What is the best course of treatment for intestinal obstruction?

Intestinal Obstruction Management

Initial Management Strategy

Begin with conservative non-operative management for all patients without signs of peritonitis, strangulation, or ischemia—this approach successfully resolves 70-90% of cases and should include bowel rest (NPO), selective nasogastric decompression only if actively vomiting, intravenous crystalloid resuscitation, electrolyte correction, and administration of water-soluble contrast agent. 1, 2

Conservative Management Protocol (First 72 Hours)

• Nothing by mouth (NPO) with intravenous crystalloid rehydration to correct dehydration and prevent renal injury 1, 2
• Nasogastric tube decompression only if patient has active vomiting or significant abdominal distension—avoid routine placement as it increases respiratory complications 2, 3
• Water-soluble contrast administration (e.g., Gastrografin) serves both diagnostic and therapeutic purposes, significantly reducing need for surgery 1, 2
  • If contrast reaches colon within 4-5 hours, 90% resolution rate with conservative management 2
  • If no contrast in colon by 24 hours, surgical intervention likely needed 2
• Monitor and correct electrolytes (sodium, potassium, chloride, bicarbonate) as hydroelectrolytic imbalances are common 1, 2
• Serial clinical examinations every 4-6 hours to detect development of peritonitis, fever, tachycardia, or worsening pain 1

Absolute Indications for Immediate Surgery

Proceed directly to emergency surgical exploration without trial of conservative management if any of the following are present:

• Signs of peritonitis (rebound tenderness, guarding, rigidity) 1, 2, 3
• Clinical signs of strangulation or ischemia (fever, tachycardia, continuous severe pain, elevated lactate >2.5 mmol/L, leukocytosis with left shift) 1, 2
• Pneumoperitoneum with free fluid on CT imaging 1, 3
• Closed-loop obstruction identified on CT scan 2, 3
• Severe sepsis or septic shock (may require damage control surgery with resection, stapled bowel ends, and laparostomy) 1, 3

When Conservative Management Fails

• Surgery is indicated after 72 hours of conservative management without improvement 1, 2, 3
• Do not prolong conservative treatment beyond this timeframe as it increases morbidity and mortality 3

Cause-Specific Management

Small Bowel Obstruction Due to Adhesions

• Laparotomy remains the standard surgical approach for most cases requiring operation 1, 2
• Laparoscopic adhesiolysis can be considered in highly selected patients who are hemodynamically stable, have single adhesive band on CT with clear transition point, and minimal bowel distension 1, 2
  • Risk of iatrogenic bowel injury is 3-17.6% with laparoscopy 2
  • All enterotomies must be identified intraoperatively to avoid missed perforations 2
• Use adhesion barriers (hyaluronate carboxymethylcellulose) during surgery in young patients to reduce recurrence from 4.5% to 2.0% at 24 months 2

Complicated Hernias (Inguinal, Femoral, Incisional, Umbilical)

• Prosthetic mesh repair is treatment of choice for most complicated hernias 1
• Suture repair without mesh is preferred if perforation or bowel resection occurs with contaminated surgical field due to risk of mesh infection 1
• Laparoscopic approach can be used when no bowel resection/anastomosis is needed; otherwise mini-open approach (small laparotomy) is required 1

Large Bowel Obstruction

Sigmoid Volvulus Without Ischemia

• Endoscopic detorsion followed by same-admission sigmoid colectomy with primary anastomosis is the best strategy 1
• Exclusively endoscopic therapy without subsequent surgery should be reserved only for high-surgical-risk patients 1
• If ischemic volvulus or failed derotation, proceed immediately to surgery 1

Cecal Volvulus

• Right hemicolectomy is the only option—endoscopy has no role 1

Diverticular Large Bowel Obstruction

• Resection and primary anastomosis should be attempted regardless of bowel preparation after successful conservative treatment in same admission 1
• Hartmann procedure reserved for high-risk patients 1

Malignant Large Bowel Obstruction

• Resection and primary anastomosis is best option in absence of significant risk factors or perforations (anastomotic leak rate 2.2-12%, comparable to elective procedures) 1
• Hartmann procedure for patients with high surgical risk or perforations 1
• For extraperitoneal rectal cancer, postpone resection of primary tumor and fashion stoma to permit proper staging and neoadjuvant treatment 1
• Metal stents preferred over colostomy for palliation of left-sided obstructing colon cancer 2, 3

Malignant Bowel Obstruction (Palliative Setting)

For patients with advanced cancer and limited life expectancy (weeks to months), prioritize pharmacologic management over surgery to optimize quality of life and allow home/hospice care. 1, 3

Pharmacologic Management Protocol

• Octreotide 150 mcg subcutaneously twice daily (up to 300 mcg twice daily)—consider early due to high efficacy and tolerability in reducing gastrointestinal secretions 1, 3
• Opioids for pain control via rectal, transdermal, subcutaneous, or intravenous routes 1, 3
• Anticholinergics (scopolamine, hyoscyamine, glycopyrrolate) to reduce secretions 1, 3
• Corticosteroids (up to 60 mg/day dexamethasone; discontinue if no improvement in 3-5 days) 1, 3
• Antiemetics: Do NOT use metoclopramide in complete obstruction as it increases gastrointestinal motility; may be beneficial in incomplete obstruction 1
• Intravenous or subcutaneous fluids only if evidence of dehydration 1

Endoscopic/Interventional Options

• Percutaneous endoscopic gastrostomy tube for drainage in proximal obstruction with intractable vomiting 1
• Endoscopic stent placement for appropriate anatomic locations 1
• Nasogastric tube drainage only on limited trial basis if other measures fail—increases aspiration risk and patient discomfort 1, 3

Nutritional Support

• Total parenteral nutrition only if expected improvement in quality of life with life expectancy of many months to years 1, 3

Inflammatory Bowel Disease (Crohn's Disease/Ulcerative Colitis)

• Surgery is mandatory for symptomatic intestinal strictures that don't respond to medical therapy and aren't amenable to endoscopic dilatation 1, 3
• Endoscopic balloon dilation has 89-92% technical success rate for primary or anastomotic strictures 2, 3
• Any colorectal stricture must be biopsied endoscopically to rule out malignancy 1, 3
• Laparoscopic approach recommended if emergency surgery indicated in hemodynamically stable patients with appropriate expertise 1
• Subtotal colectomy with ileostomy is emergency operation of choice for severe acute refractory colitis 1

Diagnostic Imaging Priorities

• CT scan is the preferred imaging technique with high sensitivity and specificity for diagnosing location, degree, and cause of obstruction 2
• Water-soluble contrast administration enhances diagnostic value of CT and predicts need for surgery 2
• Plain abdominal radiographs have limited value (sensitivity only 60-70%) and should not be relied upon alone 2
• MRI is valid alternative in children and pregnant women (sensitivity 95%, specificity 100%) 2

Critical Laboratory Markers

• Elevated lactate, leukocytosis with left shift, and elevated C-reactive protein indicate peritonitis or intestinal ischemia requiring immediate surgery 1, 2, 3
• Obtain complete blood count, C-reactive protein, lactate, electrolytes, BUN/creatinine, and coagulation profile 2

Common Pitfalls to Avoid

• Do not rely on classic clinical signs alone to predict gangrenous intestine—accuracy is only 14% 3
• Do not prolong conservative management beyond 72 hours without improvement 3
• Do not use metoclopramide long-term in elderly patients (risk of irreversible tardive dyskinesia) 3
• Do not use stimulant laxatives or fiber in non-ambulatory patients with low fluid intake 3
• Do not routinely place nasogastric tubes in patients without active vomiting 3
• Examine all hernial orifices during physical examination—incarcerated hernias require prompt operative intervention 2