What is the management of partial small bowel obstruction (Small Bowel Obstruction, SBO)?

From the Guidelines

Management of partial small bowel obstruction should begin with a conservative approach, including bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression, for a period of 24-72 hours, as this approach is effective in approximately 70-90% of patients with adhesive small bowel obstruction, as noted in the Bologna guidelines 1.

Key Components of Conservative Management

• Bowel rest (nothing by mouth) to reduce bowel movement and alleviate pressure
• Intravenous fluid resuscitation to correct fluid and electrolyte imbalances, which is crucial in preventing dehydration and kidney injury, as highlighted in the Bologna guidelines 1
• Nasogastric tube decompression to relieve pressure and nausea, with the choice between naso-gastric tubes and long intestinal tubes depending on the clinical scenario, although a more recent trial suggests that long tubes may be more effective in certain cases 1
• Pain management with medications, such as morphine or hydromorphone, to control pain and discomfort
• Antiemetics, such as ondansetron, to control nausea and vomiting

Monitoring and Surgical Intervention

• Serial physical examinations, laboratory tests, and imaging studies to assess progress and identify potential complications
• If symptoms improve, diet can be gradually advanced from clear liquids to regular food
• If the obstruction worsens or fails to resolve, surgical intervention becomes necessary, which may involve adhesiolysis, resection of damaged bowel segments, or repair of hernias, as discussed in the WSES position paper on small bowel obstruction in virgin abdomen 1
• Underlying causes, such as adhesions, hernias, inflammatory bowel disease, or tumors, should be identified and addressed to prevent recurrence, with the management approach being largely comparable to that of patients with small bowel obstruction after previous abdominal surgery, as proposed in the WSES position paper 1

Duration of Conservative Management

• The optimal duration of non-operative treatment is subject to debate, but most authors consider a 72-hour period as safe and appropriate, as noted in the Bologna guidelines 1
• Continuing non-operative treatment for more than 72 hours in cases with persistent high output from a decompression tube, but no other signs of clinical deterioration, remains subject to debate, and should be decided on a case-by-case basis, taking into account the individual patient's condition and response to treatment.

From the Research

Management of Partial Small Bowel Obstruction

• The management of partial small bowel obstruction (SBO) can be challenging, and the approach may vary depending on the etiology and clinical status of the patient 2.
• Patients with partial obstruction without signs of strangulation can be initially treated conservatively, with a success rate of 79% in one study 3.
• Conservative management includes intravenous fluid resuscitation, analgesia, and bowel rest, with the option of nasogastric tube decompression if necessary 4, 5.
• The use of water-soluble contrast (WSC) has been shown to stimulate bowel function and may reduce hospital length of stay, although its role in partial SBO management is still being investigated 5.
• Operative treatment is typically reserved for patients with strangulation, those who fail conservative management, or those with complicated obstructions 4, 3.
• The decision to operate or manage conservatively should be made on a case-by-case basis, taking into account the patient's overall condition and the likelihood of successful nonoperative treatment 6.

Diagnostic Considerations

• Imaging studies, such as computed tomography (CT) and ultrasound, are essential for diagnosing SBO and determining the level and cause of obstruction 4, 2.
• Plain radiographs may be useful in some cases but are not reliable for excluding the diagnosis of SBO 4.
• The clinical presentation of partial SBO can be variable, but signs of strangulation, such as fever, hypotension, and peritonitis, should prompt urgent surgical evaluation 4, 3.

Treatment Outcomes

• Studies have shown that patients with partial SBO who are treated conservatively have a higher recurrence rate compared to those who undergo operative treatment 6.
• However, conservative management can be successful in selected patients, and the use of WSC may help reduce hospital length of stay and improve outcomes 5.
• Further research is needed to determine the optimal management strategy for partial SBO and to identify predictors of successful nonoperative treatment 6, 5.