Large Bowel Obstruction-Story of the Twist and the Telescope

Christian J. Ochoa Gillian Lieberman, MD

March 2002

Large Bowel Obstruction-Story of the Twist and the Telescope Christian J. Ochoa, Harvard Medical School- Year III Gillian Lieberman, MD

Christian J. Ochoa Gillian Lieberman, MD

Some Causes of Large Bowel Obstruction (LBO) „ „ „ „ „ „

Mechanical *Diverticulitis Intussusception *Sigmoid Volvulus *Cecal Volvulus *Cancer Adhesions

*most common

Functional „ „ „

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Post-Op ileus Inflammatory disorders Metabolic (e.g., hypokalemia) Toxic megacolon Ogilvie's syndrome nonobstructive colon dilatation 2

Christian J. Ochoa Gillian Lieberman, MD

Symptoms of LBO Abdominal pain „ Distention „ Constipation „ Obstipation „ Nausea „ Vomiting. „

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Christian J. Ochoa Gillian Lieberman, MD

Imaging Menu for LBO „ „

Supine and Upright Abdominal x-ray Barium Enema „

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Single or double contrast

CT „

Oral water soluble contrast, IV contrast and rectal contrast

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Christian J. Ochoa Gillian Lieberman, MD

Meet Patient I „

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20 year old woman presented to the ED with 12 hours of abdominal pain, nausea. and vomiting low grade fever. No past surgical history PMH: Polycystic ovarian disease

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Christian J. Ochoa Gillian Lieberman, MD

Patient I Zanogram

Frontal CT scout

Lateral CT scout

Dilated cecum Images courtesy of BIDMC Radiology Department; PACS

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Christian J. Ochoa Gillian Lieberman, MD

Patient I Axial CT CT Axial with IV and rectal contrast

Cecum

Images courtesy of BIDMC Radiology Department; PACS

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Christian J. Ochoa Gillian Lieberman, MD

Patient I CT Coronal reconstructions

Cecum

Contrast In Descending colon

Diagnosis: Cecal Volvulus Images courtesy of BIDMC Radiology Department; PACS 8

Christian J. Ochoa Gillian Lieberman, MD

Discussion of Cecal Volvulus „

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Need embryologic failure of the ascending colon to be fixed by its retroperitoneal attachments. Can be dx by plain radiographs in 38% to 89%. 89% In one large review, the abdominal plain film suggested the diagnosis in 46% of patients, but was diagnostic in only 17 %. BE may dx an additional 20%, and may also be therapeutic. Not to be performed in patients who are suspected of having intestinal gangrene. Netter, F. CIBA Collection 9

Christian J. Ochoa Gillian Lieberman, MD

Discussion of Cecal Volvulus Supine

Upright

Cecum

Air Fluid level

ACR Gastrointestinal Learning File, Copyright 1998 ACRI

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Christian J. Ochoa Gillian Lieberman, MD

Discussion of Cecal Volvulus Barium Enema „Law

of LaPlace, T = P × D; where T is wall tension; P, pressure; and D, diameter).

Outline of Cecum

„Acute

dilatation of the cecum to 10 cm suggests the potential for ischemia and if greater than 13 cm, rupture is thought to Ascending colon be imminent.

Point of Obstruction ACR Gastrointestinal Learning File, Copyright 1998 ACRI

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Christian J. Ochoa Gillian Lieberman, MD

Cecal Vs. Sigmoid Volvulus „

Cecal „

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40%-50% are Cecal depending on age and geographic location. Haustra are typically preserved. Surgery indicated since it is a closed loop obstruction with variable amounts of small bowel involved.

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Sigmoid „

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40-70% Sigmoid depending on age and geographic location. U-shaped structure with lack of haustration. Occurs more frequently in the elderly. Nonoperative management measures attempted in all patients, except in signs of ischemia.

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Christian J. Ochoa Gillian Lieberman, MD

Meet Patient II „

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27 year old Male with h/o Peptic Ulcer Disease with complaints of 3 weeks worsening abdominal pain and reported a one week history of diarrhea two to three times per day, non-bloody, no mucus, and no melena. Denied any weight loss. Past surgical history: Repair of varicocele Physical Exam: Question of a palpable right upper to right middle quadrant mass.

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Christian J. Ochoa Gillian Lieberman, MD

Patient II Diagnostics Supine CT scout Small bowel gas

Transverse Colon

Right Colonic Mass

Descending Colon

Images courtesy of BIDMC Radiology Department; PACS

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Christian J. Ochoa Gillian Lieberman, MD

Intussusception-CT Cecum and ascending colon Small bowel with contrast

Ileum with contrast Images courtesy of BIDMC Radiology Department; PACS

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Christian J. Ochoa Gillian Lieberman, MD

Intussusception-CT Descending colon with contrast and feces Mesenteric fat

Images courtesy of BIDMC Radiology Department; PACS

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Christian J. Ochoa Gillian Lieberman, MD

CT Coronal Reconstruction

Cecum and Ascending colon

Ileum with contrast

Images courtesy of BIDMC Radiology Department; PACS

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Christian J. Ochoa Gillian Lieberman, MD

Discussion of Intussusception „

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Intussusception is defined as the invagination of a proximal segment of bowel (intussusceptum) into an adjacent distal segment (intussuscipiens). Mostly a pediatric disorder but 5% occurs in adults, mostly due to underlying cause. „

The most common lesions associated are neoplasms inflammatory lesions, and Meckel's diverticula.

Netter, F. CIBA Collection 18

Christian J. Ochoa Gillian Lieberman, MD

Discussion of Intussception

Intussuscipien

Medial wall defect

Coiled spring appearance with barium enema.

Relief of intussusception with BE, by hydrostatic pressure. Medial wall defect suggestive of carcinoma.

ACR Gastrointestinal Learning File, Copyright 1998 ACRI

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Christian J. Ochoa Gillian Lieberman, MD

Menu of Tests for Intussusception „

Plain film-Supine and Upright „

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Ultrasound „ „

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May identify lead point Good for children

Contrast Studies-BE or air contrast „

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A soft-tissue density projecting into the gas of the large bowel (representing the intussusception) is called the "crescent sign".

Advantage of air contrast is that it is benign compared to barium and may also reduce the amount of radiation exposure and cost during intussusception reduction. BE or air contrast reduction successful in 75-90% in ileocolic intussusception

CT „ „

In adults it is useful in identifying underlying cause. In children it may be too time consuming and does not allow for reduction of the intussusception. 20

Christian J. Ochoa Gillian Lieberman, MD

Ultrasound for Intussusception „

Sensitivity and specificity reach 100% in children.

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A lack of perfusion in the intussusceptum detected with color duplex imaging may indicate ischemia. Kitagawa, S. & Migdady, M. Intussusception in children. UpToDate 2002

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Christian J. Ochoa Gillian Lieberman, MD

Follow-up on Our Patients „

Patient I „

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Cecal volvulus with right colectomy.

Patient II Ileocolectomy „ Adenocarcinoma of the cecum, moderately differentiated. „ T3 N1 with 1 out of 21 lymph nodes being positive „

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Christian J. Ochoa Gillian Lieberman, MD

References „ „ „ „

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ACR Gastrointestinal Learning File, Copyright 1998 ACRI Bonis, P. & Hodin, R. Cecal Volvulus. UpToDate® ©2002 Bonis, P. & Hodin, R. Sigmoid Volvulus. UpToDate® ©2002 Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 6th ed., 1998 W. B. Saunders Company Kitagawa, S. & Migdady, M. Intussusception in children. UpToDate 2002 Netter, F. CIBA Collection Gastrointestinal Part II 1986 Ott, DJ & Chen, M. Specific Acute Colonic Disorders. Radiological Clinics of North America. Vol 32 Number 5, p871-883. Sept. 1994 Rolandelli, R. & Roslyn, J. Colon and Rectum. Townsend: Sabiston Textbook of Surgery, 16th ed., 2001 W. B. Saunders Company. P930-973

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Christian J. Ochoa Gillian Lieberman, MD

Acknowledgements „ „

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Joseph Barry, MD Larry Barbaras and Cara Lyn D’amourWebmasters Gillian Lieberman, MD Pamela Lepkowski

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