Which specialist should a patient with small bowel obstruction (SBO) see?

Management of Small Bowel Obstruction: Specialist Referral

Patients with small bowel obstruction (SBO) should be primarily evaluated and managed by a general surgeon, as surgical intervention may be required in many cases, particularly those with complete obstruction, signs of strangulation, or failed conservative management. 1

Initial Evaluation and Specialist Involvement

• General Surgeon: The primary specialist for SBO management

  • Should be consulted early in the course of suspected SBO
  • Responsible for determining need for operative vs. non-operative management
  • Performs surgical intervention when indicated

• Gastroenterologist: May be involved in:

  • Cases of partial or low-grade SBO where endoscopic intervention might be considered
  • Placement of self-expanding metal stents for malignant obstructions
  • Management of underlying conditions like Crohn's disease

• Radiologist: Critical role in:

  • Performing and interpreting diagnostic imaging (CT scan with IV contrast is gold standard)
  • Water-soluble contrast studies that can be both diagnostic and therapeutic
  • Determining the location, cause, and severity of obstruction

Management Algorithm Based on Clinical Presentation

For Acute/High-Grade SBO:

1. Immediate surgical consultation for patients presenting with:

   • Signs of peritonitis
   • Fever, tachycardia, or metabolic acidosis
   • Evidence of bowel ischemia on imaging
   • Complete obstruction with clinical deterioration

2. Initial conservative management under surgical supervision for:

   • Partial obstructions without signs of ischemia
   • Patients without peritonitis or clinical deterioration
   • Conservative management includes:
     • IV fluid resuscitation
     • Nasogastric tube decompression
     • Pain management
     • Water-soluble contrast studies

For Intermittent/Low-Grade SBO:

1. Gastroenterology consultation may be appropriate for:
   • Chronic, intermittent symptoms
   • Suspected motility disorders
   • Need for specialized imaging (CT enterography, CT enteroclysis)

Special Considerations

• Virgin Abdomen SBO: Despite having no prior surgery, these patients should still be managed primarily by surgeons, as approximately 50% will have adhesions as the cause, and surgical management rates are high (39-83%) 2

• Complicated Cases: May require a multidisciplinary team approach including:

  • Pain specialists for chronic pain management
  • Nutritional support team for patients requiring parenteral nutrition
  • Psychiatrist/psychologist for patients with contributing psychosocial issues 2

Pitfalls to Avoid

• Delaying surgical consultation - this is a common error that can lead to increased morbidity and mortality
• Prolonged conservative management in patients with signs of strangulation
• Failure to recognize complete versus partial obstruction
• Inadequate fluid resuscitation before surgical intervention
• Overlooking opioid use which can mask symptoms and invalidate tests of small bowel motility 1

Outcome-Based Approach

The management pathway should prioritize reducing morbidity and mortality. Timely surgical consultation is essential as the mortality rate for SBO is approximately 10% overall but increases to 30% with bowel necrosis or perforation 3. Early involvement of the appropriate specialist can significantly improve outcomes by ensuring prompt diagnosis and appropriate management decisions.

Remember that CT scan with IV contrast is the gold standard for diagnosis with diagnostic accuracies greater than 90% for high-grade SBO 2, 1, and should be ordered promptly to guide specialist management decisions.