Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 15 March 2006

BOWEL OBSTRUCTION - A VERY FRUSTRATING PROBLEM

          The lady was 56 years old and came to the emergency room because of bloating and abdominal pain.  She had been ill for approximately two days.  She stated that during this time whenever she ate something, she vomited it back and she had had no bowel movement for three days.  She did not have a fever.  On physical exam, her abdomen was quite protuberant.  She said she felt like she did when she was ready to deliver.  An x-ray was taken and showed that she had gas in her small bowel, a very abnormal finding.  With the whole clinical picture, at this point, she was diagnosed as having a small bowel obstruction.  She and her family had a thousand questions at this point.  In order to answer her questions, we first had to explain normal bowel function.

          The gastrointestinal tract, whereby your food is digested, begins at your mouth and runs approximately 25 to 30 feet as a long tube that exits at the anus.  The small bowel takes up most of this length with about six feet devoted to the large bowel and about three feet devoted to the distance from the mouth to the end of the stomach.  The rest of it is all small bowel.  There is musculature in the wall of the stomach, the small bowel, and even the colon that squiggles and contracts, pushing the food forward from the mouth through to the anus.  Absorption of food occurs all the way along the entire tract.  A bowel obstruction is what occurs when something blocks the movement of food through the intestinal tract.

          The most common cause of a bowel obstruction is an adhesion.  Adhesions occur when some infectious or inflammatory processes develop in the abdomen and loops of small bowel stick together with too sharp a curve for food to get around and move on.  Other forms of obstruction include a poor blood supply so that a piece of the small bowel actually doesn’t work or, very rarely, tumors occur in the small bowel.  Usually, there is no way to know exactly what is wrong without an operation.

          Now begins the problem.  If a person has an adhesion in the bowel, it very frequently comes from a previous surgery on the abdomen.  If you operate again, there is a chance of making more adhesions and more problems in the future so we like very much not to have to operate on people that have a small bowel obstruction.  Sometimes it is necessary, but is done only after prolonged consideration.

          It is that prolonged consideration that is so frustrating.  The best way to treat a small bowel obstruction is to put a tube thru the nose down to the stomach to suck out all of the stomach juice and whatever fluids are secreted into the bowel.  This produces what is called “bowel rest.”  Very frequently, simply giving the bowel time to relax and let the inflammation subside will allow the obstruction to release and no surgery is necessary.  However, to do this takes three or four or five days of sitting with a tube down your throat, not eating, and waiting.  Patients hate this, but it is the best alternative to avoid surgical interventions.  Just as a boil adequately drained will heal up, with the redness and swelling going away, taking the irritation off of the small bowel will allow the swelling to go down and the bowel obstruction release.

          The problem of care of a small bowel obstruction is timing.  When to stop waiting and go ahead and operate is a judgment call the surgeon needs to make.  Usually, this is by the third to the fifth day.  If an obstruction doesn’t release by the fifth day, it is unlikely that it will do so spontaneously without surgery and therefore surgery is recommended.  But surgery for a small bowel obstruction is no picnic.  There follow several more days of having a tube down your throat, not eating, and living on intravenous fluids, along with the post-operative surgical discomfort.  Therefore, we prefer not to operate if possible.

          Things that would indicate the need for surgery earlier or for sure is if we suspect that a piece of bowel has gotten inadequate blood supply and may be dead.  This is very dangerous and needs to be operated upon early.  Alternatively, if there are tumors present in the bowel, these need to be addressed surgically.  Sometimes the surgery is so simple that just snipping a band of adhesion between two loops of bowel will release the obstruction with a very quick recovery time.  But it is not always that easy.

          The healthcare providers at your local clinics and St. Mary’s Hospital in Pierre are well aware of the various considerations on how to manage a small bowel obstruction.  The surgeons, especially, are very careful in trying to avoid surgical intervention when it can be done.  They do not want grumpy customers any more then any merchant or professional.  As a note of advice to the general public, the sooner a person is seen to deal with this problem, the more likely the person is to avoid surgical intervention.  Several days of nausea and vomiting is not always due to “a little flu.”  Getting checked out early can save a lot of grief and maybe even a life.