ICU · Gastroenterology
Intestinal obstruction in ICU: mechanical and adynamic
Also known as Bowel obstruction · Small bowel obstruction · Large bowel obstruction · Pseudo-obstruction · Ogilvie syndrome · Volvulus · Strangulated bowel
Intestinal obstruction: blockage of bowel lumen (mechanical) or failure of peristalsis (adynamic/paralytic ileus). Small bowel obstruction (SBO): adhesions (60%), hernias (15%), malignancy (15%), Crohn's, intussusception. Large bowel obstruction (LBO): colorectal cancer (60%), volvulus (10-15%), diverticulitis (10%), faecal impaction. Pseudo-obstruction (Ogilvie): massive colonic dilation without mechanical obstruction, in critically ill patients. Strangulation: blood supply compromised → ischaemia → necrosis → perforation → peritonitis → death. ICU management: resuscitation, NGT decompression, 'drip and suck', surgery for strangulation/peritonitis/failed conservative. Pseudo-obstruction: neostigmine, colonoscopic decompression, surgery if fails.
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Red flags
- Strangulation (ischaemia) — tachycardia, fever, peritonitis, raised lactate → emergency surgery, mortality 10-30%
- Peritonitis (perforation) — rigid abdomen, free gas → emergency surgery
- Caecal diameter >9-12cm (Ogilvie) — perforation risk, neostigmine or colonoscopic decompression
- Closed-loop obstruction — volvulus, hernia → rapid strangulation, emergency surgery
- Sigmoid volvulus with 'coffee bean' sign — endoscopic detorsion, surgery if fails/recurrent
Meet the patient
A 68-year-old man with a previous open colectomy for diverticular disease arrives with 48 hours of colicky central abdominal pain, distension, bilious vomiting, and absolute constipation — no flatus, no stool. He is febrile to 37.9, tachycardic at 108, with a tense tympanitic abdomen and active tinkling bowel sounds. His potassium is 3.2 and his lactate is 1.4.[1]
Two questions decide his next hour, and they decide every obstruction: is the bowel strangulated? (continuous pain, peritonitis, a raised lactate, and CT signs of ischaemia send him to theatre now — strangulation rules out conservative treatment), and is this a simple adhesive SBO that will settle with drip and suck? (non-operative treatment works for most patients). Hold those two and the management ladder below slots into place.[1][2][3]
References10ShowHide
- [1]Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the World Society of Emergency Surgery ASBO working group World J Emerg Surg, 2018.PMID 29946347
- [2]Di Saverio S, Coccolini F, Galati M, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the World Society of Emergency Surgery ASBO working group World J Emerg Surg, 2013.PMID 24112637
- [3]Zielinski MD, Eiken PW, Bannon MP, et al. Small bowel obstruction-who needs an operation? A multivariate prediction model World J Surg, 2010.PMID 20217412
- [4]Millet I, Taourel P, Ruyer A, et al. Value of CT findings to predict surgical ischemia in small bowel obstruction: A systematic review and meta-analysis Eur Radiol, 2015.PMID 25850889
- [5]Rondenet C, Millet I, Corno L, et al. Increased unenhanced bowel-wall attenuation: a specific sign of bowel necrosis in closed-loop small-bowel obstruction Eur Radiol, 2018.PMID 29679213
- [6]Zielinski MD, Bannon MP Current management of small bowel obstruction Adv Surg, 2011.PMID 21954676
- [7]Mu JF, Wang Q, Wang SD, et al. Clinical factors associated with intestinal strangulating obstruction and recurrence in adhesive small bowel obstruction: A retrospective study of 288 cases Medicine (Baltimore), 2018.PMID 30142844
- [8]Ponec RJ, Saunders MD, et al. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med, 1999.PMID 10403850
- [9]Vanek VW, Al-Salti M Acute pseudo-obstruction of the colon (Ogilvie syndrome). An analysis of 400 cases. Dis Colon Rectum, 1986.PMID 3753674
- [10]Tian BWCA, Vigutto G, et al. WSES consensus guidelines on sigmoid volvulus management. World J Emerg Surg, 2023.PMID 37189134