What is the treatment for bowel obstruction?

Treatment of Bowel Obstruction

The treatment of bowel obstruction depends critically on whether it involves the small or large bowel, the underlying cause, and the presence of ischemia or perforation—with initial management prioritizing resuscitation and imaging, followed by either conservative management (effective in 70-90% of small bowel obstruction cases) or surgical intervention for large bowel obstruction, ischemia, or failed conservative therapy. 1, 2

Initial Resuscitation and Assessment

All patients require immediate supportive care including:

• Intravenous crystalloid fluid resuscitation to correct intravascular depletion 1, 2
• Nasogastric tube decompression for gastric decompression 1, 2
• Foley catheter insertion to monitor urine output 1
• NPO status to reduce intestinal workload 2
• Electrolyte monitoring and correction 2

Multidetector CT with intravenous contrast is the imaging modality of choice to determine the cause, location, and complications of obstruction 1, 3. The CT report must address four critical points: confirming obstruction, identifying transition points or closed loops, establishing the cause, and identifying signs of ischemia or perforation 3.

Small Bowel Obstruction Management

Conservative Management (First-Line for Most Cases)

Non-operative management is effective in 70-90% of small bowel obstruction cases without peritonitis, strangulation, or ischemia 2. This approach includes:

• Continued NPO status, IV fluids, and nasogastric decompression 2
• Water-soluble contrast agents (Gastrografin) serve both diagnostic and therapeutic purposes, with contrast reaching the colon within 4-24 hours predicting successful non-operative management 2
• Administration of water-soluble contrast significantly reduces the need for surgery 2

Conservative management should be attempted for 72 hours maximum before considering surgical intervention 2. Regular reassessment is essential to detect clinical deterioration 1, 2.

Surgical Indications for Small Bowel Obstruction

Immediate surgery is required for:

• Signs of peritonitis, strangulation, or bowel ischemia 2
• Closed-loop obstruction on imaging 2
• Failed conservative management after 72 hours 2
• Perforation 2

For adhesive small bowel obstruction requiring surgery, laparotomy remains the standard approach, though laparoscopic adhesiolysis may decrease morbidity in carefully selected patients 4. The risk of intestinal injury is higher with laparoscopy, requiring careful patient selection 4. Recurrence rates after operative treatment are 8% at 1 year and 16% at 5 years 4.

For complicated hernias with bowel obstruction:

• Prosthetic mesh repair is preferred for most cases 4
• If perforation or bowel resection occurs with contaminated fields, suture repair is preferred due to infection risk 4
• Laparoscopic approach is appropriate when no bowel resection is needed 4

Large Bowel Obstruction Management

Sigmoid Volvulus

For sigmoid volvulus without ischemia or perforation, endoscopic detorsion followed by same-admission sigmoid colectomy with primary anastomosis is the recommended strategy 4, 1. This approach has:

• Success rates of 70-95% for endoscopic detorsion 4
• 4% morbidity and 3% mortality 4
• Recurrence rates up to 71% if surgery is not performed 4

Endoscopic detorsion alone without subsequent surgery should be reserved only for high-surgical-risk patients, though recurrence rates remain high 1. Immediate surgical intervention is necessary for ischemic volvulus or failed derotation 1.

Cecal Volvulus

Right hemicolectomy is the only treatment option for cecal volvulus—endoscopy has no role 4, 1.

Malignant Large Bowel Obstruction

For obstructing left-sided colon cancer:

• Self-expanding metallic stents as a bridge to elective surgery offer better short-term outcomes than emergency surgery, with lower stoma rates and comparable long-term outcomes 4, 1
• However, stents should not be considered the universal treatment of choice and should be reserved for selected cases in centers with significant expertise 4
• For palliation, self-expanding metallic stents are preferred to colostomy with similar mortality/morbidity but shorter hospital stays 4

For patients without significant risk factors or perforation, resection with primary anastomosis is recommended 1. For high-risk patients or those with perforation, staged procedures such as Hartmann procedure are more appropriate 1, 5.

Emergency surgery for malignant large bowel obstruction carries mortality rates almost three times higher than elective resections, with anastomotic leak rates of 2.2-12% 1, 5.

Diverticular Large Bowel Obstruction

Resection and primary anastomosis is the preferred approach after successful conservative management, regardless of bowel preparation status 4, 1. For high-risk patients, conservative therapy or Hartmann procedure may be considered 1.

Critical Monitoring Parameters

Close monitoring for clinical deterioration is essential, including:

• Development of peritonism 1
• Increasing white blood cell count 1
• Rising lactate levels 1
• Signs of ischemia or perforation on serial examinations 1, 3

Immediate surgery is necessary if any signs of clinical deterioration develop 1.

Common Pitfalls to Avoid

• Do not delay surgery beyond 72 hours in small bowel obstruction without clear improvement 2
• Do not perform endoscopic detorsion for sigmoid volvulus without planning same-admission definitive surgery unless the patient is high-risk 4, 1
• Do not attempt laparoscopic adhesiolysis without careful patient selection due to higher risk of intestinal injury 4
• Do not use self-expanding metallic stents for left colon cancer outside of centers with significant expertise 4
• Do not perform primary resection in elderly high-risk patients with malignant obstruction—create a diverting stoma instead 5