What is the best approach to manage acute intestinal obstruction in a patient with a history of abdominal surgery or underlying medical conditions?

Management of Acute Intestinal Obstruction

Initial Resuscitation and Assessment

Begin immediate intravenous fluid resuscitation with correction of metabolic derangements, nasogastric decompression, and bowel rest as the foundation of management for uncomplicated acute intestinal obstruction. 1

• Obtain complete blood count, metabolic panel, and serum lactate level to assess for metabolic derangements and potential ischemia 1
• Initiate antibiotic coverage against gram-negative organisms and anaerobes if fever and leukocytosis are present 1
• Perform imaging with abdominal radiography or computed tomography to confirm diagnosis and identify the level and cause of obstruction 1, 2

Risk Stratification Based on Clinical Presentation

High-Risk Features Requiring Immediate Surgery

Proceed directly to surgical exploration without delay if any of the following are present:

• Evidence of vascular compromise (elevated lactate, peritoneal signs, hemodynamic instability) 1
• Signs of perforation or peritonitis 2
• Incarcerated abdominal wall hernia 3
• Clinical signs suggesting strangulation (fever, tachycardia, continuous pain, peritoneal irritation) 3

Moderate-Risk Features in Post-Bariatric Surgery Patients

In patients with prior bariatric surgery (RYGB or sleeve gastrectomy) presenting with persistent abdominal pain and inconclusive imaging, perform exploratory laparoscopy within 12-24 hours. 4, 5

• This population has high risk of internal hernia (53.9% of late obstructions post-RYGB) which can rapidly progress to bowel ischemia 4
• Early laparoscopic exploration prevents late diagnosis and reduces need for bowel resection 4
• Diagnostic laparoscopy is safe even in pregnant post-bariatric patients 4

Lower-Risk Features Amenable to Conservative Trial

Consider 24-48 hours of conservative management for:

• Postoperative adhesive obstruction in patients with multiple prior surgeries and incomplete/partial obstruction 3
• Neoplastic-associated obstruction with concomitant medical problems 3
• Absence of strangulation signs and normal lactate 1

Critical caveat: If any uncertainty exists about strangulation risk, proceed to prompt operative intervention rather than continuing observation 3

Surgical Approach Algorithm

For Post-Bariatric Surgery Patients

Begin laparoscopic exploration systematically from the ileocecal junction (distal to obstruction) and proceed proximally. 4, 5

• Inspect the three potential internal hernia sites: transverse mesocolon (retrocolic bypasses), Petersen's space, and jejuno-jejunostomy mesenteric defect 4
• If internal hernia is found, assess intestinal viability immediately 4
• Close all mesenteric defects with non-absorbable suture material in running or interrupted fashion 4
• Use indocyanine green (ICG) fluorescence angiography when available to evaluate bowel perfusion and determine resection extent 4, 5

For Intussusception

Resect the affected bowel segment rather than simple reduction, as resection results in fewer recurrences. 4, 5

• Reduction alone may be considered only if the bowel is clearly viable 4

For Proximal Obstruction Post-Sleeve Gastrectomy

Perform endoscopic assessment first in hemodynamically stable patients. 4

• Endoscopic pneumatic dilation is safe and effective first-line treatment for gastric stenosis 4
• Be prepared for immediate surgical intervention if perforation occurs during dilation 4

For Bezoar-Related Obstruction

Attempt endoscopic removal if the bezoar is in the stomach; proceed to surgery if located distally in small bowel. 4

• Surgical options include milking the bezoar into cecum or enterotomy for removal 4

Intraoperative Decision-Making Based on Bowel Viability

Hemodynamically Stable Patients with Segmental Ischemia

Perform limited intestinal resection and anastomosis. 4

• Use ICG fluorescence to precisely determine resection margins and assess anastomotic perfusion 4

Hemodynamically Unstable Patients with Extended Ischemia

Implement damage control surgery with open abdomen approach rather than attempting definitive repair. 4

• This applies to cases with extensive intestinal ischemia or peritonitis 4

Common Pitfalls to Avoid

• Do not delay surgical exploration in post-bariatric patients beyond 12-24 hours if pain persists despite inconclusive imaging, as internal hernias can rapidly progress to ischemia 4, 5
• Do not attempt laparoscopy in patients with severe abdominal distension and massively dilated bowel unless highly experienced, as bowel injury risk exceeds 6-10% 6
• Do not continue conservative management beyond 48 hours if obstruction fails to resolve, as this increases risk of strangulation 1, 3
• Do not overlook the entire small bowel if no obvious cause is found initially—assess for adhesions, intussusception, and volvulus throughout 4