Research Article

Conservative Treatment is the First Choice for Mechanical Bowel Obstruction Caused by Colonic Inertia

Wang F#, Deng C#and Jin H*
National Center of Colorectal Surgery, The 3rd Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, China
#These authors contributed equally to this work


*Corresponding author: Heiying Jin, National Center of Colorectal Surgery, The 3rd Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, 1 Jinling Road, Nanjing 210001, China


Published: 02 Jun 2016
Cite this article as: Wang F, Deng C, Jin H. Conservative Treatment is the First Choice for Mechanical Bowel Obstruction Caused by Colonic Inertia. Clin Surg. 2016; 1: 1028.

Abstract

Objective: To analyze and determine the clinical characteristics and diagnosis of mechanical bowel obstruction caused by colonic inertia and finds the best way to manage.
Methods: We reviewed the medical record of all 23 patients who diagnosed with mechanical bowel obstruction caused by colonic inertia in National Center for Colorectal Surgery, the Third Affiliated Hospital of Nanjing University of Chinese Medicine from 2005 to 2013 and analyze the clinical character characteristics and follow up them after treatment.
Results:21 patients were relieved by conservative treatment. Abdominal distension occurs repeatedly in one patient, ileostomy was performed for him. The patient who had history of transverse colostomy and the stoma closing surgery was not relived by conservative treatment and the obstruction progressed. Emergency Subtotal colectomy and ilealrectal anastomosis was performed for her. Follow-up 1-8 years (mean follow-up time: 4.7yrs ) was done for the 23 patients. Two patients who were performed surgical operation without any discomfort. The symptoms of bowel obstruction were recurrence in 8 patients, symptoms of 6 patients were relieved by conservative treatment again, and subtotal colectomy and ilealrectal anastomosis was performed for 2 patients. The remaining 13 patients without recurrence.
Conclusion: The conservative treatment is the first choice for mechanical bowel obstruction caused by colonic inertia. Ileostomy is a good choice for the patients whose obstruction symptoms sustained. At the emergency condition, the total colectomy should not be performed for it is in high risk.
Keywords: Colonic inertia; Bowel obstruction; Clinical characteristics; Management

Introduction

Colonic inertia results from the severe functional disturbance of colonic motility and no specific reason had been found. Patients with colonic inertia often complain of infrequent defecation, abdominal distention, formation of stool stone and sometimes causing the bowel obstruction [1,2]. However, in clinical experience, some patients without very long history of constipation may present abdominal pain, distension, vomiting, stop exhaust, defecation, sometimes present colon intestinal pattern and ileum peristalsis waves on right lower quadrant. The symptoms of distal small bowel obstruction cannot be relived through transverse colostomy, and it is difficult to deal with in clinical experience. We defined the symptom as "mechanical bowel obstruction caused by colonic inertia (MBOCI)". In our study, we report 23 consecutive patients with mechanical bowel obstruction caused by colonic inertia in National Center for Colorectal Surgery, the third Affiliated Hospital of Nanjing University of Chinese Medicine from Mar. 2005 to Dec.2013. We analyze their clinical features and treatment of the MBOCI.


Materials and Methods

Diagnostic criteria of MBOCI

① with or without constipation history; ② present with symptoms of bowel obstruction as abdominal distension, pain, anal stop exhaust, defecation; ③ present with colon intestinal pattern and ileum peristalsis waves; ④ abdominal X ray show distal ileum obstruction often exist in abdominal X ray. Colon, even rectum, expanded exists in abdominal CT scan. And there is no evidence of colon tumor or stool mass obstruction; ⑤ no colorectal tumor was found via colonoscopy after the enema, bowel infarction was excluded.

Figure 1

Another alt text

Figure 1
Abdominal X ray of patients with MBOCI (show patients presented with intestinal pattern; abdominal X ray of all patients showing characteristics of distal ileum obstruction).

Figure 2

Another alt text

Figure 2
Abdominal CT scan of patients with MBOCI (Colon expanded exist in abdominal CT scan, even rectum expanded).

Clinical data collection and patient’s follow-up

Patients with MBOCI in National Center for Colorectal Surgery, the third Affiliated Hospital of Nanjing University of Chinese Medicine from Mar. 2005 to Dec.2013. All clinical data were reviewed and collected the information about patient’s age, sex, clinical characteristics. All the patients were followed-up in out-patient clinics. The study was proved by the ethic committee of the third Affiliated Hospital of Nanjing University of Chinese Medicine and all the patients got the informed consent.


Results

Characteristics of patients with MBOCI

Twenty three patients were diagnosed with MBOCI in National Center for Colorectal Surgery, the third Affiliated Hospital of Nanjing University of Chinese Medicine from Mar. 2005 to Dec.2013. (7 male, 16 female, median age 51years, range 16-75 years). Ten patients have no constipation history. Two patients have 1-2 months history of constipation. Eleven patients have 1-10 years constipation history. One patient had history of transverse colostomy and the stoma closing surgery. One patient had history of rectal cancer surgery, and another one presented with abdominal distension, pain after eating "buckwheat" for 3 months. One patient presented with abdominal distension, pain after diarrhea for 2 months and the remaining patients had no obvious incentive. All patients presented with symptoms of bowel obstruction as abdominal distension, pain, anal stop exhaust and defecation. All patients presented with symptoms
of mechanical bowel obstruction as hyperactive bowel sounds. 15 patients presented with ileum peristalsis waves. All patients presented with intestinal pattern; abdominal X ray of all patients showing characteristics of distal ileum obstruction (Figure 1). Colon expanded exists in abdominal CT scan, even rectum expanded in 5 patients (Figure 2). And there is no evidence of colon tumor or stool mass obstruction.

Treatment strategy and short-term outcome

All patients were given conventional treatment for bowel obstruction, such as nutritional support, anti-infection, maintain fluid and electrolyte balance. Also, "small chengqitang" (traditional Chinese medicine) was given by enema. 21 patients were relieved by conservative treatment after 2 to 7days. Laxative medication was given after hospital discharge. One patient presented abdominal distension repeatedly within 2 months and ileostomy was performed for him. The patient who had history of transverse colostomy and the stoma closing surgery was not relived by conservative treatment and the obstruction progressed. Emergency Subtotal colectomy and ilealrectal anastomosis was performed for her.

Long-term outcome after treatment

Follow-up 2-10 years (mean follow-up time: 5.7yrs) was done for the 23 patients. Two patients who were performed surgical operation without any discomfort. The symptoms of bowel obstruction were recurrence in 8 patients, symptoms of 6 patients were relieved by conservative treatment, and subtotal colectomy and ilealrectal anastomosis was performed for 2 patients. The remaining 13 patients without recurrence (Table 1).


Discussion

Bowel obstruction remains a frequently encountered problem in abdominal surgery, and was classified by the location of obstruction, whether the obstruction is partial or complete, with or without blood circulation disorder, whether the obstruction is functional or mechanical, reasons of obstruction. In clinical practice, the "mechanical bowel obstruction caused by colonic inertia (MBOCI)" can be diagnosed as simple mechanical low level small bowel obstruction. Because of the colonic inertia and normal function of small bowel, the MBOCI can present mechanical bowel obstruction in small bowel and functional obstruction in colon and rectum. MBOCI should be differentially diagnosed to Ogilvie syndrome [3-5], chronic intestinal pseudo-obstruction [6-9], and paralytic ileus [10].

Ogilvie's syndrome is acute colonic dilatation without organic obstruction in a previously healthy colon. The exact cause of Ogilvie's syndrome remains unknown. It may be that relatively increased sympathetic tone and/or decreased parasympathetic tone leading to relaxed colon. Paralytic ileus usually coexisting with Ogilvie's syndrome [4-6]. Chronic intestinal pseudo-obstruction is a severe digestive syndrome characterized by derangement of gut propulsive motility, in the absence of any obstructive process. It may be idiopathic or secondary to a variety of diseases. Based on histological features intestinal pseudo-obstruction can be classified into three main categories: neuropathies, mesenchymopathies, and myopathies, according on the predominant involvement of enteric neurones, interstitial cells of Cajal or smooth muscle cells, respectively [8,9]. Paralytic ileus may be caused by abdominal surgery or certain medications, such as opioids, and the patient can be gradually recover after conservative treatment [10]. MBOCI seems to be a special type of mechanical distal ileum obstruction.

For lack of knowledge to MBOCI in the past, conventional treatments for bowel obstruction may be ineffective. In our study, one patient had history of transverse colostomy for bowel obstruction, but the symptoms of bowel obstruction were not relived. To relive the symptom of MBOCI, the colonic inertia should be treat. In our study, except for conventional treatments for bowel obstruction were given, "small chengqitang" (traditional Chinese medicine) was given by enema. These herbs can improve the motility of colon and can relive the symptom of MBOCI.

Colonoscopy was underwent for patients with MBOCI to exclude colon tumor or stool mass obstruction, also abdominal distension will be relived obviously after the examination of colonoscopy. If the conservative treatment does not work, ileostomy should be choice of treatment for the patients MBOCI. It should be further discussed on deciding whether to perform Subtotal colectomy and timing of the surgery and emergency subtotal colectomy should not avoid because of high mortality and morbiduty [11,12]. In our series, one patient was not relived by conservative treatment, the obstruction progressed. Subtotal colectomy and ileo-rectal anastomosis was performed for him. But the complications experienced after surgery, such as slow recovery of intestinal motility, surgical wound infection and pneumonia. Therefore, even at the emergency condition, the sutotal colectomy should not be avoided; ileostomy may be a good choice at the moment. In our study, symptoms of bowel obstruction were recurrence in 8 patients, symptoms of 6 patients were relieved by conservative treatment, and subtotal colectomy and ilealrectal anastomosis was performed for 2 patients in other hospital. The mechanism of MBOCI remains unknown. Pathological examination
of the patient who underdone total colectomy suggested no abnormalities, and intestinal ganglion cells also are normal. Further studies are necessary for the etiology.

In conclusion, MBOCI is a special type of bowel obstruction. Symptoms of mechanical low bowel obstruction usually presents abruptly, with colon intestinal pattern and ileum peristalsis waves. Colon, even rectum, expanded exist in abdominal CT scan. And there is no evidence of colon tumor or stool mass obstruction. The conservative treatment is the main choice for mechanical bowel obstruction caused by colonic inertia. Ileostomy is a good choice for the patients whose obstruction symptoms sustained. At the emergency condition, the total colectomy should not be avoided and the proper surgical moment should be further discussed.

Table 1

Another alt text

Table 1
Results of treatment and follow-up.

References

  1. Zhao JS, Tong WD. [Pathophysiology of slow transit constipation]. Zhonghua Wei Chang Wai Ke Za Zhi. 2012; 15: 758-760.
  2. Chuangang Fu. Indications for surgical treatment and the choice of surgical approach for Constipation. Chinese Journal of Gastrointestinal Surgery. 2007; 1: 109-111
  3. Ben Ameur H, Boujelbene S, Beyrouti MI. [Treatment of acute colonic pseudo-obstruction (Ogilvie's Syndrome). Systematic review]. Tunis Med. 2013; 91: 565-572.
  4. Wiersema US, Bruno MJ, Tjwa ET. On colonoscopy in acute colonic pseudo obstruction. Eur J Intern Med. 2013; 24: e86-87.
  5. Zapatier JA, Ukleja A. Intestinal obstruction and pseudo-obstruction in patients with systemic sclerosis. Acta Gastroenterol Latinoam. 2013; 43: 227-230.
  6. Gabbard SL, Lacy BE. Chronic intestinal pseudo-obstruction. Nutr Clin Pract. 2013; 28: 307-316.
  7. Fukudo S, Kuwano H, Miwa H. Management and pathophysiology of functional gastrointestinal disorders. Digestion. 2012; 85: 85-89.
  8. De Giorgio R, Cogliandro RF, Barbara G, Corinaldesi R, Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol Clin North Am. 2011; 40: 787-807
  9. Ohkubo H, Iida H, Takahashi H, Yamada E, Sakai E, Higurashi T, et al. An epidemiologic survey of chronic intestinal pseudo-obstruction and evaluation of the newly proposed diagnostic criteria. Digestion. 2012; 86: 12-19.
  10. Zaide Wu, Mengchao Wu. Huang Si surgery.M.7edition.Beijing: People Health Press. 2008.
  11. Reshef A, Alves-Ferreira P, Zutshi M, Hull T, Gurland B. Colectomy for slow transit constipation: effective for patients with coexistent obstructed defecation. Int J Colorectal Dis. 2013; 28: 841-847.
  12. CHan EC, Oh HK, Ha HK, Choe EK, Moon SH, Ryoo SB, et al. Favorable surgical treatment outcomes for chronic constipation with features of colonic pseudo-obstruction. World J Gastroenterol. 2012; 18: 4441-4446.