What is the management of intestinal obstruction?

Management of Intestinal Obstruction

The management of intestinal obstruction requires prompt assessment for signs of peritonitis, strangulation, or ischemia to determine the need for emergency surgery, while non-surgical management is effective in 70-90% of cases without these complications. 1, 2

Initial Evaluation and Diagnosis

• Physical examination should focus on identifying peritonitis, strangulation, or ischemia requiring emergency intervention, including assessment of abdominal distension, abnormal bowel sounds, and examination of all hernial orifices 1, 2
• Laboratory tests should include complete blood count, C-reactive protein, lactate, electrolytes, BUN/creatinine, and coagulation profile 2
• Elevated C-reactive protein, leukocytosis with left shift, and elevated lactate may indicate peritonitis or intestinal ischemia 2
• CT scan with intravenous contrast is the preferred imaging technique with superior diagnostic accuracy compared to conventional radiography 1, 2
• CT can identify the location, degree, and potential causes of obstruction, with water-soluble contrast enhancing diagnostic value 1
• Plain abdominal radiographs have limited diagnostic value with only 60-70% sensitivity 1

Non-Surgical Management

• Non-surgical management is the initial approach for most cases without signs of peritonitis, strangulation, or ischemia, with success rates of 70-90% 1, 2

• Key components include:

  • Nothing by mouth (NPO) 1
  • Nasogastric or long intestinal tube decompression 1, 2
  • Fluid resuscitation with crystalloids 1
  • Monitoring and correction of electrolytes 1
  • Water-soluble contrast administration (which can be both diagnostic and therapeutic) 1, 2

• Water-soluble contrast reaching the colon within 4-24 hours predicts successful non-operative management; if contrast has not reached the colon on an abdominal X-ray 24 hours after administration, this indicates a high likelihood of non-operative management failure 1, 2

Indications for Surgical Intervention

• Immediate surgical intervention is required for: 1, 2

  • Signs of peritonitis
  • Strangulation
  • Intestinal ischemia
  • Closed-loop obstruction on imaging
  • Free perforation with pneumoperitoneum and free fluid 3
  • Failure of non-surgical management after 72 hours

• For patients with severe sepsis/septic shock, damage control surgery with resection, stapled intestinal ends, and temporary closure may be necessary 1

Cause-Specific Management

Adhesive Small Bowel Obstruction

• Most common cause of intestinal obstruction in adults 1, 4
• Non-operative management should be tried first in the absence of peritonitis, strangulation, or ischemia 1, 2

Malignant Bowel Obstruction

• For patients with years to months to live, surgery is the primary treatment after appropriate imaging 3, 1
• For patients with advanced disease or poor condition (weeks to days to live), medical management is preferable 3
• Medical measures may include opioid analgesics, anticholinergic drugs, corticosteroids, and antiemetics 3
• Octreotide is highly recommended early in the diagnosis due to high efficacy and tolerability 3
• Total parenteral nutrition can be considered to improve quality of life in patients with longer life expectancy 3

Inflammatory Bowel Disease

• Free perforation is an absolute indication for emergency surgery 3
• Surgery is mandatory for symptomatic strictures that don't respond to medical therapy and aren't amenable to endoscopic dilatation 3
• Any colorectal stricture should be assessed with endoscopic biopsies to rule out malignancy 3
• Endoscopic balloon dilation has proven successful for primary intestinal or anastomotic strictures in Crohn's disease, with 89-92% technical success rate 3, 1

Obstructing Colon Cancer

• For left-sided obstructing colon cancer, self-expanding metallic stents are preferred over colostomy as they are associated with similar mortality/morbidity rates but shorter hospital stay 1, 2

Complications and Pitfalls

• Common complications include dehydration with renal injury, electrolyte disturbances, malnutrition, and aspiration 1, 2
• Recurrence of intestinal obstruction due to adhesions is possible after non-surgical management (12% within 1 year, increasing to 20% after 5 years) 1, 2
• Water-soluble contrast agents may further dehydrate patients due to their higher osmolarity, shifting fluids into the bowel lumen 2
• In patients with complete obstruction, antiemetics that increase gastrointestinal motility should be avoided 2

Special Considerations in Chronic Small Intestinal Dysmotility

• Treatment should be directed at the main symptom, using as few drugs as possible, avoiding high doses of opioids and unnecessary surgery 3
• If the patient has taken long-term opioids, narcotic bowel syndrome may have occurred, and a gradual supervised opioid withdrawal should be considered 3
• For malnourished patients, nutritional support should progress from oral supplements to enteral feeding (gastric, then jejunal if needed) to parenteral support if other methods fail 3
• A venting gastrostomy may reduce vomiting but can have problems such as leakage 3
• Nutritional status should be optimized before any surgical procedure 3