Symptoms

Biliary obstruction may cause right upper quadrant abdominal pain that radiates to the right flank, nausea, vomiting, jaundice, clay-colored stools, and green or dark urine.

Symptoms

Patients typically complain of colicky abdominal pain, nausea, vomiting (if the obstruction is in the proximal small intestine), or inability to pass gas or stool. Thirst, dizziness, malaise, and other symptoms of dehydration may be present. The physical examination may show a distended, gas-filled abdomen, which is often tympanitic and diffusely tender. Auscultation reveals bowel sounds, borborygmi, and rushes, which may be loud enough to hear without the stethoscope. The examiner may sometimes find a palpable mass or an incarcerated hernia.

Treatment

The patient is given nothing orally, and when nausea and vomiting are present, a nasogastric (Levin, Salem Sump) or intestinal (Cantor, Miller-Abbott) tube is placed to remove upper intestinal contents anddecompress the bowel. Fluids and electrolytes are given intravenously. A large intestinal obstruction due to fecal impaction may be relieved by disimpaction or enemas. When obstructions do not resolve with conservative measures and supportive care, surgery may be needed.

Patient care

In partial obstruction, the patient's condition is monitored closely, including assessment of bowel sounds, vital signs, abdominal girth, fluid and electrolyte balance, and acid-base balance. The patient is assessed for signs of dehydration. Frequent oral hygiene is provided. Prescribed pain medications, antiemetics, and antibiotics are administered. Opioids are sometimes withheld or used sparingly because they may slow peristalsis. Noninvasive pain relief strategies (e.g., relaxation techniques, imagery, repositioning, massage, and music therapy) may be effective for individual patients. The patient is asked to alert health care providers if pain changes from colicky to constant, because this may signal perforation. Throughout, the patient receives support and encouragement. Ischemia is the most serious consequence of intestinal obstruction, because it leads to peritonitis, perforation, hemorrhage, and gangrene. Ischemia makes the bowel more permeable, allowing normal intestinal flora such as Escherichia coli and Klebsiella to penetrate the bowel wall and enter the peritoneal cavity, potentially leading to peritonitis and/or septic shock. Intravenous fluids are required; blood products and antibiotics may be needed, depending on complications experienced by the patient.

If conservative treatment fails for partial or incomplete mechanical obstruction, or if the obstruction is initially diagnosed as vascular or mechanical and complete, the patient is prepared for nasogastric suctioning, endoscopy, or surgery. If the patient requires a colostomy or ileostomy (which may be a temporary measure or may be permanent, depending on the cause of the obstruction), an enterostomal therapist makes recommendations regarding stoma location and provides further positive reinforcement and emotional support. Postoperative care is explained; if the patient is well enough to understand, he is taught exercises to aid ventilation and prevent complications due to immobility. Following surgery, all necessary postoperative care is given, including care of the surgical wound, maintenance of ventilatory status and fluid and electrolyte balance, and relief of pain and discomfort. Vital signs are closely monitored. Oral care is provided, along with misting of mucous membranes while the decompression tube remains in place, and the amount and color of drainage are recorded. Clear fluids may be initiated with the tube clamped to determine toleration. The tube is removed and diet advanced as bowel sounds return. Incentive spirometry, antiembolic or pneumatic hose, and early ambulation help to prevent complications related to immobility. Any necessary postoperative activity limitations are discussed with the patient. Before discharge, any prescribed medications, their proper use, desired responses, and adverse effects are reviewed. Incision and/or colostomy care is taught and signs of infection, activity restrictions, and signs or symptoms for which the surgeon should be called are reviewed with the patient before discharge. The importance of following a structured bowel regimen is emphasized (particularly if the cause of obstruction was a fecal impaction). The patient is encouraged to eat a high-fiber diet, drink plenty of fluids, and exercise daily.

Treatment

Depending upon the cause of the obstruction, nasal douches, inhalations, or operative care, including resection of septum, turbinectomy, removal of polyp, opening and draining sinuses, or removal of foreign body.