What is the management of intestinal obstruction?

From the Guidelines

Management of intestinal obstruction should start with a multidisciplinary approach, considering the patient's expectations, prognosis, and functional status, as well as the characteristics of the obstruction, and initial treatment should include bowel rest, intravenous fluids, and nasogastric tube decompression to relieve symptoms and prevent complications. The initial management of bowel obstruction involves supportive treatment with intravenous crystalloids, anti-emetics, and bowel rest, as recommended by the study published in the World Journal of Emergency Surgery in 2019 1. Isotonic dextrose-saline crystalloid and balanced isotonic crystalloid replacement fluids containing supplemental potassium in an equivalent volume to the patient’s losses are recommended. Nasogastric suction can be diagnostically useful to analyze gastric contents and therapeutically important to prevent aspiration pneumonia decompressing the proximal bowel.

Key Components of Initial Management

• Intravenous fluid resuscitation with normal saline or lactated Ringer's solution
• Placement of a nasogastric tube to decompress the stomach and proximal intestines
• Pain management with opioid analgesics like morphine or hydromorphone
• Antiemetics such as ondansetron or metoclopramide to control nausea and vomiting
• Bowel rest with NPO (nothing by mouth) status

The decision about specific interventions should be made in a multidisciplinary setting, including oncologists, surgeons, and endoscopists, as recommended by the study published in Clinical Gastroenterology and Hepatology in 2021 1. For patients with malignant bowel obstruction, surgery after CT scan is the primary treatment option, although medical management can include pharmacologic measures, parenteral fluids, endoscopic management, and enteral tube drainage, as discussed in the study published in the Journal of the National Comprehensive Cancer Network in 2016 1.

Considerations for Malignant Bowel Obstruction

• Surgery is the primary treatment option for patients with years to months to live
• Medical management can include pharmacologic measures, parenteral fluids, endoscopic management, and enteral tube drainage
• Risk factors for poor surgical outcome include ascites, carcinomatosis, palpable intra-abdominal masses, multiple bowel obstructions, previous abdominal radiation, advanced disease, and poor overall clinical status

Non-operative management is effective in approximately 70–90% of patients with adhesive small bowel obstruction, and the cornerstone of non-operative management is nil per os and decompression using a naso-gastric tube or long intestinal tube, as discussed in the study published in the World Journal of Emergency Surgery in 2018 1. The duration of non-operative management is subject to debate, but most authors consider a 72-h period as safe and appropriate.

Considerations for Adhesive Small Bowel Obstruction

• Non-operative management is effective in approximately 70–90% of patients
• The cornerstone of non-operative management is nil per os and decompression using a naso-gastric tube or long intestinal tube
• The duration of non-operative management is subject to debate, but most authors consider a 72-h period as safe and appropriate

From the Research

Management of Intestinal Obstruction

The management of intestinal obstruction can be divided into several key areas, including:

• Diagnosis and assessment of the obstruction
• Initial management and stabilization of the patient
• Determining the need for operative vs. nonoperative therapy
• Symptom management and palliative care

Initial Management

Initial management of intestinal obstruction typically involves:

• Intravenous fluid resuscitation to correct fluid and electrolyte imbalances 2
• Analgesia to manage pain
• Bowel rest to reduce bowel activity
• Nasogastric tube placement to decompress the bowel and remove contents proximal to the site of obstruction 2, 3
• Imaging studies, such as computed tomography or ultrasound, to confirm the diagnosis and assess the severity of the obstruction 2, 3

Operative vs. Nonoperative Therapy

The decision to operate or manage the obstruction nonoperatively depends on several factors, including:

• The cause and severity of the obstruction
• The presence of complications, such as strangulation or perforation
• The patient's overall health and performance status
• Surgery is typically required for complete complicated obstructions, strangulation, or cases that fail nonoperative therapy 2, 3

Symptom Management and Palliative Care

Symptom management and palliative care are critical components of intestinal obstruction management, particularly for patients with malignant bowel obstruction:

• Pharmacological agents, such as corticosteroids, octreotide, and anti-cholinergic agents, can be used to manage symptoms and improve quality of life 4, 5
• Analgesics, anti-emetics, and anti-cholinergics can be used to control pain, nausea, and vomiting 4, 5
• Palliative care and hospice should be discussed with patients who have advanced malignancy and poor prognosis 3, 5