What are the appropriate admitting orders for treatment (t/c) of partial gut obstruction?

Admitting Orders for Partial Small Bowel Obstruction

For partial small bowel obstruction, admit the patient with NPO status, IV fluid resuscitation, nasogastric tube decompression, antibiotic prophylaxis targeting gram-negative and anaerobic organisms, serial abdominal exams, and CT imaging with IV contrast to confirm diagnosis and assess for complications. 1, 2, 3

Initial Resuscitation and Stabilization

• Make patient NPO (nil per os) immediately to prevent further bowel distension and reduce risk of aspiration 2, 3
• Initiate aggressive IV fluid resuscitation with isotonic crystalloids to correct dehydration and electrolyte abnormalities, as bowel dilatation causes third-spacing and intraluminal fluid accumulation 2, 3
• Insert nasogastric tube for decompression to reduce proximal bowel distension, decrease mural tension, and improve mucosal perfusion 2, 3
• Correct electrolyte abnormalities identified on metabolic panel, particularly potassium, sodium, and chloride derangements from vomiting and third-spacing 2, 3

Diagnostic Workup

• Order CT abdomen/pelvis with IV contrast as the primary imaging modality, which is highly sensitive and specific for detecting and characterizing small bowel obstruction, localizing the site, identifying the etiology, and detecting complications such as ischemia or closed-loop obstruction 1, 2, 3
• Obtain baseline laboratory studies including complete blood count (looking for leukocytosis, neutrophilia, bandemia suggesting ischemia), comprehensive metabolic panel, and serum lactate level (elevated lactate suggests bowel ischemia) 1, 2, 3
• Plain abdominal radiographs are less sensitive than CT but may be obtained initially if CT is not immediately available 1, 3

Antibiotic Prophylaxis

• Administer prophylactic antibiotics targeting gram-negative bacilli and anaerobic bacteria even in the absence of systemic signs of infection, as intestinal obstruction causes bacterial translocation across the bowel wall 1, 3
• Appropriate regimens include piperacillin-tazobactam, cefoxitin, or combination therapy with a third-generation cephalosporin plus metronidazole 1, 3
• Discontinue prophylactic antibiotics after 24 hours (or 3 doses) if no evidence of perforation or systemic infection develops 1
• Escalate to therapeutic antibiotics with broader spectrum coverage if fever, leukocytosis, or signs of sepsis develop, suggesting bowel ischemia or perforation 1, 3

Monitoring and Serial Assessment

• Order serial abdominal examinations every 4-6 hours to detect development of peritoneal signs (severe direct tenderness, involuntary guarding, rigidity, rebound tenderness) that suggest bowel ischemia, perforation, or need for surgical intervention 2, 3
• Monitor vital signs closely for tachycardia, fever, hypotension, or orthostasis indicating dehydration, sepsis, or clinical deterioration 2, 3
• Repeat laboratory studies (CBC, lactate) if clinical deterioration occurs, as marked leukocytosis, bandemia, and lactic acidosis suggest advanced obstruction with ischemia 2, 3

Pain Management

• Provide appropriate analgesia with opioids for pain control, recognizing that pain out of proportion to physical exam findings suggests bowel ischemia or strangulation 4, 2
• Avoid masking peritoneal signs with excessive analgesia during the initial assessment period 3

Water-Soluble Contrast Challenge (Optional)

• Consider administering 100 mL of water-soluble contrast (diatrizoate meglumine/sodium diluted in 50 mL water) via nasogastric tube with follow-up abdominal radiographs at 8 and 24 hours to differentiate partial from complete obstruction 1
• If contrast reaches the colon by 24 hours, the patient rarely requires surgery and conservative management is likely to succeed 1
• This protocol does not require fluoroscopy and helps predict success of conservative measures 1

Surgical Consultation

• Obtain early surgical consultation for all patients with small bowel obstruction, as delay in surgery when indicated increases risk of complications and mortality (up to 30% with bowel necrosis/perforation versus 10% overall) 2, 3
• Indications for urgent surgical intervention include evidence of bowel ischemia (elevated lactate, severe pain, peritoneal signs), closed-loop obstruction, volvulus, complete obstruction failing conservative management after 3-5 days, or clinical deterioration despite medical therapy 1, 2, 3

Critical Pitfalls to Avoid

• Never administer enemas in patients with suspected or confirmed bowel obstruction, as this can precipitate perforation, exacerbate obstruction, and cause life-threatening complications 5
• Avoid prokinetic agents (metoclopramide) if complete obstruction is suspected, as they can worsen symptoms and increase perforation risk 4, 6
• Do not delay imaging while pursuing conservative management, as early CT diagnosis is critical for detecting complications like ischemia that require urgent surgery 1, 2
• Recognize that physical examination and laboratory tests alone are neither sensitive nor specific for detecting bowel ischemia or strangulation—maintain high index of suspicion and low threshold for surgical consultation 1, 2

Expected Clinical Course

• Most partial small bowel obstructions (approximately 70-80%) resolve with conservative medical management within 3-5 days 2, 3
• Adhesions account for 65% of cases, hernias 10%, malignancy 5%, Crohn's disease 5%, and other causes 15% 2
• Failure to improve within 3-5 days of conservative management or development of complications warrants surgical intervention, preferably by laparoscopy when feasible 2, 3