Date Published: July 14, 2009
Publisher: Public Library of Science
Author(s): Salomone Di Saverio, Gregorio Tugnoli, Paolo Emilio Orlandi, Marco Casali, Fausto Catena, Andrea Biscardi, Omeshnie Pillay, Franco Baldoni, Ronald C. W. Ma
Abstract: Salomone Di Saverio and colleagues discuss the diagnosis and management of a man presenting with symptoms of partial intestinal obstruction.
Partial Text: In summer 2008, a 73-year-old man arrived in the emergency room with vague abdominal pain. On examination, his abdomen was distended and tympanic, but soft and non-tender on palpation. The patient had been immobile and bed-ridden since 1995, when he had neurosurgical resection of a medullary ependymoma of the spine, with residual paraplegia, peripheral neuropathy, and a neuropathic bladder with secondary chronic renal failure. The patient had a medical history of hypertension and type II diabetes mellitus and suffered from chronic constipation with recurrent episodes of partial bowel obstruction.
The full diagnostic workup is shown in Box 1, and Figure 1 shows a flow diagram for diagnostic assessment of bowel obstruction. The usual sequence of investigations starts with plain abdominal X-ray (see Figure 1). In the absence of grossly distended bowel loops on X-ray, and if the patient’s condition is stable, ultrasound can be useful to rule out (1) other conditions or diseases causing paralytic ileus or (2) the presence of intraperitoneal free fluid. If the plain abdominal X-ray shows air fluid levels and grossly distended bowel loops, the level and possible site of obstruction must be assessed (i.e., small bowel or large bowel), and the further diagnostic workup proceeds accordingly. When in doubt, or when the clinical and radiological findings are not clear enough to suggest the best further diagnostic steps, abdominal computed tomography (CT) scan may be helpful, with the eventual adjunct of triple contrast (intravenous, oral, and/or rectal). The last diagnostic options are diagnostic laparoscopy or exploratory laparotomy.
This patient has partial large bowel obstruction. The differential diagnosis is between malignant obstructing diseases, such as colon cancer, or benign conditions, such as sigmoid volvulus or diverticulitis. These benign conditions can be life-threatening because of the risk of colonic ischaemia and/or perforation.
In patients receiving palliative care, the underlying causal factors for constipation are likely to be long-standing. The patient’s bowel pattern needs to be carefully assessed, with a focus on looking for modifiable factors. For example, if a particular pharmacological agent is identified as a possible causative factor, it may be helpful to change the agent or the route of its administration. It is also helpful to anticipate the constipating effects of medications, such as opioids, and to provide laxatives prophylactically. Other concomitant or contributing factors such as electrolyte imbalances or metabolic/endocrine abnormalities should be identified and corrected. However, the underlying cause of constipation is often unavoidable and pharmacological treatment is often necessary .
Serial plain abdominal X-rays had already been performed. Colonoscopy was not feasible, because the severe faecal impaction may have hindered the progression of the endoscope and affected the sensitivity of the exam by covering and camouflaging possible mucosal lesions of the colonic wall. Contrast enema would probably not have been effective or diagnostic. Therefore abdominal CT scan with multiplanar reconstruction and three-dimensional (3-D) reconstruction appeared to be the best option as a further diagnostic step, in order to assess the presence of an anatomic cause for the patient’s bowel obstruction.
Rehydration, multiple enemas, the prokinetic agent neostigmine (see Box 4), and laxatives were continued with gradual relief of the bowel obstruction and resolution of the faecal impaction.
If people in Western societies continue to live longer, we are likely to see an increase in the number of institutionalised elderly people with impaired mobility. Both ageing and immobility are risk factors for constipation. The estimated prevalence of constipation is between 2%–28%, and the number of people reporting constipation increases with age –. Constipation is more severe in those with pre-existing neurological illness and injury ,. A US study found that constipation was more common in women, African Americans, people from lower socioeconomic levels, and those living in rural areas and northern states . Faecal impaction is common in frail ill elderly people or in people of any age if they have a neurologic impairment (e.g., spinal cord injury, stroke, multiple sclerosis, spina bifida).