eMedicine Specialties > Emergency Medicine > Gastrointestinal

Obstruction, Small Bowel: Treatment & Medication

Author: Brian A Nobie FACEP, MD, Director of Recruitment, Consulting Staff, Florida Emergency Physicians, Florida Hospital, Celebration Health
Contributor Information and Disclosures

Updated: Nov 12, 2009

Treatment

Emergency Department Care

Initial ED treatment consists of aggressive fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically, antibiotics, and early surgical consultation.

  • Initial decompression can be performed by placement of a nasogastric (NG) tube for suctioning GI contents and preventing aspiration.
  • Antibiotics are used to cover against gram-negative and anaerobic organisms.
  • Monitor airway, breathing, and circulation (ABCs).
    • Blood pressure monitoring
    • Cardiac monitoring in selected patients (especially elderly patients or those with comorbid conditions)

Consultations

  • General surgeon (early and without delay): Laparoscopy is being used in addition to laparotomy and has been shown to reduce hospital stay, speed recovery, and decrease morbidity.

Medication

Fluid replacement with aggressive intravenous resuscitation using isotonic saline or lactated Ringer solution is indicated. Oxygen and appropriate monitoring are also required. Antibiotics are used to cover gram-negative and anaerobic organisms.

Antibiotics

These agents are for prophylaxis in surgical intervention, if needed.


Cefazolin (Ancef, Kefzol, Zolicef)

First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth.

Adult

1-2 g IV 1 h before surgery

Pediatric

20 mg/kg IV 1 h before surgery

Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test results for glucose

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy


Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

Adult

2 g IV 1 h before surgery

Pediatric

20 mg/kg IV 1 h before surgery

Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy


Cefotetan (Cefotan)

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.
Dosage and route of administration depend on condition of patient, severity of infection, and susceptibility of causative organism.

Adult

1-2 g IV 1 h before surgery

Pediatric

Not established

Consumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


Cefuroxime (Ceftin, Kefurox, Zinacef)

Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis.
Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

Adult

1.5 g IV 1 h before surgery

Pediatric

50 mg/kg IV 1 h before surgery

Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Reduce dosage by one half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


Meropenem (Merrem)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication

Antiemetic

These agents should be administered for symptomatic relief, usually in conjunction with GI decompression via placement of an NG tube to suction.


Promethazine (Phenergan)

For symptomatic treatment of nausea and vomiting. Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Adult

12.5-25 mg PO/IV/IM/PR q4h prn

Pediatric

<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d prn

May have additive effects when used concurrently with other CNS depressants or anticonvulsants; elderly persons may be particularly susceptible to experience decreased mental status; coadministration with epinephrine may cause hypotension

Documented hypersensitivity; children <2 y (incidences of death due to respiratory depression)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; start with lower dose in elderly patients


Ondansetron (Zofran)

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally, used in the prevention of nausea and vomiting. Metabolized in the liver through the P-450 pathway.

Adult

4-8 mg PO q8h; alternatively, 4 mg IV q8h

Pediatric

4 mg PO q8h; alternatively, 0.1-0.15 mg/kg IV q8h

Although potential exists for cytochrome P-450 inducers (barbiturates, rifampin, carbamazepine, and phenytoin) to change half-life and clearance of ondansetron, dosage adjustment is not usually required

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause headache

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.


Morphine sulfate (Astramorph, MS Contin, MSIR, Oramorph)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q2-4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of dose

Pediatric

Neonates: 0.05-0.2 mg/kg dose IV/IM/SC prn
Children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

More on Obstruction, Small Bowel

Overview: Obstruction, Small Bowel
Differential Diagnoses & Workup: Obstruction, Small Bowel
Treatment & Medication: Obstruction, Small Bowel
Follow-up: Obstruction, Small Bowel
Multimedia: Obstruction, Small Bowel
References
Further Reading
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Further Reading

Clinical guidelines

EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction. Practice management guidelines for small bowel obstruction. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2007. 42 p.

Ros PR, Huprich JE, Bree RL, Foley WD, Gay SB, Glick SN, Heiken JP, Levine MS, Rosen MP, Shuman WP, Greene FL, Expert Panel on Gastrointestinal Imaging. Suspected small bowel obstruction. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 5 p.

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Keywords

SBO, small bowel obstruction, small bowel obstruction symptoms, small bowel obstruction treatment, small bowel obstruction causes, obstruction of the small bowel, Crohn disease, Crohn's disease, hernia, bowel necrosis, bowel ischemia, peritonitis, inflammatory bowel disease, volvulus, congenital atresia, pyloric stenosis, intussusception

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Contributor Information and Disclosures

Author

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

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier 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.

 
 
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