What is the best course of action for a patient who is 30 days post Lower Segment Caesarean Section (LSCS) and now presents with bowel obstruction-like features?

Management of Bowel Obstruction 30 Days Post-LSCS

Obtain an urgent CT scan with IV contrast immediately, and if it confirms bowel obstruction without signs of ischemia or perforation, initiate conservative management with nasogastric decompression and IV fluids, but maintain a low threshold for surgical exploration within 24-48 hours given the post-cesarean context where adhesions are the likely cause and delayed intervention significantly increases mortality. 1, 2

Immediate Diagnostic Approach

CT abdomen and pelvis with IV contrast is the mandatory first-line imaging study, achieving >90% accuracy in diagnosing bowel obstruction, determining the grade (partial vs. complete), identifying the transition point, and detecting complications requiring surgery 1, 2. Plain radiographs have limited value with only 60-70% sensitivity and should not delay CT imaging 1.

Critical CT findings to assess include:

• Transition point location and characteristics (adhesive bands are the most common cause post-cesarean) 1, 3
• Signs of bowel ischemia: abnormal bowel wall enhancement, intramural hyperdensity, bowel wall thickening, mesenteric edema, pneumatosis, or mesenteric venous gas 1
• Presence of hernias (68% of patients with both SBO and hernia on CT require surgery) 4
• Degree of proximal bowel dilation and presence of distal bowel gas 2

Laboratory evaluation must include CBC, CRP, lactate, electrolytes, and coagulation profile 1, 5. Elevated lactate, leukocytosis with left shift, and elevated CRP indicate peritonitis or intestinal ischemia requiring immediate surgery 1, 5.

Initial Management Strategy

If CT Shows Partial Obstruction Without Complications:

Begin conservative non-operative management, which successfully resolves 70-90% of cases 2, 5:

• NPO status with nasogastric tube decompression 2, 5
• Aggressive IV crystalloid resuscitation and electrolyte correction 5, 6
• Water-soluble contrast challenge (Gastrografin protocol): administer 100 mL of hyperosmolar iodinated contrast with follow-up radiographs at 8 and 24 hours 1, 2. If contrast reaches the colon by 24 hours, surgery is rarely needed; if not, this predicts failure of conservative management with 96% sensitivity and 98% specificity 1

If CT Shows Complete Obstruction Without Complications:

Initiate conservative trial in stable patients, but surgical intervention must not be delayed beyond 72 hours if no improvement occurs 2. The management protocol includes:

• Immediate nasogastric decompression and Foley catheter 2
• Aggressive fluid resuscitation 2, 6
• Water-soluble contrast challenge 2
• Surgical consultation within 24 hours of admission 2

Critical caveat: Post-cesarean patients have a different risk profile than typical adhesive SBO. While patients with prior SBO history are less likely to require surgery (20.3% vs. 35.2% in those without prior SBO) 4, the 30-day post-operative window places this patient at higher risk for early postoperative complications including adhesions from hemostatic agents 7.

Absolute Indications for Immediate Surgery

Proceed directly to emergency surgical exploration without trial of conservative management if any of the following are present 1, 2, 5:

• Clinical peritonitis (involuntary guarding, abdominal rigidity, rebound tenderness) 6
• Signs of strangulation or bowel ischemia 1, 2
• Laboratory markers suggesting ischemia (marked leukocytosis, bandemia, lactic acidosis) 5, 6
• CT findings of bowel compromise (pneumatosis, portal venous gas, free air) 1, 2
• Hemodynamic instability 1

Delay in surgical intervention beyond 48 hours is associated with significant increase in mortality, especially with ischemia present 1. Overall mortality is 10% but increases to 30% with bowel necrosis or perforation 6.

Surgical Approach Considerations

Laparoscopic adhesiolysis can be considered in highly selected stable patients with suspected simple adhesive obstruction, clear visualization of the obstruction site, and no dense adhesions 1, 5, 3. However, conversion to open surgery is mandatory if there are dense adhesions, inability to visualize the obstruction site, iatrogenic intestinal perforation, bowel necrosis, or technical difficulties 3.

For post-cesarean patients specifically, the surgical exploration should assess for:

• Adhesive bands (most common cause, 65% of all SBO) 6
• Unusual causes including hemostatic agents (gelatin sponges placed during cesarean can cause early postoperative adhesive obstruction) 7
• Hernias (10% of SBO cases) 6

Critical Pitfalls to Avoid

• Do not rely on plain radiographs alone—they are neither sensitive nor specific enough and will prolong evaluation 1
• Do not delay CT imaging in favor of prolonged clinical observation 1, 2
• Do not continue conservative management beyond 72 hours without improvement, as this significantly increases morbidity and mortality 2, 6
• Normal lactate and white blood cell count do not exclude ischemia—clinical judgment and CT findings must guide decision-making 1
• In the post-cesarean population, maintain heightened suspicion for surgical causes given the recent abdominal surgery and potential for hemostatic agent-related adhesions 7

Monitoring During Conservative Management

If conservative management is initiated, reassess clinically every 12-24 hours for:

• Worsening abdominal pain or development of peritoneal signs 6
• Failure to improve within 48-72 hours 2
• Development of fever, tachycardia, or hemodynamic instability 6
• Rising lactate or white blood cell count 5

Any clinical deterioration mandates immediate surgical consultation and likely operative intervention 2, 6.