Large bowel obstruction is a surgical emergency which must be quickly differentiated from pseudo-obstruction to ensure that timely and correct treatment is provided. The classic signs and symptoms are abdominal pain, distention, vomiting, nausea, and absolute constipation.
Patient age can help determine the most likely cause.
Consider malignancy in all patients who present with large bowel obstruction.
Suspect bowel perforation where there is persistent tachycardia, fever, and/or abdominal pain and tenderness.
Surgical emergency where a mechanical interruption (either complete or partial) occurs to the flow of intestinal contents, with multiple potential causes (e.g., malignant colorectal disease, colonic volvulus, benign stricture). This topic covers acquired obstruction in adults.
History and exam
Key diagnostic factors
- colicky abdominal pain
- abdominal distention
- tympanic abdomen
- change in bowel habits
- hard feces
- empty rectum
- soft stools
- recent weight loss
- rectal bleeding
- abnormal bowel sounds
- palpable rectal mass
- palpable abdominal mass
- positive fecal occult blood test
- abdominal tenderness
- abdominal rigidity
Other diagnostic factors
- history of radiotherapy
- history of gynecologic symptoms
- nausea and vomiting
- groin swelling
- pelvic mass
- ingestion of foreign body
- older age
- female sex
- mental illness
- low or high dietary fiber
- previous colorectal resection
- previous abdominal surgery
- inflammatory bowel disease
- laxative abuse
1st investigations to order
- serum electrolytes
- renal function
- serum amylase/lipase
- coagulation studies
- plain abdominal x-ray
Investigations to consider
- CT abdomen and pelvis
- contrast enema
- flexible/rigid endoscopy
foreign body ingestion
Adrian A. Maung, MD, FACS, FCCM
Associate Professor of Surgery
Division of General Surgery, Trauma and Surgical Critical Care
Department of Surgery
Yale School of Medicine
Surgical Director of Perioperative Services
Adult Trauma Medical Director
Yale New Haven Hospital
AAM declares that he has no competing interests.
Dr Adrian A. Maung would like to gratefully acknowledge Dr George Malietzis, Dr John T. Jenkins, and Dr Alisdair J. MacDonald, previous contributors to this topic.
GM, JTJ, and AJM declare that they have no competing interests.
Alessandro Fichera, MD, FACS, FASCRS
Department of Surgery
University of Chicago
AF declares that he has no competing interests.
Robert H. Diament, MD
RHD declares that he has no competing interests.
- Acute colonic pseudo-obstruction (Ogilvie syndrome)
- Small bowel obstruction
- Chronic/idiopathic megacolon
- Clinical practice guidelines for the management of colon cancer
- Clinical practice guidelines for the perioperative evaluation and management of frailty among older adults undergoing colorectal surgery
Bowel cancer: questions to ask your doctorMore Patient leaflets
Venepuncture and phlebotomy: animated demonstration
Central venous catheter insertion: animated demonstrationMore videos
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer