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Case history

image A 52-year-old man presented to the acute oncology assessment unit with increasing abdominal pain. He had a diagnosis of metastatic descending colon adenocarcinoma (CT4aN2M1). The primary tumour remained in situ and he had completed six cycles of first-line palliative chemotherapy (irinotecan and fluorouracil [5-FU]). The most recent restaging CT scan of the chest, abdomen and pelvis showed multiple pulmonary emboli and progressive disease in the liver and primary tumour. He was due to commence second-line chemotherapy with oxaliplatin and 5-FU and had received appropriate anticoagulation. His bowel habit had been erratic because of increasing opiate use; he had not opened his bowels for 4 days but was passing flatus, with no episodes of nausea and one episode of vomiting. He described increasing abdominal distension over the preceding week.

Abdominal X-ray performed on admission identified prominent bowel loops and faecal loading in the ascending colon; his abdomen was soft, with tenderness in the right iliac fossa; bowel sounds were scattered and quiet. Rectal examination identified stool in the rectum. He was given laxatives and admitted for further observation. Over the next 24 h the pain significantly worsened and an urgent CT scan was arranged. His case was discussed with the acute surgical team. It was not possible to perform a colonic stent, owing to progression of the sigmoid tumour and impending caecal perforation. Following discussion with the patient, surgical team, oncologists, palliative care team and the patient’s family, he underwent an emergency laparotomy with right hemi-colectomy, ileostomy and colonic mucous fistula formation.

Initial postoperative recovery was complicated by the development of a large wound haematoma requiring further drainage. He then went on to develop overwhelming intra-abdominal sepsis and continued to deteriorate over a few days. He died 3 weeks after presentation to the acute oncology unit, which was 5 months after his initial diagnosis.

What are the causes of acute bowel obstruction?

What is the initial investigation of bowel obstruction presenting acutely?

What are the management options for acute bowel obstruction?

What is the role of the wider multidisciplinary team (MDT) in the management of patients presenting with malignant bowel obstruction?

What are the causes of acute bowel obstruction?

Large bowel obstruction is a common feature in the primary presentation of gastrointestinal malignancies. The cause of obstruction may be from a single disease site where intraluminal disease or faecal impaction is the major contributing factor. In malignancies where there is intra-abdominal carcinomatosis the cause of obstruction may be due to mechanical disturbances of motility; there is a higher risk of multiple sites of small or large bowel obstruction in patients with malignancies.1

Non-malignant causes of obstruction should always be considered in the differential diagnosis; adhesions from previous surgical procedures or post-pelvic radiotherapy may be important factors in the presentation of this patient group (Table 34.1).

Table 34.1Causes of bowel obstruction.

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