What is the role of dexamethasone (corticosteroid) in the treatment of small bowel obstruction?

From the Guidelines

Dexamethasone may be considered as an adjunctive therapy in the treatment of small bowel obstruction, particularly when the goal is to maintain gut function, at a dose of 4-12 mg IV daily, with discontinuation if no improvement is seen within 3-5 days. The use of dexamethasone in this context is based on its anti-inflammatory properties, which may help reduce bowel wall edema and inflammation, potentially facilitating resolution of the obstruction 1. However, it is essential to weigh the potential benefits against the risks, including the masking of signs of infection or peritonitis, delayed wound healing, and other systemic effects.

When considering the use of dexamethasone, it is crucial to assess the patient's overall clinical status, including risk factors for poor surgical outcome such as ascites, carcinomatosis, palpable intra-abdominal masses, multiple bowel obstructions, previous abdominal radiation, and advanced disease 1. The primary treatments for small bowel obstruction, including bowel rest, nasogastric tube decompression, intravenous fluids, and possibly surgery, should not be replaced by dexamethasone, but rather used in conjunction with it in selected cases.

Key points to consider in the management of small bowel obstruction include:

• The goal of treatment, whether it is to maintain gut function or to manage symptoms when gut function is no longer possible
• The use of pharmacologic measures, such as opioids, antiemetics, and corticosteroids, alone or in combination
• The potential benefits and risks of interventions, including total parenteral nutrition, venting gastrostomy tubes, and endoscopically placed stents
• The importance of discussing surgical risks and alternatives with patients and families, particularly in cases where the patient's condition is poor or the disease is advanced 1.

In terms of morbidity, mortality, and quality of life, the management of small bowel obstruction should prioritize interventions that improve symptoms, reduce the risk of complications, and enhance the patient's overall well-being, while also considering the potential risks and benefits of each treatment option 1.

From the Research

Role of Dexamethasone in Small Bowel Obstruction

• Dexamethasone, a corticosteroid, has been used in the management of small bowel obstruction, particularly in cases of malignant small bowel obstruction (MSBO) related to advanced epithelial ovarian cancer 2.
• The efficacy of dexamethasone in achieving symptom control in women with advanced epithelial ovarian cancer presenting with MSBO has been evaluated, with 89% of women initially achieving partial or complete symptom control 2.
• Dexamethasone responsiveness did not change with recurrent admissions, and platinum-responsive patients were more likely to respond to dexamethasone than platinum-resistant patients 2.

Comparison with Other Treatments

• The use of nasogastric decompression in small bowel obstruction has been questioned, with studies suggesting that it may not be necessary in patients without active emesis, and may even be associated with increased risk of pneumonia and respiratory failure 3.
• Parenteral nutrition has been evaluated as an alternative to early reoperation in the management of early postoperative small bowel obstruction, with 91% of patients successfully recovering bowel function and resuming enteral nutrition without reoperation 4.
• Somatostatin and dexamethasone have been used in combination to promote resolution of early postoperative small bowel obstruction with obliterative peritonitis, with improved outcomes compared to conservative treatment alone 5.

Key Findings

• Dexamethasone is a useful adjunctive therapy in the management of symptoms associated with MSBO in women with epithelial ovarian cancer 2.
• The optimal dosing and duration of dexamethasone treatment for small bowel obstruction are not well established, and further studies are needed to determine the most effective treatment regimen 2.
• A nonoperative approach to small bowel obstruction, including the use of dexamethasone and other conservative measures, may be effective in managing symptoms and avoiding the need for surgical intervention 6.