have nausea, vomiting, and obstipation, although some patients continue to pass flatus and liquid stool. Leukocytosis, fever, ap.d abdominal tenderness are not uncommon but are not present in every patient. The typical patient is male and over 50 years old. Etiology Ogilvie in 1948 described two patients with enormous dilation of the colon without mechanical cause that he ascribed to an imbalance between the parasympathetic and sympathetic innervation to the colon. 52 In both cases, malignancy had invaded the celiac axis and, Ogilvie theorized, had interrupted the sympathetic Innervation of the colon, leaving the parasympathetic influence unopposed. The typical patient with colonic pseudoobstruction in 1987 does not have the same findings of invasion of the retroperitoneum by tumor, although an imbalance of sympathetic innervation is thought to play a role in the pathogenesis of disease. The patients usually have other serious illnesses or frequently are recovering from a major operation when they develop acute distention of the cecum. This syndrome must be differentiated from other entities, but diagnosis can be difficult. Gastric distention can be identified and cured when a nasogastric tube is placed; sigmoid volvulus is diagnosed and treated by sigmoidoscopy, usually with a large rush of gas and liquid feces. Pseudo-obstruction can be difficult to distinguish from cecal volvulus, but both need urgent decompression to avert perforation of the colon. 21 • 23 Treatment Tentative diagnosis of colonic pseudo-obstruction should lead to urgent colonoscopic examination for diagnosis ap.d then therapeutic decompression of the cecum in the fluoroscopy suite if possible. 6 • 50 Generally, decompres~ion of the cecum should be performed whenever its diameter exceeds 12 em. Carbon dioxide gas rather than air is used for insuffiation during the colonoscopic examination to further reduce distention of the cecum. Fluoroscopy allows more rapid intubation of the colon as well as definitive information on the success or failure of decompression. Initial decompression with coloqoscopy should be followed by serial examinations to identify recurrence of cecal distention, which occurred in 22 per cent of cases in one series. 80 Often, a gentle saline enema prior to colonoscopy will prevent

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expensive and maddening clogging of the suction channels of the colonascope with stool. A number of endoscopists also recommend use of a long tube to be advanced into position with the colonoscope to decompress the colon after withdrawal of the endoscope, thus alleviating the need for repeat colonoscopic decompression. 1• 6 • 7 · 23

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