What is recurrent adhesive small bowel obstruction (SBO)?

Recurrent Adhesive Small Bowel Obstruction

Recurrent adhesive small bowel obstruction (SBO) is a condition where patients experience multiple episodes of bowel blockage caused by intra-abdominal adhesions (fibrous bands of scar tissue), occurring after an initial episode of adhesive SBO. 1

Epidemiology and Natural History

Recurrence is common and increases with each subsequent episode:

• 12% of non-operatively treated patients are readmitted within 1 year, rising to 20% after 5 years 1
• 8% of operatively treated patients experience recurrence after 1 year and 16% after 5 years 1
• The likelihood of reobstruction increases and the time interval between episodes decreases with each additional admission 2
• Patients with matted adhesions have a 49% readmission rate compared to 25% for those with single band adhesions 2

Risk Factors for Recurrence

Type of adhesions is the strongest predictor:

• Matted adhesions (multiple dense adhesions) carry nearly double the recurrence risk compared to single band adhesions 2
• History of colorectal surgery increases odds of matted adhesions by 2.7-fold 2
• Vertical incisions increase odds of matted adhesions by 2.5-fold 2
• Younger patients have higher lifetime risk for recurrent episodes 1

Clinical Presentation

Patients present with cardinal features of obstruction:

• Abdominal pain, distension, nausea, vomiting, and obstipation 3
• Triad of severe pain, pain out of proportion to findings, and presence of abdominal scar suggests closed-loop obstruction requiring urgent surgery 3
• Physical examination must assess for peritonitis, strangulation, or ischemia which mandate emergency operation 1

Diagnostic Approach

CT scan with IV contrast is the diagnostic technique of choice:

• CT has higher sensitivity and specificity than plain radiographs (which only have 60-70% sensitivity) 4
• CT identifies transition points, closed-loop obstructions, and signs of ischemia 5
• Water-soluble contrast administration enhances diagnostic value and predicts need for surgery 4
• Elevated C-reactive protein, leukocytosis, and elevated lactate suggest peritonitis or ischemia 4

Management Strategy

Non-operative management should be attempted first in stable patients without peritonitis, strangulation, or ischemia:

Initial Conservative Treatment (70-90% success rate) 1, 3

• Nothing by mouth (NPO) 4
• Nasogastric tube decompression 1
• IV fluid resuscitation with crystalloids and electrolyte correction 4
• Water-soluble contrast (Gastrografin) administration—both diagnostic and therapeutic 4, 6
  • Contrast reaching colon within 4-24 hours predicts successful non-operative resolution 4
  • Significantly reduces need for surgery 4
• 72-hour trial is safe and appropriate 4

Indications for Surgical Intervention

Immediate surgery required for: 1, 4

• Peritonitis
• Signs of strangulation or bowel ischemia
• Closed-loop obstruction on imaging
• Hemodynamic instability

Delayed surgery indicated for: 4, 6

• Failure of non-operative management after 72 hours
• Worsening symptoms during conservative treatment
• Persistent obstruction despite water-soluble contrast

Surgical Approach

Laparoscopic adhesiolysis is preferred in selected cases:

• Ideal candidates: hemodynamically stable patients with single adhesive band on CT, clear transition point, and minimal bowel distension 4
• Reduces morbidity, mortality, and surgical infections compared to open surgery 4
• Contraindicated with very distended bowel loops 4
• Conversion to open surgery required in 4-24% of cases due to dense adhesions or iatrogenic bowel injury 7
• Risk of iatrogenic bowel injury is 3-17.6% 4

Prevention of Recurrence

Adhesion barriers should be used in high-risk patients:

• Younger patients benefit most from adhesion barrier application during surgery 1
• Hyaluronate carboxymethylcellulose barriers reduce recurrence from 4.5% to 2.0% at 24 months 4
• Minimally invasive surgical techniques reduce adhesion formation 1

Outcomes and Prognosis

Comparative outcomes between operative and non-operative management:

• Non-operative treatment results in shorter hospital stay (5 days vs 16 days) 1
• Similar overall recurrence rates (34% non-operative vs 32% operative) 2
• Non-operative patients have shorter time to readmission (median 0.7 vs 2.0 years) 2
• Fewer total inpatient days over all admissions with non-operative approach (4 vs 12 days) 2

Critical Pitfalls to Avoid

• Do not delay surgery in patients with peritonitis, strangulation, or ischemia—these require immediate operative intervention 1, 4
• Do not assume all SBO in patients with prior surgery is adhesive—consider recurrent cancer, occult hernia, or other etiologies 8
• Do not miss enterotomies during laparoscopic adhesiolysis—all bowel injuries must be identified intraoperatively to avoid delayed perforation 4
• Do not extend non-operative management beyond 72 hours without clear improvement 4