Small-Bowel Obstruction Treatment & Management

  • Author: Brian A Nobie, MD, FACEP; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Oct 5, 2011
 

Approach Considerations

Emergency Department Care

Initial emergency department (ED) treatment consists of aggressive fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically, early surgical consultation, and administration of antibiotics. (Antibiotics are used to cover against gram-negative and anaerobic organisms.)

Initial decompression can be performed by placement of a nasogastric (NG) tube for suctioning GI contents and preventing aspiration. Monitor airway, breathing, and circulation (ABCs).

Blood pressure monitoring, as well as cardiac monitoring in selected patients (especially elderly patients or those with comorbid conditions), is important.

Nonoperative inpatient care

Continued NG suction provides symptomatic relief, decreases the need for intraoperative decompression, and benefits all patients. No clinical advantage to using a long tube (nasointestinal) instead of a short tube (NG) has been observed.

A nonoperative trial of as many as 3 days is warranted for partial or simple obstruction. Provide adequate fluid resuscitation and NG suctioning. Resolution of obstruction occurs in virtually all patients with these lesions within 72 hours. Good data regarding nonoperative management suggest it to be successful in 65-81% of partial small-bowel obstruction (SBO) cases without peritonitis.[5, 16] Nonoperative treatment for several types of SBO are as follows:

  • Malignant tumor - Obstruction by tumor is usually caused by metastasis; initial treatment should be nonoperative (surgical resection is recommended when feasible)
  • Inflammatory bowel disease - To reduce the inflammatory process, treatment generally is nonoperative in combination with high-dose steroids; consider parenteral treatment for prolonged periods of bowel rest, and undertake surgical treatment, bowel resection, and/or stricturoplasty if nonoperative treatment fails.
  • Intra-abdominal abscess - CT scan ̶ guided drainage is usually sufficient to relieve obstruction
  • Radiation enteritis - If obstruction follows radiation therapy acutely, nonoperative treatment accompanied by steroids is usually sufficient; if the obstruction is a chronic sequela of radiation therapy, surgical treatment is indicated
  • Incarcerated hernia - Initially use manual reduction and observation; advise elective hernia repair as soon as possible after reduction
  • Acute postoperative obstruction - This is difficult to diagnose, because symptoms often are attributed to incisional pain and postoperative ileus; treatment should be nonoperative
  • Adhesions - Decreasing intraoperative trauma to the peritoneal surfaces can prevent adhesion formation
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Surgical Care

A strangulated obstruction is a surgical emergency. In patients with a complete small-bowel obstruction (SBO), the risk of strangulation is high and early surgical intervention is warranted. Patients with simple complete obstructions in whom nonoperative trials fail also need surgical treatment but experience no apparent disadvantage to delayed surgery.

Laparoscopy has been shown to be safe and effective in selected cases of SBO.[17, 18] A review of retrospective clinical trials showed that laparoscopy showed better results in terms of hospital stay and mortality reduction versus open surgery, but prospective, randomized, controlled trials to assess all outcomes are still needed.[19]

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Contributor Information and Disclosures
Author

Brian A Nobie, MD, FACEP  Director of Recruitment, Consulting Staff, Florida Emergency Physicians, Florida Hospital, Celebration Health

Brian A Nobie, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph J Sachter, MD, FACEP  Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center

Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  2. Thompson WM, Kilani RK, Smith BB, Thomas J, Jaffe TA, Delong DM, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?. AJR Am J Roentgenol. Mar 2007;188(3):W233-8. [Medline].

  3. Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. AJR Am J Roentgenol. Jan 2001;176(1):167-74. [Medline].

  4. Sheedy SP, Earnest F 4th, Fletcher JG, Fidler JL, Hoskin TL. CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation. Radiology. Dec 2006;241(3):729-36. [Medline].

  5. Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. Jun 2008;64(6):1651-64. [Medline].

  6. Kim JH, Ha HK, Sohn MJ, Shin BS, Lee YS, Chung SY, et al. Usefulness of MR imaging for diseases of the small intestine: comparison with CT. Korean J Radiol. Jan-Mar 2000;1(1):43-50. [Medline]. [Full Text].

  7. Beall DP, Fortman BJ, Lawler BC, Regan F. Imaging bowel obstruction: a comparison between fast magnetic resonance imaging and helical computed tomography. Clin Radiol. Aug 2002;57(8):719-24. [Medline].

  8. Regan F, Beall DP, Bohlman ME, Khazan R, Sufi A, Schaefer DC. Fast MR imaging and the detection of small-bowel obstruction. AJR Am J Roentgenol. Jun 1998;170(6):1465-9. [Medline].

  9. Raptopoulos V, Schwartz RK, McNicholas MM, Movson J, Pearlman J, Joffe N. Multiplanar helical CT enterography in patients with Crohn's disease. AJR Am J Roentgenol. Dec 1997;169(6):1545-50. [Medline].

  10. Bodily KD, Fletcher JG, Solem CA, Johnson CD, Fidler JL, Barlow JM, et al. Crohn Disease: mural attenuation and thickness at contrast-enhanced CT Enterography--correlation with endoscopic and histologic findings of inflammation. Radiology. Feb 2006;238(2):505-16. [Medline].

  11. Engin G. Computed tomography enteroclysis in the diagnosis of intestinal diseases. J Comput Assist Tomogr. Jan-Feb 2008;32(1):9-16. [Medline].

  12. Rajesh A, Maglinte DD. Multislice CT enteroclysis: technique and clinical applications. Clin Radiol. Jan 2006;61(1):31-9. [Medline].

  13. Gollub MJ. Multidetector computed tomography enteroclysis of patients with small bowel obstruction: a volume-rendered "surgical perspective". J Comput Assist Tomogr. May-Jun 2005;29(3):401-7. [Medline].

  14. Cappell MS, Batke M. Mechanical obstruction of the small bowel and colon. Med Clin North Am. May 2008;92(3):575-97, viii. [Medline].

  15. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. Aug 2011;28(8):676-8. [Medline].

  16. Fevang BT, Fevang J, Stangeland L, Soreide O, Svanes K, Viste A. Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience. Ann Surg. Apr 2000;231(4):529-37. [Medline]. [Full Text].

  17. Zerey M, Sechrist CW, Kercher KW, Sing RF, Matthews BD, Heniford BT. The laparoscopic management of small-bowel obstruction. Am J Surg. Dec 2007;194(6):882-7; discussion 887-8. [Medline].

  18. Khaikin M, Schneidereit N, Cera S, Sands D, Efron J, Weiss EG, et al. Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness. Surg Endosc. May 2007;21(5):742-6. [Medline].

  19. Cirocchi R, Abraha I, Farinella E, Montedori A, Sciannameo F. Laparoscopic versus open surgery in small bowel obstruction. Cochrane Database Syst Rev. Feb 17 2010;CD007511. [Medline].

 
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Small bowel obstruction. Image courtesy of Ademola Adewale, MD.
Small bowel obstruction. Image courtesy of Ademola Adewale, MD.
Small bowel obstruction. Image courtesy of Ademola Adewale, MD.
 
 
 
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