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Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. Patients may develop bowel obstruction at any time in their clinical history, with a prevalence ranging from 5.5% to 42% in those with ovarian cancer and from 10% to 28.4% in those with colorectal cancer. The causes of the obstruction may be benign postoperative adhesions, a focal malignant or benign deposit, or relapse or diffuse carcinomatosis. The symptoms, which are almost always present, are intestinal colic, continuous abdominal pain, nausea, and vomiting. Although surgery should be the primary treatment for malignant obstruction, it is now recognized that some patients with advanced disease or in generally poor condition are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. In this review, the indications for surgery are examined, the use of nasogastric tube and percutaneous gastrostomy evaluated, and the pharmacologic approach described.
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PMID:Management of bowel obstruction in advanced cancer. 752 46

Conservative management of bowel obstruction in advanced cancer patients has been recognized as efficacious in controlling distressing symptoms such as nausea, vomiting and pain. A retrospective analysis of prevalence, treatment and outcome was performed. A group of 25 patients with signs of bowel obstruction were studied from 1001 consecutive patients receiving palliative care at home. A score for total distress was calculated to assess the gastrointestinal symptoms at diagnosis, after 1 week of treatment and 1 day before death. The mean survival was 19 days. Six patients were admitted to hospital, 3 of whom underwent surgery and died in the immediate postoperative period. The patients diagnosed in hospital and discharged received a nasogastric tube (7 cases) and a central venous line. The nasogastric tube was removed after gastrointestinal secretions had been controlled by a combination of drugs, and parenteral nutrition or hydration, mainly started in hospital, was discontinued only a few days before death (13 cases, mean duration 19 days). The distress symptom score was statistically reduced after 1 week of treatment and on the day before death when compared to the referral time. The most frequent combination of drugs was octreotide, haloperidol and low doses of morphine. A subcutaneous route was preferred for administering the drugs. Utilization of a wide range of drugs permits good symptom control for bowel obstruction in patients followed at home.
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PMID:Bowel obstruction in home-care cancer patients: 4 years experience. 754 74

Complications possibly related to battle injuries are not necessarily discovered immediately postwounding, but may surface many months or years later. Sometimes, the relationship is evident, but often it is difficult to prove the connection. Between 1975 to 1989, we treated 260 veteran wounded from Israel's wars (1948 to 1982). Of these, 122 patients suffered from abdominal complaints, and this study relates only to this group. Eighty percent of them had undergone surgery caused by abdominal trauma at the time of the original injury, and the remaining 20% were injured in areas other than the abdomen. Their complaints manifested several weeks to 35 years postinjury. Diagnosis was delayed for 1 to 8 years in 70% of the patients. Acute or chronic pain, dyspepsia, intolerance to certain foods, early satiety, nausea, vomiting, distension, disturbances in bowel movements, and discharge from unhealed wounds were the most frequently encountered complaints. After evaluation and diagnostic work-up, it was possible to establish diagnosis and afford appropriate treatment in 97 (77%) of the patients. Peptic ulcers were found in 31 patients; 10 required surgery for ulcer-related complications. Acute and repeated attacks of intestinal obstruction occurred in 19 patients; 14 required surgery. The cause of obstruction was adhesions in nine, and strictures, incarcerated hernias, and abscess formation in the rest. Ventral hernias at surgical, ostomy, and drain sites were found and repaired in 49 patients. Abdominal wall sinuses originating from foreign bodies or osteomyelitis were found in 13 patients, and low output enterocutaneous fistulas were found in three patients. Chronic abdominal abscesses were found in 15 patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Late abdominal complications in war wounded. 786 59

A 35-year-old female presented with recurrent right lower quadrant pain, nausea, and vomiting. She was afebrile with diffuse abdominal tenderness. Plain x-ray of abdomen revealed small bowel obstruction. A barium x-ray of the small bowel showed stricture of the terminal ileum. A CT scan of the abdomen showed a 6-cm mass in right lower quadrant. She was empirically managed as having Crohn's disease. She underwent laparotomy after failure of medical management with high-dose steroids. There was ulceration and narrowing of terminal ileum. Frozen sections revealed endometriosis. Ileocecectomy was performed. Histopathology of resected specimen confirmed the diagnosis of endometriosis, and there was no evidence of chronic inflammatory bowel disease or neoplasia. Ileal endometriosis should be considered in the differential diagnosis of Crohn's disease in menstruating females presenting with perimenstrual symptoms.
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PMID:Small bowel endometriosis masquerading as regional enteritis. 817 27

Intestinal obstruction during pregnancy is a rare and dangerous complication. The causes of its occurrence are previous operations ad inflammation and one of their results: adhesions. Symptoms of intestinal obstruction (nausea, vomiting, constipation) rarely occur simultaneously and often accompany normal pregnancy, hampering diagnosis. Abdominal X-ray often represents the only complementary investigation diriment for diagnosis. A case of intestinal obstruction at 36 weeks gestation is reported to emphasize diagnostic difficulties of this rare pregnancy complication.
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PMID:[A case of intestinal obstruction in pregnancy]. 817 65

Benign abdominal cystic tumors are rare. They include retroperitoneal, mesenteric, and omental cysts. Most of these lesions present with vague abdominal pain and nausea. Less commonly they will present with bowel obstruction due to external compression. The diagnosis of these tumors is by abdominal ultrasound or computed tomography. Surgical enucleation is the treatment of choice. Laparoscopic surgical techniques are replacing or complimenting open abdominal surgical procedures. As the indications for these techniques increase, newer applications will arise. Presented here is a case of laparoscopic excision of a mesenteric cyst.
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PMID:Laparoscopic excision of a mesenteric cyst. 834 89

Enteral feedings demonstrably lower the risk of septic complications. However, complications associated with the specific method of enteral feeding may diminish the intended benefits. The objective was to determine the short and long-term complications associated with needle catheter jejunostomy (NCJ). All NCJs placed at a Level I trauma center over an 8-year period were reviewed. Short-term complications directly attributable to NCJ were defined as tube leakage with intraabdominal or intraparietal spillage, intraabdominal abscess, small bowel obstruction at the catheter site, tube blockage or dislodgement, or soft tissue infection. Telephone interviews were conducted to elicit long-term complications, including operations to correct a complication of the NCJ, chronic nausea, vomiting, diarrhea, bloating, hernia, or change in appetite. Of 122 study patients, short-term complications (N = 22) included two abscesses, one bowel obstruction, two abdominal wall infections, three leaks, one local soft tissue infection, one enterocutaneous fistula, three blocked catheters, and nine tube dislodgements. Fifty patients were contacted by telephone; 19 had long-term complications, including two operations for adhesions. Complications associated with NCJ are common, may be life-threatening, and may require surgical intervention. In many cases, other methods of enteral feeding access may be preferable to NCJ.
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PMID:Analysis of complications and long-term outcome of trauma patients with needle catheter jejunostomy. 854 Jun 44

Chronic intestinal pseudo-obstruction denotes the clinical picture that results due to the failure of intestinal peristalsis to overcome the normal resistance to flow and is characterized by recurrent episodes of signs and symptoms of intestinal obstruction in the absence of any mechanical compromise of the intestinal lumen. The region(s) of the gut affected may be isolated or diffuse. It is not uncommon to find evidence of autonomic neuropathy and smooth muscle dysfunction with extraintestinal manifestations such as urinary symptoms from abnormal ureter or bladder function. Intestinal pseudo-obstruction can be caused by a variety of diseases, and for simplicity, certain authors have divided it into myopathic and neuropathic categories. Intestinal pseudo-obstruction may present at any age with a variable amount of abdominal pain, distension, nausea, diarrhea, or constipation and with laboratory abnormalities usually reflecting the degree of malabsorption and malnutrition present. The radiologic findings are varied but commonly include paralytic ileus or signs of apparent clinical obstruction with dilated loops of bowel. The number of pseudo-obstruction cases is dependent on how one defines the condition. It appears prudent to require radiographic abnormalities consistent with obstruction on a plain film of the abdomen for the diagnosis. More recently, studies have focused on the gastrointestinal manometric abnormalities of the stomach and small intestine in chronic intestinal pseudo-obstruction during fasting and fed states; however, sensitivity and specificity of these abnormalities are not well defined. Treatment is aimed at limiting symptoms and maintaining adequate nutrition. Prokinetic agents should be tried in an attempt to restore normal intestinal propulsion. However, their overall efficacy appears to be variable. It is still too premature to consider intestinal pacing or small bowel transplantation in this condition. Surgical approaches to chronic intestinal pseudo-obstruction should be limited to patients refractory to medical therapy, and even then, an approach focused on the patient's primary presenting symptoms should be considered.
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PMID:Chronic intestinal pseudo-obstruction. 854 80

During pregnancy, intestinal obstruction due to sigmoid volvulus is extremely rare. Only 73 cases have been reported. A 24-year-old black woman, gravida 2, para 1, presented during Week 36 of an otherwise uneventful pregnancy, with intermittent abdominal pain and constipation, and no history of nausea, vomiting, fever, chills, previous medical problems, or prior abdominal surgery. Her previous pregnancy was a spontaneous vaginal delivery of a normal full-term neonate. On examination, she was afebrile, with abdominal tenderness. Laboratory studies revealed elevated WBC count of 13,500. She was admitted and given a Fleet enema, with no result or change in abdominal pain. Pain worsened; reexamination of her cervix revealed 3 cm dilation. After Pitocin augmentation, a viable male infant with Apgars of 7 and 9 was delivered. Postpartum, abdominal pain continued, with worsening abdominal distention. Radiograph revealed a massively distended colon. Physical examination 12 hours postdelivery indicated peritonitis. Exploratory laparotomy revealed volvulated, gangernous, massively distended sigmoid colon. The sigmoid colon was resected and Hartmann's colostomy performed. She was discharged on postoperative Day 4. Sigmoid volvulus complicating pregnancy is an uncommon and potentially devastating development that should be suspected with worsening abdominal pain and evidence of bowel obstruction. Prompt intervention is necessary to minimize maternal and fetal morbidity.
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PMID:Sigmoid volvulus in pregnancy. 861 67

A total of 121 consecutive patients with midgut carcinoid tumors underwent regular clinical control and 158 laparotomies for abdominal symptoms with 1 to 11 years (mean 5.2 years) of follow-up. Metastases were present in 93% of the patients at study inclusion and developed at initially uninvolved sites with an overall probability of 0.38. Patients without initial tumor spread developed mesenteric or liver metastases with the probability of 0.25 (mean delay 12 years), whereas those with mesenteric metastases exhibited a probability 0.56 to develop liver metastases (mean delay 6.1 years). Spread to extraabdominal sites in patients with mesenteric and liver metastases exhibited a probability of 0.22 (mean delay 4.3 years), and this spread was especially frequent (probability 0.60) in patients with only liver metastases at inclusion. Patients without the carcinoid syndrome (52%) mainly suffered from more or less episodic abdominal pain, nausea, and diarrhea. Marked mesenteric fibrosis detected at surgery (n = 59) generally was accompanied by symptoms of abdominal pain and weight loss, and it often required urgent intervention due to intestinal obstruction or ischemia. Complete or partial symptom alleviation was accomplished in 82% of the operated patients, and generally was most auspicious after primary acute or subacute procedures (n = 54). The complete or partial symptom improvements after surgery lasted for mean 5.3 years and tended to be longer after elective (n = 50) than acute operations. The findings substantiate encouraging results of laparotomy in a compromised cohort of patients with midgut carcinoid tumors. Because the patients also displayed a generally slow progression of metastases, liberal indications for laparotomy should prevail in symptomatic and possibly also asymptomatic individuals with midgut carcinoid tumors.
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PMID:Progression of metastases and symptom improvement from laparotomy in midgut carcinoid tumors. 867 69


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