What are the next steps in managing a patient with a large bowel obstruction?

From the Guidelines

The patient with a large bowel obstruction should be managed with a stepwise approach, starting with bowel rest, intravenous fluid resuscitation, and nasogastric tube placement, followed by surgical consultation and potential intervention, as the most recent and highest quality study suggests that early surgical consultation is crucial in managing large bowel obstruction 1. The initial management of the patient includes:

• Bowel rest (nothing by mouth)
• Intravenous fluid resuscitation with normal saline or lactated Ringer's solution to correct fluid and electrolyte imbalances
• Nasogastric tube placement for decompression
• Administration of broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours
• Pain management with opioid analgesics like morphine 2-4mg IV every 4 hours as needed Diagnostic imaging including abdominal X-rays and CT scan with contrast should be obtained to confirm the diagnosis and identify the cause and location of obstruction. Depending on the etiology, initial management may include endoscopic decompression for volvulus or placement of a rectal tube. Surgical consultation should be obtained early, as many cases will require operative intervention such as resection with primary anastomosis, colostomy creation, or removal of the obstructing lesion, as suggested by the study published in the World Journal of Emergency Surgery in 2019 1. The decision about specific interventions should be made in a multidisciplinary setting, taking into account the characteristics of the obstruction, patient’s expectations, prognosis, expected subsequent therapies, and functional status, as recommended by the AGA clinical practice update in 2021 1. Close monitoring of vital signs, abdominal examination, and laboratory values including complete blood count, electrolytes, and lactate is essential to detect complications early, as large bowel obstruction can rapidly progress to perforation, peritonitis, and septic shock if not properly managed. In cases where surgery is not feasible, palliative care options such as self-expanding metallic stents or venting gastrostomy tubes may be considered to relieve symptoms and improve quality of life, as discussed in the study published in the Journal of the National Comprehensive Cancer Network in 2016 1.

From the FDA Drug Label

5.10 Gastrointestinal Effects Do not administer morphine sulfate injection to patients with gastrointestinal obstruction, especially paralytic ileus because morphine sulfate injection diminishes propulsive peristaltic waves in the gastrointestinal tract and may prolong the obstruction

The next steps in managing a patient with a large bowel obstruction do not include the administration of morphine sulfate injection, as it may worsen the obstruction.

• Key considerations for this patient include:
  • Fluid resuscitation has been initiated, as evidenced by the improvement in blood pressure after 1 L of fluids.
  • Further management should focus on addressing the bowel obstruction, which may involve surgical consultation and potential intervention.
  • Caution should be exercised when considering the use of any medications that may exacerbate the obstruction or worsen the patient's condition 2.

From the Research

Next Steps in Management

The patient, a 72-year-old male, presents with a large bowel obstruction, as indicated by the outpatient CT scan. Given the patient's initial low blood pressure (84/50) that improved to 170/80 after receiving 1 L of fluids, the following steps can be considered:

• Fluid Resuscitation: Continue to monitor the patient's fluid status and provide additional fluids as needed to maintain adequate blood pressure and perfusion of vital organs 3, 4.
• Imaging and Diagnosis: The patient has already undergone a CT scan, which is a crucial diagnostic tool for identifying large bowel obstructions. The scan can help determine the location and potential cause of the obstruction 4.
• Management Strategy: The management of large bowel obstruction depends on the underlying cause, which can be intrinsic (e.g., tumor), extrinsic (e.g., adhesions), benign, or malignant. Treatment options may include endoscopy, diversion, or resection 3, 4.
• Surgical Intervention: In some cases, surgical intervention may be necessary to relieve the obstruction. The decision to operate should be made based on the patient's overall condition, the severity of the obstruction, and the potential risks and benefits of surgery 4, 5.
• Nasogastric Tube Placement: The use of nasogastric tubes in patients with bowel obstruction is a topic of debate. Some studies suggest that nasogastric tube placement may not be necessary in all cases and may even be associated with poorer outcomes 6.

Considerations for Specific Patient Populations

• Elderly Patients: Elderly patients, such as the 72-year-old male in this case, may be at higher risk for complications from bowel obstruction and may require more careful management and monitoring 5.
• Patients with Malignant Obstructions: Patients with malignant large bowel obstructions may require urgent surgical intervention to relieve the obstruction and prevent complications such as perforation or sepsis 4, 5.

Key Principles of Management

• Early Diagnosis and Intervention: Early diagnosis and treatment of large bowel obstruction are critical to preventing complications and improving outcomes 3, 4.
• Individualized Care: Management of large bowel obstruction should be tailored to the individual patient's needs and circumstances, taking into account factors such as the underlying cause of the obstruction, the patient's overall health status, and the potential risks and benefits of different treatment options 3, 4.