In the United States, the most common causes of large bowel obstruction are colonic neoplasm, volvulus, hernia, diverticular disease, and inflammatory bowel disease. Adhesions secondary to previous inflammation or operation commonly cause small bowel obstruction but are a rare cause of large bowel obstruction.¹ In women, abdominal hysterectomy is the most common abdominal operation that results in postoperative adhesions. We report the case of a large bowel obstruction secondary to an adhesive band in a woman who underwent hysterectomy 15 years earlier. There are very few reported cases in the literature of large bowel obstruction secondary to adhesions.

Case report

A 58-year-old white woman presented to the emergency department with vague abdominal pain, nausea, vomiting, and an inability to pass flatus for 2 days. She had a known history of constipation but reported no use of laxatives. She had undergone a total abdominal hysterectomy for fibroids 15 years earlier. She had no allergies and currently was not taking any medications. A screening colonoscopy done 4 months prior to her presentation to the emergency department demonstrated no colonic abnormalities.

On physical examination, the patient was afebrile, hemodynamically stable, and in no acute distress. Her abdomen was soft, moderately distended, and tympanic to percussion. There was localized tenderness in the left lower quadrant but no evidence of guarding, rigidity, or rebound tenderness. The hernial orifices were normal. Rectal examination revealed normal tone and no palpable masses. Laboratory values were within normal limits.

A computed tomography (CT) scan of the abdomen and pelvis revealed a high-grade bowel obstruction secondary to an extrinsic compression from a possible mass at the mid-sigmoid colon (Figure 1). Based on this diagnosis of large bowel obstruction, the patient was admitted to the surgical service, and intravenous hydration was initiated. Colonoscopy was performed; a tight stenosis was noted at the mid-sigmoid level, and the scope could not be advanced further. She was taken to the operating room for an exploratory laparoscopy.

Figure 1—CT scan of the abdomen and pelvis showing a high-grade bowel obstruction and extrinsic compression at the mid-sigmoid colon.

Figure 2—Intraoperative photograph showing a single adhesive band obstructing the mid-sigmoid colon.

Figure 3—Intraoperative photograph showing laparoscopic lysis of the adhesion.

A diagnostic laparoscopy revealed a single adhesive band constricting the mid-sigmoid colon (Figure 2). The adhesion extended from the left pelvic sidewall to the medial mesentery of the sigmoid colon. Lysis of the adhesive band was performed using an endoscopic stapler (Figure 3). The abdomen was inspected for further pathology and was unremarkable. Following the adhesiolysis, sigmoidoscopy was done intraoperatively, which showed normal sigmoid mucosa. The scope was advanced past the mid-sigmoid region without difficulty. The patient resumed a regular diet on postoperative day 1 and was discharged home later that day.

Discussion

Colonic obstruction is most commonly attributed to a neoplasm or volvulus. Other etiologies include incarcerated hernias, inflammatory bowel disease, diverticular disease, stricture, intussusception, and fecal impaction. In neonates and children, the differential diagnosis should also include Hirschsprung's disease. Adhesions, which are fibrous bands between two or more adjacent anatomic structures, are a common cause of small bowel obstruction but a very rare cause of large bowel obstruction. They can be congenital, traumatic, inflammatory, or iatrogenic in origin.^1,2

In a systematic review of 1,252 intestinal obstruction cases at the University of Minnesota, it was found that only 31% (388) of mechanical bowel obstructions were secondary to adhesive bands.^3,4 The diagnosis of adhesive obstruction was confirmed by operation or autopsy in 274 cases and by conservative treatment with serial examinations and radiographs in 114 cases. The etiology of the adhesions was attributed to previous operations in 79.4% of patients, inflammatory diseases in 17.8%, and congenital bands in 2.8%. Operations on the large bowel, appendectomies, and previous lysis of adhesions were the most common preceding surgical procedures, and appendicitis and diverticulitis were the most frequently encountered inflammatory diseases. The majority of intestinal obstructions occurred in the small bowel (88.4%), followed by colonic occlusions (8%), and a mixed variety involving both the large and the small bowel (3.6%). The authors noted that the type of adhesion also influenced the location of the obstruction. Large bowel and mixed obstructions were commonly caused by inflammatory adhesions (30.5%) or congenital bands (22.3%) but rarely were attributed to postoperative adhesions (6.8%).

Krebs and associates conducted a similar review of mechanical intestinal obstruction in 368 patients who had gynecologic diseases.⁵ Of these patients, 83% had gynecologic malignancies; the incidence of small bowel obstruction was 77%, and large bowel obstruction was 23%. The major cause of mechanical small bowel obstruction in 62% of patients was extrinsic compression from a neoplasm. Other etiologies of small bowel obstruction included radiation-induced stricture (17%), postoperative adhesions (14%), and inflammatory stricture and adhesions (3%). Obstruction of the large bowel was attributed to extrinsic neoplasm in 45% of cases. Strictures and adhesions that were associated with radiation therapy caused 26% of large bowel obstructions. Other causes included fecal impaction in 9% of cases and intrinsic neoplasms in 8%.

As noted in the literature, most large bowel obstructions are secondary to neoplasms, with postoperative adhesions accounting for a minor percentage of cases. Our patient had undergone a total abdominal hysterectomy 15 years before presenting with a large bowel obstruction secondary to a single adhesive band, which extended from the lateral pelvic sidewall to the medial mesentery of the sigmoid colon.

Conclusion

Although there are only a few case reports of large bowel obstruction caused by adhesive bands, this etiology should be considered in the differential diagnosis of any patient presenting with obstructive symptoms and a history of gynecologic surgery. The initial diagnosis of a colonic neoplasm as the source of our patient's large bowel obstruction was based on her age, symptoms, and findings from the CT scan and colonoscopy. Exploration found a single adhesive band constricting the mid-sigmoid colon, which was successfully treated with laparoscopic lysis.

References

1. Wecksell A, Spier N. Colonic obstruction. Adhesive remnant of infundibular-pelvic ligament constricting midascending colon. NY State J Med. 1978;78(6):962-964.
2. Weigel CJ. Pericolic adhesions and hernias causing intestinal obstruction. Am J Proctol. 1966;17(5):388-394.
3. Perry JF Jr, Smith GA, Yonehiro EG. Intestinal obstruction caused by adhesions; a review of 388 cases. Ann Surg. 1955;142 (5):810-816.
4. Smith GA, Perry JF Jr, Yonehiro EG. Mechanical intestinal obstruction; a study of 1,252 cases. Surgery Gynecol Obstet. 1955; 100:651.
5. Krebs HB, Goplerud DR. Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients. Am J Obstet Gynecol. 1987;157(3):577-583.