Approach Considerations

In 2013, the World Society of Emergency Surgery published updated guidelines for the diagnosis and management of adhesive SBO (ASBO). The recommendations include the following^[27]:

In the absence of signs of strangulation and a history of persistent vomiting or combined computed tomography (CT) scan signs, patients with partial ASBO can be safely managed with nonoperative management; tube decompression should be attempted
Water-soluble oral contrast medium (WSCM) is recommended for both diagnostic and therapeutic purposes in patients undergoing nonoperative management
Nonoperative management can be prolonged for up to 72 hours in the absence of signs of strangulation or peritonitis; surgery is recommended after 72 hours of nonoperative management without resolution
Open surgery is frequently used for patients with strangulating ASBO and after failed conservative management; in appropriate patients, a laparoscopic approach using an open access technique is recommended
Hyaluronic acid: Carboxycellulose membrane and icodextrin decrease the incidence of adhesions, and icodextrin may reduce the risk of reobstruction

Emergency Department Care

Initial emergency department (ED) treatment of small-bowel obstruction (SBO) 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 SBO cases without peritonitis.^{[10, 13]}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

Water-soluble oral contrast medium

Studies have evaluated the use of WSCM as a tool in the management of SBO and as a predictive tool for nonoperative resolution of adhesive SBO. Although it does not cause resolution of the SBO, WSCM may reduce the hospital stay in patients not requiring surgery.

However, a more recent systematic review that analyzed retrospective data (2006-2009) from 242 patients in 10 studies with uncomplicated acute adhesive SBO indicated no benefit of administering gastrografin compared with saline solution in reducing the need for surgical intervention (24% vs 20%, respectively) or bowel resection (8% and 4%). Results were similar for both groups with respect to the time interval between the initial CT scan and surgery, as well as the time interval between oral refeeding and discharge.^[28]The sole potential risk factor for failure of nonoperative management was age.

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.^{[6, 7]}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.^[29]

Surgical outcomes for SBO, particularly malignant bowel obstruction, have relatively high risk for mobidity and mortality.^[30]In a retrospective study (2012-2015) of 2233 patients who underwent surgery for bowel obstruction, those with malignant bowel obstruction had a 14.5% adjusted mortality rate and a 32.2% adjusted complication rate. Independent prognostic factors for mortality included bowel resection, disseminated disease, advanced age, higher American Society of Anesthesiologists score (IV/V), as well as the presence of sepsis, albumin level below 3.5 g/dL, hematocrit below 30%, cirrhosis, ascites, and urinary tract infection.^[30]

Medication

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