eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Small-Bowel Obstruction: Treatment & Medication

Author: Jaime Shalkow, MD, Head of Surgical Oncology, Division of Surgery, National Institute of Pediatrics, Mexico; Head-Professor of Pediatric Surgical Oncology, Universidad Nacional Autonoma de Mexico
Coauthor(s): Jose Asz, MD, Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico; Nicholas A Shorter, MD, Professor of Clinical Surgery and Clinical Pediatrics, State University of New York-Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York-Downstate Medical Center; Bruce Friedberg, MD, Staff Physician, Department of Emergency Medicine, Mount Diablo Medical Center; Mainor Antillon, MD, Director, Pancreaticobiliary Endoscopy and Endosonography Program, Department of Internal Medicine, Division of Gastroenterology, King-Drew Medical Center; Associate Clinical Professor, Department of Medicine, University of California at Los Angeles; Thomas Tsou, MD, Director of Fast Tract and Pediatrics, Associate Professor, Departments of Medicine and Emergency Medicine, Charles R Drew University and University of California at Los Angeles
Contributor Information and Disclosures

Updated: Nov 21, 2008

Treatment

Medical Care

  • General principles in small-bowel obstruction treatment
    • Stabilize the patient and monitor ABCs.
    • Replace fluids with diligent intravenous resuscitation, using isotonic sodium chloride solution or lactated Ringer solution.
    • Early bowel decompression with an nasogastric (NG) tube decreases the chance of bowel necrosis and perforation.
    • Administer broad-spectrum antibiotics when necrosis or perforation is suspected.
  • Intussusception
    • Stabilize the patient's ABCs and replace large fluid losses. Administer nothing by mouth (NPO) to the child and place an NG tube to decompress the obstruction from above. The use of antibiotics is appropriate for management of bacterial translocation.
    • Barium, water, or air enema reduction is appropriate after surgical consultation if symptom duration is less than 24 hours and if the patient has no signs of peritonitis. Enemas successfully reduce 80-95% of all intussusceptions, with better success rates in short-duration intussusceptions.
    • Children whose symptoms persist longer than 24 hours, or have signs of peritonitis, should not be considered candidates for enema reduction. Stabilize these children and immediately transport them to the operating room because untreated intussusception is almost always fatal. The recurrence rate is higher after radiographic than after surgical reduction. Surgery is also indicated for patients whose intussusception cannot be reduced after 2 enema attempts.
  • Adhesive small-bowel obstruction
    • Only about 6-7% of children with adhesive small-bowel obstruction require immediate laparotomy. Approximately one half of these patients respond to medical treatment, which includes NPO, intravenous fluids, NG decompression, and antibiotics. Children younger than 1 year tend to respond poorly to conservative management. No single agent or treatment has proven effective in preventing adhesion formation after a laparotomy.
    • The use of water-soluble contrast via NG tube may decrease the need for surgery in some patients. Water-soluble contrast media (Gastrografin) cause redistribution of intravascular and extracellular fluid into the intestinal lumen because of their hyperosmolarity. As a result, these media decrease intestinal wall edema and act as a direct stimulant to intestinal peristalsis
  • Incarcerated hernia
    • Stabilize the patient's ABCs and focus on replacing the large fluid losses.
    • Nonoperative reduction of a nonstrangulated hernia is possible in approximately 95-98% of cases. Facilitate the reduction by sedating the patient and placing the patient in a mild Trendelenburg position. Gentle traction on the hernia and the contents of the sac usually suffices to reduce the volume and rapidly retract the contents of the sac into the abdominal cavity.
    • The only contraindication to nonoperative reduction is a long-standing incarceration with evidence of peritoneal irritation.
    • Antibiotic therapy is usually unwarranted, but critically ill infants with perforation and peritonitis require coverage for aerobic gram-negative organisms and anaerobic infections.
  • Necrotizing enterocolitis (NEC)
    • NEC management involves cessation of enteral feeds, gastric decompression on low continuous suction with a sump-type tube, fluid management to correct hypovolemia, parenteral nutrition with a centrally located intravenous catheter once fluid resuscitation is complete, and antibiotic therapy.
    • Direct antimicrobial therapy is aimed at enteric bacteria (eg, Escherichia coli, Klebsiella species, Enterococcus species, anaerobic colonic flora, [Clostridia species]).
    • Serial abdominal examinations are preferably performed by the same examiner.
    • Obtain radiographs of the abdomen, including cross-table lateral films, every 6-8 hours for the first 48 hours.
    • Obtain blood, urine, sputum, and CSF cultures, if indicated.
  • Meconium disease
    • Treatment of MI requires evacuating the meconium. Nonsurgical methods relieve the obstructions of more than 50% of patients.
    • The therapy of choice for uncomplicated MI is nonoperative hyperosmolar enema (Gastrografin or Omnipaque), with enterotomy and irrigation reserved for enema failures. Dilute Gastrografin with N -acetylcysteine may also be administered using an NG tube from above to help loosen the meconium. Distal intestinal obstruction syndrome may be treated in the same way.
    • Complicated cases (meconium peritonitis, meconium pseudocyst, perforation, intestinal atresia) require exploration and bowel resection with primary anastomosis or stoma creation.
    • Meconium plug syndrome is usually relieved with rectal stimulation (suppositories, washouts, or contrast enemas).

Surgical Care

  • Intussusception: Intussusception can be reduced by radiographic means in 80-95% of patients. Surgical reduction is indicated when symptoms have been present for more than 24 hours, in the presence of shock that cannot be corrected, when a lead point has been identified, when necrosis or perforation are present, or if the intussusception is irreducible by radiographic means.
  • Incarcerated hernia: After reducing the hernia, elective repair is possible 24-48 hours after the edema subsides. For patients whose hernias cannot be reduced and for patients with strangulation, immediate surgery is mandatory to prevent the incarceration from progressing to perforation and frank peritonitis.
  • Malrotation of the bowel with midgut volvulus
    • Preserving intestinal viability requires rapid diagnosis and surgery for malrotation with midgut volvulus. Initiate NG suction and intravenous hydration when entertaining the possibility of midgut volvulus. If abdominal plain radiographic findings confirm the diagnosis, defer contrast studies and take the child directly to the operating room.
    • A Ladd procedure is the preferred treatment. It includes evisceration and inspection of the mesenteric root, derotation of the volvulus (which has always been reported to occur in a clockwise direction), lysis of Ladd bands with kocherization of the duodenum along the right abdominal gutter, opening of the visceral peritoneum that covers the mesentery, and replacing the small bowel into the right side of the abdomen and the large bowel into the left side (in a position of nonrotation). It also includes an appendectomy (usually an inversion appendectomy) because the cecum and appendix are located in an unusual place. The procedure can also be laparoscopically performed.
    • Any frankly necrotic bowel should be resected and end-to-end anastomosis performed unless the peritoneal cavity is grossly contaminated or the condition of the patient does not allow it; in such cases, stomas should be created.
  • Postoperative adhesive small-bowel obstruction: A possible diagnosis of adhesive small-bowel obstruction requires prompt surgical consultation because delay can lead to intestinal necrosis. Patients usually present with a single-point obstruction. Adhesiolysis is the treatment of choice. This can be achieved laparoscopically or with laparotomy. Some patients require bowel resection because of perforation or necrosis.
  • Duplication cysts
    • The treatment for duplications is surgical excision, even in an asymptomatic patient who is incidentally diagnosed. The prevalence of gastric mucosa suggests that the duplications should not be left indefinitely. The procedure may depend on the location of the cyst.
    • In esophageal duplications, the cyst is excised, and a mucosectomy is performed if the muscular layer shared with the esophagus is left behind. The entire muscular wall can be excised with the cyst, taking care not to penetrate the esophageal mucosa.
    • Duplications of the small intestine usually require resection and anastomosis. In rectal duplications, only the mucosal lining usually needs to be excised because the duplication and normal rectum share the muscularis layer. If malignant degeneration is suspected, total excision including the normal rectum may be necessary. Infected duplications may require initial drainage, followed by a staged resection. Laparoscopically assisted resection of ileocecal duplications is safe and effective.
  • Annular pancreas: Surgical management is similar to that of duodenal atresia. Diamond-shaped duodenoduodenostomy is the preferred approach (Kimura procedure).
  • Necrotizing enterocolitis: Indications for surgery include pneumoperitoneum, fixed dilated bowel loop, abdominal wall discoloration, or children whose conditions deteriorate or show no improvement with conservative therapy. Portal venous air suggests extensive intestinal necrosis but does not indicate that celiotomy is necessary.
  • Mesocolic hernia: Surgically reduce the hernia and repair the potential hernia pouch, either electively (for reducible hernias) or emergently (for incarcerated hernias.)
  • Cecal volvulus: Surgical reduction of the cecal volvulus and pexy to the lateral peritoneal wall is usually required, in addition to fluid resuscitation, bowel decompression, and ABC monitoring.
  • Jejunoileal atresia and stenosis: Surgical resection of the atretic segment is followed by end-to-end anastomosis. The proximal dilated bowel may need to be tapered to fit the smaller distal intestine. Care should be taken to preserve as much intestinal length as possible in order to prevent short bowel syndrome, mainly in patients with multiple atresias. These have classically been repaired through transverse supraumbilical incision, although single jejunoileal atresias have been successfully approached through a smaller periumbilical incision (as the one described for hypertrophic pyloric stenosis).
  • Meconium ileus: Surgical management by either primary resection and anastomosis or an ileostomy is sometimes required.
  • Duodenal atresia and stenosis: The usual treatment for duodenal atresia is a linear or diamond-shaped duodenoduodenostomy (Kimura procedure). Duodenojejunostomy is another option. A duodenal web is much rarer and can be treated with duodenotomy and excision of the web, with or without duodenoplasty.

Consultations

  • Consult with a pediatric or general surgeon, depending on availability.

Diet

  • Administer NPO.

Medication

Bowel obstructions often require surgical interventions, but start antibiotic administration in the emergency department (ED) first. Antibiotic coverage must include gram-negative aerobic and gram-negative anaerobic organisms. (The following list of antibiotics is not all-inclusive.)

Antibiotics

Therapy must cover all likely pathogens in the clinical setting.


Clindamycin (Cleocin)

A lincosamide useful in treating serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome, where it preferentially binds to 50S ribosomal subunit, inhibiting bacterial growth.

Adult

450-900 mg IV q8h

Pediatric

Neonates:
Dependent on PMA, weight, and postnatal age
PMA <29 weeks and postnatal age 0-28 days: 5-7.5 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 5-7.5 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 5-7.5 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 5-7.5 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 5-7.5 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 5-7.5 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 5-7.5 mg/kg/dose IV/PO q6h
Infants and children: 20-40 mg/kg/d IV divided tid/qid

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

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

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis


Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (used alone in Clostridium difficile enterocolitis).

Adult

1 g IV loading dose, followed by 0.5 g IV q6h or 1 g IV q12h

Pediatric

Neonates:
<1200 grams: 7.5 mg/kg IV q48h
<7 days and >1200 grams: 7.5-15 mg/kg IV daily or divided q12h
>7 days and >1200 grams: 15-30 mg/kg IV daily or divided q12h
Infants and children: 30 mg/kg IV daily or divided q6h; not to exceed 4 g/d

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

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

Precautions

Do not use in first trimester of pregnancy; adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Aztreonam (Azactam)

Monobactam that inhibits cell wall synthesis during bacterial growth. Active against gram-negative bacilli. Effective against aerobic gram-negative organisms.

Adult

2 g IV q8h

Pediatric

Dosing adjusted by PMA, postnatal age, and weight
PMA <29 weeks and postnatal age 0-28 days: 30 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 30 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 30 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 30 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 30 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 30 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 30 mg/kg/dose IV/PO q6h
Infants and children: 30 mg/kg IV q6-8h

Tetracyclines may reduce effects

Pregnancy

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

Precautions

Adjust dose in renal insufficiency


Cefoxitin (Mefoxin)

Second-generation cephalosporin used to treat infections caused by susceptible gram-positive cocci and gram-negative rods. Effective against aerobic and anaerobic gram-negative organisms.

Adult

2 g IV q8h

Pediatric

Dosing adjusted by PMA, postnatal age, and weight
PMA <29 weeks and postnatal age 0-28 days: 25-33 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 25-33 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 25-33 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 25-33 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 25-33 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 25-33 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 25-33 mg/kg/dose IV/PO q6h
Infants and children: 80-100 mg/kg/d IV divided tid/qid

Probenecid may increase effects; 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

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis


Cefotetan (Cefotan)

Second-generation cephalosporin used to treat infections caused by susceptible gram-positive cocci and gram-negative rods; not FDA-approved for use in children.

Adult

2 g IV q12h; not to exceed 6 g/d

Pediatric

Not established, limited data suggest the following dose
Infants and children: 20-40 mg/kg IV/IM q12h; not to exceed 6 g/d

Consumption of alcohol within 72 h 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 50% if CrCl 10-30 mL/min and by 75% if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


Imipenem and cilastatin (Primaxin)

Effective against aerobic and anaerobic gram-negative organisms.

Adult

500 mg IV q6h

Pediatric

<1 week and >1500 grams: 25 mg/kg IV q12h1-4 weeks and >1500 grams: 25 mg/kg IV q8h4 weeks to 3 months and >1500 grams: 25 mg/kg IV q6h >3 months: 15-25 mg/kg/IV q6h

Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures

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

Adjust dose in renal insufficiency; avoid use in children <12 y; caution with history of seizures


Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during active growth stage. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive, most gram-negative, and most anaerobic organisms.

Adult

3 g (base dose on ticarcillin component) IV q4-6h; not to exceed 18-24 g/d

Pediatric

Neonates: Dosing adjusted by PMA, postnatal age, and weight; dosage based on ticarcillin component
Maintenance doses:
PMA <29 weeks and postnatal age 0-28 days: 75-100 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 75-100 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 75-100 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 75-100 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 75-100 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 75-100 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 75-100 mg/kg/dose IV/PO q6h
Infants and children: 75 mg/kg (base dose on ticarcillin component) IV q6h; not to exceed 18-24 g/d

Tetracyclines may decrease effects; high concentrations may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Pregnancy

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

Precautions

Obtain CBC count prior to initiating therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, measure BUN and creatinine levels during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

More on Small-Bowel Obstruction

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Treatment & Medication: Small-Bowel Obstruction
Follow-up: Small-Bowel Obstruction
Multimedia: Small-Bowel Obstruction
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

small-bowel obstruction, small bowel obstruction, SBO, intussusception, incarcerated hernia, malrotation of the bowel with midgut volvulus, postoperative adhesive small bowel obstruction, duplication cysts, annular pancreas, necrotizing enterocolitis, NEC, mesocolic hernia, cecal volvulus, jejunoileal atresia and stenosis, meconium Ileus

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Contributor Information and Disclosures

Author

Jaime Shalkow, MD, Head of Surgical Oncology, Division of Surgery, National Institute of Pediatrics, Mexico; Head-Professor of Pediatric Surgical Oncology, Universidad Nacional Autonoma de Mexico
Disclosure: Nothing to disclose.

Coauthor(s)

Jose Asz, MD, Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico
Disclosure: Nothing to disclose.

Nicholas A Shorter, MD, Professor of Clinical Surgery and Clinical Pediatrics, State University of New York-Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York-Downstate Medical Center
Disclosure: Nothing to disclose.

Bruce Friedberg, MD, Staff Physician, Department of Emergency Medicine, Mount Diablo Medical Center
Bruce Friedberg, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Mainor Antillon, MD, Director, Pancreaticobiliary Endoscopy and Endosonography Program, Department of Internal Medicine, Division of Gastroenterology, King-Drew Medical Center; Associate Clinical Professor, Department of Medicine, University of California at Los Angeles
Disclosure: Nothing to disclose.

Thomas Tsou, MD, Director of Fast Tract and Pediatrics, Associate Professor, Departments of Medicine and Emergency Medicine, Charles R Drew University and University of California at Los Angeles
Thomas Tsou, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jorge H Vargas, MD, Clinical Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition
Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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