Can I give ketorolac (Nonsteroidal Anti-Inflammatory Drug) to a patient with a suspected small bowel obstruction?

Ketorolac Should Not Be Given in Suspected Small Bowel Obstruction

Ketorolac is contraindicated in patients with suspected small bowel obstruction due to increased risks of gastrointestinal complications and potential worsening of the underlying condition. 1, 2

Rationale for Contraindication

• NSAIDs including ketorolac can cause gastrointestinal bleeding, perforation, and exacerbate small bowel injury, which would be particularly dangerous in a patient with compromised bowel integrity from obstruction 1
• Ketorolac has been associated with gastric ulceration and perforation, particularly in elderly patients, which could complicate the clinical picture of bowel obstruction 3
• NSAIDs are known to cause small bowel strictures (diaphragm disease) that can themselves lead to small bowel obstruction, making ketorolac particularly inappropriate in this setting 2
• Even a single dose of ketorolac has been documented to cause significant intra-abdominal bleeding in postoperative patients with bowel obstruction 4

Risks Specific to Small Bowel Obstruction

• In small bowel obstruction, there is already compromised blood flow to the affected bowel segments, and NSAIDs further reduce mucosal blood flow through prostaglandin inhibition 1, 5
• Patients with small bowel obstruction often have fluid and electrolyte abnormalities that increase the risk of NSAID-induced acute kidney injury 1
• The American College of Radiology guidelines for suspected small bowel obstruction do not recommend NSAIDs as part of management 6
• NSAID use should be avoided for at least four weeks prior to small bowel evaluation in suspected bowel disorders, indicating their potential to affect bowel integrity 6

Alternative Pain Management Options

• Opioid analgesics are the preferred first-line agents for pain control in small bowel obstruction 6
• If constipation is a concern with opioids, consider:
  • Fentanyl or methadone which may have less constipating effects 6
  • Peripherally acting mu-opioid receptor antagonists (PAMORAs) can be used to manage opioid-induced constipation, though these should not be used in patients with known mechanical bowel obstruction 6
• For nausea management, consider:
  • Phenothiazines (prochlorperazine, thiethylperazine) 6
  • Dopamine receptor antagonists (metoclopramide, haloperidol) 6
  • Olanzapine may be especially helpful for patients with bowel obstruction 6

Clinical Approach to Suspected Small Bowel Obstruction

• CT abdomen and pelvis with IV contrast is the first-line imaging study with >90% diagnostic accuracy for confirming small bowel obstruction 6, 7
• Oral contrast is not required and may increase the risk of vomiting and aspiration in high-grade obstruction 8, 7
• Initial management includes nasogastric decompression and IV fluids while avoiding medications that could worsen the condition 7
• Monitor for signs of ischemia or strangulation which would require urgent surgical intervention 8, 7

Important Cautions

• Even a single dose of ketorolac can trigger significant bleeding complications in at-risk patients 4
• The risk of adverse events with ketorolac increases with high doses, prolonged therapy (>5 days), and in vulnerable populations like the elderly 1
• Long-term NSAID use is associated with small bowel diaphragm disease, an under-recognized cause of small bowel obstruction 2, 5
• Ketorolac should be avoided in patients with compromised hemostasis, which may occur in the setting of bowel obstruction due to inflammation and vascular congestion 1