From the Guidelines
Management of small bowel obstruction (SBO) without surgery should prioritize a conservative approach, including bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression, for a period of 24-72 hours, as this approach can be effective in resolving the obstruction in approximately 70-90% of patients with adhesive small bowel obstruction, as supported by the 2018 Bologna guidelines 1. The cornerstone of non-operative management is nil per os and decompression using a naso-gastric tube or long intestinal tube. Non-operative management should further include fluid resuscitation, correction of electrolyte disturbances, nutritional support, and prevention of aspiration.
- Key components of conservative management include:
- Bowel rest with nothing by mouth (NPO)
- Intravenous fluid resuscitation with balanced crystalloids at 125-150 mL/hr
- Nasogastric tube decompression
- Pain control with medications like hydromorphone 0.5-1 mg IV every 4-6 hours as needed
- Electrolyte imbalances correction, particularly potassium and magnesium
- DVT prophylaxis with enoxaparin 40 mg subcutaneously daily
- The use of water-soluble contrast studies using Gastrografin can both diagnose and potentially treat adhesive SBOs by drawing water into the bowel lumen and increasing pressure to resolve the obstruction, as mentioned in the 2019 narrative review 1.
- It is essential to monitor patients for signs of clinical improvement, such as decreased abdominal pain, return of bowel sounds, passage of flatus or stool, and reduced nasogastric output, and to detect signs of peritonitis or strangulation that would necessitate surgical intervention.
- The duration of non-operative management is subject to debate, but most authors consider a 72-h period as safe and appropriate, as stated in the 2018 Bologna guidelines 1 and the 2019 narrative review 1.
From the Research
Management of Small Bowel Obstruction (SBO) without Surgery
- The management of SBO without surgery involves a combination of intravenous fluid resuscitation, analgesia, and determining the need for operative vs. nonoperative therapy 2.
- Nasogastric tube is useful for patients with significant distension and vomiting by removing contents proximal to the site of obstruction 2.
- Water soluble contrast (WSC) has been used as a cathartic to simulate bowel function and may reduce hospital length of stay (HLOS) by 1.95 days (95%CI 0.56-3.3) 3.
- The use of WSC stimulates the bowel and may reduce HLOS, and modern aSBO treatment protocols should include NGT decompression with consideration of WSC administration 3.
Non-Operative Management (NOM) of SBO
- A study found that in patients ≥ 80 years with SBO, a NOM could yield similar results, in terms of overall mortality, compared to a surgical management 4.
- The study also found that mechanical ventilation, sepsis, cumulative major complications, and in-hospital length of stay (LOS) were significantly higher in the operative treatment group 4.
- Another study found that selection of patients for treatment without NGT decompression requires further investigation, and that there were no significant differences in operative rates, mortality, and rates of bowel resection between patients who did and did not receive NGT decompression 3.
Imaging and Care Protocols for SBO
- A collaborative SBO imaging and care protocol between general surgery and radiology resulted in reduced radiation exposure to patients and decreased CT technologist time 5.
- The protocol utilized enteric water-soluble contrast (WSC) and serial abdominal radiographs for further assessment of SBO in clinically stable patients, eliminating the need for a second CT scan 5.
- A study found that implementation of a protocol for administration of Gastrografin immediately in the emergency department efficiently sorts patients into those who will resolve their obstructions and those who will fail nonoperative management 6.