Treatment of Bowel Obstruction
The best treatment for bowel obstruction requires a multidisciplinary approach with management tailored to the cause, location, and severity of obstruction, with surgical intervention indicated for cases with signs of ischemia, peritonitis, or failed conservative management. 1
Initial Assessment and Management
Diagnosis
- CT scan with IV contrast is the gold standard for diagnosis, identifying location, cause, and potential complications 1
- Laboratory evaluation: Complete blood count, lactate, electrolytes, CRP, BUN/creatinine 1
- Water-soluble contrast studies can be both diagnostic and therapeutic 1
Conservative Management
For partial obstructions without signs of ischemia or peritonitis:
- Nasogastric tube decompression
- IV fluid resuscitation with isotonic crystalloids
- Bowel rest
- Close monitoring with serial abdominal examinations 1
Water-soluble contrast administration can predict successful non-operative management if contrast reaches the colon within 24 hours 1
Surgical Management
Indications for Immediate Surgery
- Signs of peritonitis or bowel ischemia
- Complete obstruction with severe pain
- Clinical deterioration despite conservative management 1, 2
Surgical Approaches
- Laparotomy: Traditional approach, especially for unstable patients or when extensive adhesions are expected 1
- Laparoscopic adhesiolysis: Can be considered in hemodynamically stable patients 2, 1
Specific Surgical Interventions by Cause
Adhesive Small Bowel Obstruction
Hernia-Related Obstruction
- Reduction and repair of hernia 2
- Prosthetic repair for most abdominal wall hernias
- Suture repair preferred in contaminated fields 2
Large Bowel Obstruction
- Sigmoid volvulus: Endoscopic detorsion followed by sigmoid colectomy with primary anastomosis 2
- Cecal volvulus: Right hemicolectomy 2
- Diverticular obstruction: Resection and primary anastomosis after successful conservative treatment 2
- Malignant obstruction:
- Resection and primary anastomosis if no significant risk factors
- Staged procedure (e.g., Hartmann) for high-risk patients or perforation
- For rectal cancer: Consider stoma to permit staging and neoadjuvant treatment 2
Malignant Bowel Obstruction Management
Multidisciplinary Decision-Making
- Decisions should involve oncologists, surgeons, and endoscopists 2
- Consider patient's expectations, prognosis, expected therapies, and functional status 2
Non-Surgical Options
- Self-expanding metal stents (SEMS): Option for malignant obstruction of gastric outlet, proximal small bowel, and colon 3
- Pharmacologic management:
Special Considerations for Esophageal Obstruction
- For potential resection candidates: Avoid routine SEMS insertion without multidisciplinary review 2
- For non-resection candidates: Consider SEMS or brachytherapy 2
- Use fully or partially covered SEMS, not uncovered SEMS 2
Post-Treatment Care
- Early mobilization
- Progressive diet advancement when appropriate
- Monitoring for signs of recurrent obstruction
- Close follow-up to identify underlying causes 1
Common Pitfalls to Avoid
- Delaying surgical consultation
- Prolonging conservative management in patients with signs of strangulation
- Failure to recognize complete versus partial obstruction
- Inadequate fluid resuscitation
- Overlooking closed-loop obstruction 1
- Opioid use can mask symptoms and invalidate tests of small bowel motility 1
The recurrence rate after surgical management is approximately 8% at 1 year and 16% at 5 years, with morbidity rates of 10-39% 2, 1. Early and appropriate intervention based on the cause and severity of obstruction is crucial for optimizing outcomes and reducing complications.