Bowel Blockage or Obstruction
Question:
I had ulcerative colitis, have had my large intestine removed, and have an ileostomy. I just got out of hospital after having experienced a bowel obstruction. Can this happen again?
Answer:
A bowel obstruction is when the normal movement of food, fluid, or gas is prevented from occurring within the bowel (intestines). Obstructions can be either partial, meaning some of the fluid and gas passes through, but usually solids don’t, or complete, meaning nothing is able to pass through the bowel. About 20% of people admitted to hospital with an acute abdomen (or an abdomen that quickly becomes firm, is tender to touch and painful), have an obstruction of their bowel. Of these 20%, the majority (80%) will have a small bowel obstruction like the one you experienced. There are several reasons why bowel obstructions occur, however, with your type of surgery and stoma, the two more common are adhesions (scar tissue) or food obstruction. Each of these will be discussed below.
Adhesions are bands of tissue, like scar tissue, that can abnormally connect or bind adjacent sections of the bowel together, or bind the bowel to other organs within the abdomen, or tack the bowel to the inside of the abdominal wall. This scar tissue can then prevent the normal movement of food, fluids, and gas through the intestine. Most scar tissue results from some sort of event that disrupts normal tissues. As the body repairs the disruption, it creates scar tissue. Events that can initiate this process include surgery, an infection within the abdomen, trauma, or radiation therapy. Adhesions are the most common complication of surgery, occurring in more than 90% of people who undergo a surgical procedure. The adhesions begin to form within days after surgery. In most instances, adhesions do not cause any pain or complications, and people are not aware of their presence. However, adhesions may not cause problems until months or even years after the initial surgery. If adhesions were the cause of your bowel obstruction, there is a risk that it may occur again.
The other type of obstruction that could occur is from food that becomes stuck, usually as it is trying to pass through your ileostomy. This is more of a concern during the initial 6-8 weeks after surgery, when the bowel is swollen from surgical manipulation. While the swelling is temporary, it does narrow the lumen (inner opening of your bowel), particularly as the bowel comes through the many layers of your abdominal wall (see our article on diet and ileostomies for more discussion). A narrow opening may prevent certain foods from passing through your stoma easily. Foods that are typically of concern are those with cellulose (fruits, vegetables, nuts, grains) or those with casings (like sausages and cold cuts) or tough cuts of meat, like beef. Small amounts of these are unlikely to cause problems, but larger volumes or poorly chewed/cooked fruits and vegetables may give you some difficulty. As mentioned, this type of blockage is usually only of concern in the first 6-8 weeks after surgery while the swelling settles. After this point, you should be able to eat most foods without concern.
There are some typical symptoms associated with a bowel blockage. People may have waves of crampy abdominal pain and may feel bloated. Sometimes the pain is very severe and constant. There may be a loss of appetite, and nausea and/or vomiting. The output from your ileostomy may change. With a partial small bowel obstruction, the output may be very liquid (you won’t notice any solids) and be very forceful and noisy. With a complete obstruction, there will be no liquid, solid, or gas output. If you suspect a bowel obstruction, it is important that you seek medical attention and that you don’t try to diagnose the problem yourself. You can do some things for yourself while you seek help, such as enlarge the opening of your ostomy appliance/flange to accommodate any possible stomal swelling. If you are not vomiting, you should stop eating solid food and you can try to drink fluids (water is best).
Urgent care is required if you are vomiting, have severe/constant pain, or if there has been no output from your stoma for 12 hours. In these circumstances, you should go to your closest emergency department for assessment and treatment. The doctor will ask you questions about your medical and surgical history, will do a physical examination and order some investigations such as bloodwork and an x-ray or CT scan of your abdomen. Initial treatment may include stopping any oral diet, supporting you with intravenous fluids and with medications that will relieve some of your symptoms. You might have a nasogastric tube inserted, which is a small tube that goes through your nose and into your stomach to help drain fluid from your stomach and relieve your vomiting. It may take a few days for the obstruction to resolve, at which point a normal diet will slowly be reintroduced (usually starting with fluids, then progressing to solids). You will be monitored for any signs of ongoing problems. Sometimes, depending on the severity of the obstruction or if it fails to resolve with the conservative medical management, you may require surgery to correct the problem.
While two possible sources of obstruction have been discussed, there are other potential reasons for an obstruction that have not been reviewed. No one can say definitively if you will experience another bowel obstruction. However, given your history of surgery, you are at greater risk for another episode. Most importantly, if you experience any of the symptoms described, then you need to seek medical attention to help support you through care and management of the obstruction.