Intestinal Obstruction: The Importance of Proper Examination and History Taking

Intestinal obstruction occurs when food and stool are not able to move freely along the gut. There are many possible reasons for intestinal obstruction including hernias, tumours, abdominal adhesions, volvulus (intestine twists around itself) and foreign objects.

Intestinal obstruction is a common problem with a high mortality rate unless treated promptly. Delays and improper management can cause infection, intestinal tear (perforation), pain, and death from the infection. An accurate history and examination are essential to lead to the correct investigation and management. That means doing the complete job and not moving forward until this is adequately done.

Case study

An 80-year-old man was seen in Accident & Emergency with complaints of constipation. Some important aspects of the history were not clearly identified, and the abdominal examination was limited by carrying it out with the patient in a chair. The patient was discharged under the diagnosis of constipation. The patient became unwell a few days later and deteriorated suddenly at home. He was readmitted but died shortly after admission. The post-mortem examination revealed that the cause of death was peritonitis due a perforation of an obstructing sigmoid colon cancer.

Recommendations to improve patient safety and clinical standards:

• Ensure that examinations are completed and adhere to the standards as stated in Clinical Methods: The history, physical and laboratory examinations (chapter 93) (1-2).
• The cardinal symptoms of intestinal obstruction are nausea, vomiting and colicky abdominal pain and must be identified and must be investigated accordingly if present.
• Examination of the abdomen is difficult and unreliable with the patient seated and it must be done with the patient supine on a trolley or a bed and include inspection, palpation, percussion and auscultation (1-2).
• A large bowel obstruction is a surgical emergency and the ACPGBI guidelines (3) are that urgent imaging such as CT(4-5) are required to allow surgical referral for treatment with either resection or stenting for palliation or a bridge to surgery.
• Training must be available for all staff about the features of intestinal obstruction and the correct pathway of management and staffing levels must be adequate.
• Constipation is not a diagnosis and patients must not be discharged until a diagnosis is clear.

References

1. Clinical Methods: The history, physical and laboratory examinations. 3rd edition. H Kenneth Walker, W Dallas Hall, J Willis Hurst (editors). Boston, Butterworths 1990
2. Clinical Methods: The history, physical and laboratory examinations (chapter 93) [www.ncbi.nlm.nih.gov/books/NBK420/]
3. P. J. Finan, S. Campbell, R. Verma, J. MacFie, M. Gatt, M. C. Parker, R. Bhardwaj, N. R. Hall. The Management of Malignant Large Bowel Obstruction: ACPGBI Position Statement. P. J. Colorectal disease 2008
4. Triaging patients with lower gastrointestinal symptoms. NICE 2020 Jun 16. [www.nice.org.uk/media/default/about/covid-19/specialty-guides/triaging-patients-with-lower-gi-symptoms.pdf]
5. Large bowel obstruction in the emergency department: imaging spectrum of common and uncommon causes. Ramanathan S, Ojili V, Ravi Vassa R, and Arpit Nagar A. J Clin Imaging Sci 2017; 7: 15-24.