Large bowel obstruction

Abstract

One hundred ninety-seven patients with large bowel obstruction seen in a municipal hospital were reviewed; the mortality rate was 32 per cent. This can be attributed mostly to the elderly age of the patients, the advanced state of malignancy and the duration of the obstruction. In about half the patients the usual quiet onset of obstipation and constipation was prominent, but in the other half a variety of symptoms were emphasized: hypogastric crampy pain, diarrhea, periumbilical crampy pain and acuteness of onset. The usual lesion was carcinoma, with the remaining relatively frequent lesions being volvulus and diverticulitis. Of particular interest were a few cases in which the precipitating factor was paralytic ileus producing large bowel obstruction at a natural flexion point such as the right colon, splenic flexure or sigmoid colon. Perforations could be diagnosed by characteristic physical signs and x-ray findings. The mortality rate of these patients was no different from the rest of the patients, probably emphasizing the value of antibiotics. The usual x-ray pattern of a dilated large bowel was found in 60 per cent of the patients but in the remainder, varying degrees of small bowel obstruction were seen which confused the diagnosis and required a barium enema for clarification. The typical patterns of ileocecal and sigmoid volvulus were discussed and reviewed. It is emphasized that these should be carefully known by all surgeons, since the treatment of these conditions varies from that of the usual treatment of large bowel obstruction. The ideal treatment of large bowel obstruction demands careful evaluation of the patient's condition and correction of any metabolic or physiological defect. A proper operation is decompression at a location which will not interfere with subsequent resection. The pros and cons of cecostomy for transverse colostomy are briefly reviewed. There still appears to be a place for cecostomy in the treatment of large bowel obstruction, particularly in lesions of the right colon and in the poor-risk patient. At operation it is also important to explore only minimally and to be sure to decompress. The best anesthesia for most patients appears to be endotracheal anesthesia. Rarely local anesthesia may be useful in poor-risk patients but care should be taken to prevent aspiration. The paradox of relatively low mortality in subsequent resections of the colon in patients who survive again emphasizes the severity of large bowel obstruction and the need for better preoperative treatment.