Small-Bowel Obstruction Treatment & Management
- Author: Brian A Nobie, MD; Chief Editor: Steven C Dronen, MD, FAAEM more...
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.[8, 19] 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
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.[1, 2] 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.
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