What is the treatment for a patient with a history of chronic gastritis and previous small bowel obstruction presenting with sharp abdominal pain, vomiting, and alternating diarrhea and constipation?

Immediate Evaluation for Recurrent Small Bowel Obstruction

This patient requires urgent assessment for recurrent small bowel obstruction (SBO) given the history of prior obstruction, current sharp abdominal pain, vomiting, and alternating bowel patterns—initial nonoperative management with bowel rest, nasogastric decompression, and IV fluid resuscitation should be initiated while determining if surgical intervention is needed. 1

Initial Management Approach

Immediate Stabilization

• NPO (nothing by mouth) status with nasogastric tube placement for gastric decompression to relieve vomiting and reduce bowel distension 2
• Intravenous fluid resuscitation to correct electrolyte disturbances and dehydration from vomiting and altered bowel function 1
• Obtain CT imaging immediately to differentiate between partial versus complete obstruction, assess for bowel ischemia, and identify transition points 3

Critical Assessment Points

The "gush sign" on digital rectal examination—where the examining finger passes through a stenotic segment releasing accumulated proximal contents—is pathognomonic for functional or anatomic distal obstruction and should be specifically assessed 4. Look for visible peristalsis and degree of abdominal distension 4.

Treatment Algorithm Based on Obstruction Severity

For High-Grade or Complete Obstruction

Surgery is indicated if CT shows:

• Signs of bowel ischemia (though these are not always predictive) 3
• Complete obstruction with no contrast passage 3
• Clinical deterioration despite conservative management 1

Important caveat: Patients with high-grade SBO can be managed nonoperatively in 46% of cases, but this carries a 24% recurrence rate versus 9% with surgery 3. However, operative management has significantly higher complications (23% vs 3%) and longer hospital stays (10.8 vs 4.7 days) 3.

For Partial Obstruction

Conservative management should be attempted first 3:

• Bowel rest with nasogastric decompression 2
• IV fluid and electrolyte correction 1
• Avoid prokinetic agents after bowel anastomosis from the prior obstruction 2
• Monitor for 48-72 hours for resolution 3

Symptom-Directed Therapy

Pain Management

• Hyoscine butylbromide (Buscopan) intramuscularly is preferred for colicky abdominal pain as it has direct smooth muscle antispasmodic effects and can be used long-term 2
• Dicycloverine hydrochloride is an alternative antimuscarinic agent 2
• Avoid high-dose opioids as they can worsen dysmotility and increase infection risk if nutritional support becomes necessary 2

Vomiting Control

• Ondansetron (5-HT3 antagonist) is first-line for antiemetic therapy now that domperidone and metoclopramide are not recommended for long-term use 2
• Warning: Ondansetron can cause constipation, which may worsen obstruction 2, 5
• If nasogastric drainage provides relief, consider venting gastrostomy (>20 French gauge) for persistent symptoms 2

Diarrhea Management (if bacterial overgrowth develops)

• Rifaximin is first-choice antibiotic if available on formulary for bacterial overgrowth causing diarrhea 2
• Alternative rotating antibiotics: amoxicillin-clavulanate, metronidazole, ciprofloxacin, or doxycycline in 2-6 week courses 2
• Loperamide can be used cautiously for symptomatic diarrhea relief 2, 6

Critical Pitfalls to Avoid

Medication Hazards

• Never use metoclopramide long-term due to risk of irreversible tardive dyskinesia and extrapyramidal effects 2
• Avoid cyclizine as it causes psychological dependence and increases catheter infection risk if nutritional support is needed 2
• Do not use prokinetics in patients with prior bowel anastomosis 2

Surgical Considerations

Surgery should be avoided when possible in patients with chronic dysmotility as they are at high risk for iatrogenic injury 2. However, judicious intervention may improve quality of life in select cases 2. The outcome of colectomy is particularly poor in patients with small bowel dysmotility 2.

Nutritional Support Planning

If conservative management fails and the patient becomes malnourished:

• Oral supplements and dietary adjustments first 2
• Gastric feeding if not vomiting 2
• Jejunal feeding via nasojejunal tube if gastric feeding fails 2
• Parenteral nutrition only if enteral routes fail and significant malnutrition develops 2

Underlying Gastritis Management

The chronic gastritis should be addressed concurrently but does not change acute obstruction management. Consider that bile reflux gastritis from prior surgery could contribute to symptoms and may require endoscopic evaluation once acute obstruction resolves 7.