How do you manage small bowel obstruction conservatively in an adult?

Conservative Management of Small Bowel Obstruction in Adults

Conservative management is the cornerstone of treatment for all patients with adhesive small bowel obstruction unless there are signs of intestinal ischemia or perforation, with a recommended duration of 72 hours being safe and appropriate. 1

Initial Assessment and Diagnosis

• Multidetector computed tomography (CT) with intravenous contrast is the best imaging test for diagnosing mechanical bowel obstruction, its complications, and determining appropriate management 1
• Look for signs of intestinal ischemia or perforation on CT, which would necessitate immediate surgical intervention rather than conservative management 1
• Water-soluble contrast administration is both diagnostic and therapeutic in adhesive small bowel obstruction, with high sensitivity and specificity 1

Conservative Management Protocol

Immediate Interventions

• Nil per os (NPO) status to prevent further intestinal distension 1
• Nasogastric tube decompression to remove contents proximal to the obstruction site 1, 2
  • Long trilumen naso-intestinal tubes are more effective than nasogastric tubes but require endoscopic insertion 1
  • Consider avoiding routine nasogastric decompression in patients without active emesis, as it may increase risk of pneumonia and respiratory failure 3
• Intravenous fluid resuscitation to correct fluid and electrolyte imbalances 2
• Adequate pain management, avoiding high doses of opioids which can worsen dysmotility 1

Water-Soluble Contrast Challenge

• Administer water-soluble contrast (50-150 ml) either orally or via nasogastric tube 1
• If contrast reaches the colon on abdominal X-ray within 24 hours, this predicts successful non-operative management 1
• If contrast has not reached the colon after 24 hours, this indicates likely failure of conservative management 1
• Water-soluble contrast administration correlates with significant reduction in need for surgery and shorter time to resolution 1

Monitoring During Conservative Management

• Monitor for signs of intestinal ischemia or perforation: peritonism, increasing white blood cell count, elevated lactate levels 1
• Perform immediate surgery if clinical deterioration occurs 1
• If no improvement after 72 hours of conservative management, consider surgical intervention 1

Special Considerations

• Avoid unnecessary surgery in patients with chronic intestinal dysmotility whenever possible 4
• For patients with recurrent adhesive small bowel obstruction, consider water-soluble contrast administration early in management 1
• Nutritional status should be optimized before any surgical procedure if possible 1
• If oral feeding is unsuccessful and the patient is not vomiting, consider gastric feeding 1
• If gastric feeding fails, jejunal feeding may be attempted 1

Pitfalls to Avoid

• Delaying surgery when signs of ischemia or perforation are present 1
• Prolonging conservative management beyond 72 hours without improvement 1
• Administering water-soluble contrast without adequate gastric decompression, which may lead to aspiration pneumonia 1
• Using high doses of opioids for pain control, which can worsen bowel dysmotility 1
• Failing to recognize when conservative management is unlikely to succeed (e.g., complete obstruction, high-grade partial obstruction) 2, 5

Expected Outcomes

• Approximately 70-90% of adhesive small bowel obstructions resolve with conservative management 1
• Recurrence rate after successful non-operative management is approximately 12% within 1 year and 20% within 5 years 1
• Water-soluble contrast administration reduces hospital length of stay and time to resolution of obstruction 1