What is the management approach for intestinal obstruction?

From the Guidelines

The management of intestinal obstruction involves a stepwise approach beginning with stabilization, followed by appropriate diagnostic workup and treatment based on severity, with the most recent and highest quality study suggesting that initial management includes fluid resuscitation with isotonic crystalloids and correction of electrolyte abnormalities 1. Initial management includes:

• Fluid resuscitation with isotonic crystalloids (typically normal saline or lactated Ringer's at 1-2 L bolus followed by maintenance)
• Correction of electrolyte abnormalities
• Bowel rest (nothing by mouth)
• Nasogastric tube placement for decompression
• Pain management with opioid analgesics Diagnostic evaluation should include abdominal imaging (X-rays, CT scan) to determine the location and cause of obstruction. For partial obstructions, conservative management may be sufficient, involving continued bowel rest, IV fluids, and close monitoring for 24-72 hours, as non-operative management is effective in approximately 70–90% of patients with ASBO 1. Complete obstructions generally require surgical intervention, particularly if there are signs of strangulation (fever, leukocytosis, severe pain, peritoneal signs), perforation, or closed-loop obstruction, with the decision about specific interventions made in a multidisciplinary setting including oncologists, surgeons, and endoscopists and taking into account the characteristics of the obstruction, patient’s expectations, prognosis, expected subsequent therapies, and functional status 1. The specific surgical approach depends on the underlying cause, ranging from adhesiolysis for adhesive obstructions to resection for malignant obstructions or bowel ischemia. Post-operative care includes continued fluid management, gradual advancement of diet as bowel function returns, pain control, and prevention of complications such as deep vein thrombosis and wound infections. This approach is necessary because intestinal obstruction can rapidly progress to serious complications including bowel ischemia, necrosis, perforation, and sepsis if not properly managed. In cases of malignant bowel obstruction, pharmacologic management can include opioids, antiemetics, and corticosteroids, alone or in combination, and the use of octreotide is recommended early in the diagnosis due to its efficacy and tolerability 1.

From the Research

Management of Intestinal Obstruction

The management approach for intestinal obstruction can be summarized as follows:

• Initial management includes 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, 3
• Surgery is needed for strangulation and those that fail nonoperative therapy 2, 3
• Medical management of bowel obstruction for patients with advanced cancer can include pharmacologic treatment with morphine, anticholinergics, major tranquilizers, corticosteroids, and somatostatin analogues 4
• Percutaneous gastrostomy tubes are effective for patients with proximal intestinal obstruction and intractable vomiting 4
• Management of uncomplicated obstructions includes fluid resuscitation with correction of metabolic derangements, intestinal decompression, and bowel rest 3
• A protocol for the management of adhesive small bowel obstruction can include intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and abdominal examinations every 4 hours, with the use of Gastroview to facilitate early recognition of complete obstruction 5

Treatment Options

Treatment options for intestinal obstruction include:

• Operative therapy for complete complicated obstruction, strangulation, and those that fail nonoperative therapy 2, 3
• Nonoperative therapy for uncomplicated obstructions, including fluid resuscitation, intestinal decompression, and bowel rest 3
• Medical management for patients with advanced cancer, including pharmacologic treatment and percutaneous gastrostomy tubes 4
• Palliative therapies, including preventive and medical therapies 6

Diagnostic Methods

Diagnostic methods for intestinal obstruction include:

• Radiologic imaging, such as plain radiographs, computed tomography, and ultrasound 2, 3, 5
• Laboratory values and abdominal examinations every 4 hours 5
• Use of Gastroview to facilitate early recognition of complete obstruction 5