From the Guidelines
If you suspect a patient has a small bowel obstruction, immediately consult a surgeon and arrange for urgent imaging studies, and initiate non-operative management with nil per os, decompression using a naso-gastric tube or long intestinal tube, fluid resuscitation, correction of electrolyte disturbances, nutritional support, and prevention of aspiration, as this approach is effective in approximately 70-90% of patients with adhesive small bowel obstruction (ASBO) 1.
Initial Management
While awaiting surgical evaluation:
- Make the patient nil by mouth (NPO)
- Insert a naso-gastric tube for decompression, as it is a cornerstone of non-operative management, although long intestinal tubes may be more effective in some cases 1
- Start IV fluid resuscitation (typically normal saline) to combat dehydration and electrolyte imbalances
- Administer antiemetics as needed (e.g., ondansetron 4-8 mg IV every 8 hours)
- Provide adequate pain management (e.g., morphine 2-4 mg IV every 4 hours as needed)
- Monitor vital signs, urine output, and electrolyte balance ### Duration of Non-Operative Management The duration of non-operative management is subject to debate, but most authors consider a 72-h period as safe and appropriate 1, although delays in surgery can increase morbidity and mortality 1, 2.
Surgical Consultation
Timely surgical consultation is essential as many cases require operative intervention, especially if there are signs of clinical deterioration or if non-operative management fails 1, 2.
Imaging Studies
Order an abdominal X-ray and CT scan with oral and IV contrast to confirm the diagnosis and determine the location and cause of the obstruction, as radiologic imaging plays a key role in the diagnosis and management of SBO 3.
From the Research
Management of Suspected Small Bowel Obstruction
The management of suspected small bowel obstruction involves several key steps, including:
- Intravenous fluid resuscitation, analgesia, and determining the need for operative vs. nonoperative therapy 4
- Use of nasogastric tube for patients with significant distension and vomiting to remove contents proximal to the site of obstruction 4
- Surgical intervention for strangulation and those that fail nonoperative therapy 4, 5
- Early surgical consultation to improve efficiency and outcomes 6
Diagnostic Evaluation
Diagnostic evaluation of suspected small bowel obstruction includes:
- History and physical examination to identify prior abdominal surgery, history of constipation, abdominal distension, and abnormal bowel sounds 4
- Imaging studies such as computed tomography (CT) scan with/without intravenous contrast to identify location, grade, and etiology of the obstruction 5, 7, 8
- Use of contrast agent swallow, such as Gastrografin, to determine the need for operative treatment 7
Nonoperative Management
Nonoperative management of small bowel obstruction includes:
- Fluid resuscitation and bowel rest 4
- Use of nasogastric tube to decompress the bowel 4
- Monitoring for signs of strangulation or peritonitis, which require immediate surgical intervention 4, 5
- Consideration of early surgical consultation to improve outcomes 6
Operative Management
Operative management of small bowel obstruction is indicated for: