What is the management of small bowel obstruction (SBO)?

From the Guidelines

Management of small bowel obstruction involves a stepwise approach beginning with supportive care while determining if surgical intervention is necessary, with the most recent evidence suggesting that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction 1.

Initial Management

Initial management includes:

• Bowel rest (nothing by mouth)
• Intravenous fluid resuscitation with normal saline or lactated Ringer's solution
• Nasogastric tube decompression
• Correction of electrolyte abnormalities Pain control with opioid analgesics like morphine 2-4mg IV every 4 hours or hydromorphone 0.5-1mg IV every 4 hours should be provided, as well as antiemetics such as ondansetron 4mg IV every 8 hours to manage nausea and vomiting 1.

Diagnostic Evaluation

Laboratory tests (complete blood count, electrolytes, lactate) and imaging studies (abdominal X-rays and CT scan with oral and IV contrast) are essential for diagnosis and determining the cause and severity of obstruction 1.

Conservative Management

Conservative management is appropriate for partial obstructions or those likely caused by adhesions, with most resolving within 24-72 hours, and non-operative management has been found safe and efficacious in 70% of SBOs caused by adhesions (ASBO) 1. However, signs of strangulation (fever, tachycardia, severe pain, leukocytosis, acidosis, or peritoneal signs), complete obstruction, or failure to improve with conservative measures necessitate urgent surgical intervention.

Surgical Intervention

Surgery may involve adhesiolysis, bowel resection, or repair depending on the underlying cause, and the pathophysiology involves intestinal distension proximal to the obstruction, leading to fluid sequestration, bacterial overgrowth, and potential ischemia if blood supply is compromised, making timely and appropriate management crucial to prevent complications like perforation or sepsis 1.

Some key points to consider:

• Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA 1
• A relatively high number of cases of SBO-VA were managed surgically, but in cases where a trial of non-operative management was started, this was generally successful 1
• Water-soluble contrast administration is a valid and safe treatment that correlates with a significant reduction in the need for surgery in patients with adhesive small bowel obstruction 1

From the Research

Management of Small Bowel Obstruction (SBO)

The management of SBO typically involves a combination of nonoperative and operative approaches.

• Nonoperative management includes:
  • Intravenous fluid resuscitation 2
  • Analgesia 2
  • Bowel rest 3, 4
  • Nasogastric tube decompression for patients with significant distension and vomiting 2, 3, 4
• Operative management is typically reserved for cases of strangulation or those that fail nonoperative therapy 2, 3
• The use of nasogastric decompression in SBO is not always necessary, and its use has been associated with increased risk of pneumonia and respiratory failure, as well as longer hospital length of stay 4
• Parenteral nutrition may be considered as an alternative to early reoperation in the management of early postoperative small bowel obstruction 5
• Computed tomography and ultrasound are reliable diagnostic methods for SBO 2
• A protocol for the management of adhesive small bowel obstruction may include the use of Gastroview (GV) to facilitate early recognition of complete obstruction 3

Classification and Diagnosis

• SBO can be classified as complete or partial, and complicated or simple 2
• The most reliable findings for diagnosing SBO include prior abdominal surgery, history of constipation, abdominal distension, and abnormal bowel sounds 2
• Signs of strangulation include fever, hypotension, diffuse abdominal pain, peritonitis, and several others 2
• Imaging studies, such as computed tomography and ultrasound, are essential for diagnosing SBO 2, 3, 6

Treatment Outcomes

• Patients who receive Gastroview (GV) and do not require surgery have lower hospital length of stay compared to those who require surgery 3
• Parenteral nutrition has been shown to be a safe alternative to elective surgery in clinically stable patients with persistent early postoperative small bowel obstruction 5