What is the treatment for small bowel obstruction?

From the Guidelines

The treatment for small bowel obstruction should begin with conservative management, including bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression, as this approach has been found to be safe and efficacious in 70% of cases caused by adhesions 1. The initial management of small bowel obstruction involves supportive treatment with intravenous crystalloids, anti-emetics, and bowel rest, as recommended by recent studies 1. Key components of conservative management include:

• Bowel rest (nothing by mouth)
• Intravenous fluid resuscitation with isotonic dextrose-saline crystalloid and balanced isotonic crystalloid replacement fluids containing supplemental potassium
• Nasogastric tube decompression to relieve pressure and symptoms
• Pain management with medications like morphine or hydromorphone
• Correction of electrolyte imbalances
• Administration of antibiotics such as piperacillin-tazobactam or cefazolin plus metronidazole if infection is suspected This conservative approach is usually tried for 24-72 hours in partial obstructions, and water-soluble contrast administration can be a valid and safe treatment that correlates with a significant reduction in the need for surgery 1. If the obstruction is complete, strangulated, or fails to resolve with conservative measures, surgical intervention becomes necessary, and the underlying cause determines the specific surgical approach 1. Early treatment is crucial as delayed intervention can lead to bowel ischemia, perforation, and sepsis, which significantly increase mortality risk. Recent studies suggest that guidelines on the management of adhesive small bowel obstruction might also apply to the majority of patients with small bowel obstruction in the virgin abdomen, as adhesions are found to be the cause of the obstruction in approximately half of the reported cases 1.

From the FDA Drug Label

Metoclopramide Injection may be used to facilitate small bowel intubation in adults and pediatric patients in whom the tube does not pass the pylorus with conventional maneuvers The treatment for small bowel obstruction may involve the use of metoclopramide to facilitate small bowel intubation.

• The drug can help the tube pass the pylorus when conventional maneuvers are not effective. 2

From the Research

Treatment Overview

The treatment for small bowel obstruction (SBO) can be divided into medical and surgical management.

• Medical management includes intravenous fluid resuscitation, analgesia, and determining the need for operative vs. nonoperative therapy 3.
• Nasogastric tube decompression is useful for patients with significant distension and vomiting by removing contents proximal to the site of obstruction 3, 4.
• However, the use of nasogastric tubes in patients without active emesis is not supported by evidence, as it may increase the risk of pneumonia and respiratory failure 4.

Medical Therapy

Medical therapy is the initial treatment for most patients with SBO.

• It includes bowel rest, intravenous hydration, and correction of electrolyte abnormalities 5, 6.
• The use of octreotide, metoclopramide, and dexamethasone in combination has been shown to improve symptoms and bowel function in patients with malignant bowel obstruction 7.
• Abdominal CT with oral and intravenous contrast is highly sensitive and specific in detecting and characterizing SBO, and is recommended for early diagnosis 6.

Surgical Management

Surgical management is required for patients with complete bowel obstruction, strangulation, or those who fail nonoperative therapy.

• Surgery is also indicated for patients with peritonitis, bowel ischemia, or perforation 3, 5, 6.
• Laparoscopy is the preferred surgical approach for SBO, as it reduces the risk of complications and shortens hospital stay 6.
• The timing of surgery is critical, and delayed surgery can increase the risk of complications and mortality 5, 6.