What is the surgical management approach for an adult patient with no significant medical history and intestinal obstruction?

Surgical Management of Intestinal Obstruction

For adult patients with intestinal obstruction and no significant medical history, initial management should prioritize conservative treatment with bowel decompression, IV fluid resuscitation, and water-soluble contrast administration for up to 72 hours, reserving immediate surgery only for patients with signs of peritonitis, strangulation, bowel ischemia, or hemodynamic instability. 1

Initial Assessment and Risk Stratification

The first critical step is identifying patients who require immediate surgical intervention versus those suitable for conservative management:

Absolute Indications for Emergency Surgery

• Signs of peritonitis (diffuse abdominal tenderness, guarding, rebound) 1
• Clinical evidence of strangulation or bowel ischemia (persistent fever, rising lactate, leukocytosis with left shift) 1
• Free perforation with pneumoperitoneum on imaging 1
• Hemodynamic instability despite resuscitation 2
• Closed-loop obstruction identified on CT imaging 1

Diagnostic Workup

• CT scan is the preferred imaging modality with high sensitivity and specificity for diagnosing location, degree, and cause of obstruction 1
• Laboratory evaluation should include CBC, CRP, lactate, electrolytes, BUN/creatinine, and coagulation profile 1
• Elevated lactate is particularly concerning for bowel ischemia and mandates urgent surgical consultation 1
• Physical examination must include assessment of all hernial orifices as potential obstruction sites 1

Conservative Management Protocol (First-Line for Stable Patients)

Non-operative management successfully resolves 70-90% of adhesive small bowel obstructions and should be the initial approach for hemodynamically stable patients without peritoneal signs 1

Essential Components

• Nasogastric tube decompression to prevent aspiration and reduce intraluminal pressure 1
• IV crystalloid resuscitation to correct dehydration and electrolyte disturbances 1
• Nothing by mouth (NPO) status 1
• Administration of 100 mL water-soluble contrast (Gastrografin) via NGT after adequate gastric decompression—this has both diagnostic and therapeutic value, significantly reducing need for surgery 1
• Serial abdominal examinations to monitor for clinical deterioration 1

Critical Monitoring Parameters During Conservative Management

• Contrast reaching the colon within 4-24 hours predicts successful non-operative management 1
• Rising lactate levels suggest evolving bowel ischemia and warrant immediate surgical intervention 1
• Persistent fever or leukocytosis may indicate evolving ischemia despite stable examination 1
• 72-hour period is considered safe for non-operative management—surgery is indicated if obstruction persists beyond this timeframe 1

Common Pitfall

Delaying surgery beyond 72 hours in patients with persistent obstruction increases morbidity and mortality 1. Do not continue conservative management indefinitely hoping for resolution.

Surgical Approach Selection

Laparoscopic Approach

Laparoscopic adhesiolysis is appropriate for highly selected patients meeting specific criteria 1:

• Hemodynamically stable without diffuse peritonitis 1
• Single adhesive band identified on CT with clear transition point 1
• Minimal bowel distension (very distended bowel is a contraindication) 1

Benefits of laparoscopy include reduced morbidity, mortality, and surgical site infections compared to open surgery 1. However, iatrogenic bowel injury risk is 3-17.6%, which is the primary concern 1. All enterotomies must be identified intraoperatively to avoid missed perforations 1.

Open Laparotomy

Open laparotomy remains the surgical approach of choice in most cases requiring surgery 1, and is mandatory for:

• Hemodynamically unstable patients 1
• Diffuse peritonitis 1
• Very distended bowel loops 1
• Emergency situations with signs of perforation or ischemia 1

Surgical Technique Considerations

• Use adhesion barriers during surgery in young patients—this reduces recurrence from 4.5% to 2.0% at 24 months 1
• Knife dissection rather than blunt dissection is recommended for lysis of adhesions to minimize complications 3
• Excellent intraoperative hemostasis reduces postoperative fistulas and abscesses 3

Cause-Specific Surgical Management

Crohn's Disease with Obstruction

Deferred surgery is preferred for acute small-bowel obstruction without bowel ischemia or peritonitis 4. Conservative management allows optimization of nutritional and immunosuppression status before potential elective surgery 4.

• Preoperative control of sepsis is mandatory prior to abdominal surgery 4
• For short (<5 cm) strictures of terminal ileum, both endoscopic balloon dilatation and surgery are suitable options—choice depends on local expertise and patient preference 4
• Endoscopic balloon dilation has 89-92% technical success rate for primary or anastomotic strictures 1
• Free perforation is an absolute indication for emergency surgery 1

Malignant Bowel Obstruction

• Surgery is primary treatment for patients with years-to-months life expectancy after appropriate imaging 1
• For advanced disease or poor condition, medical management is preferable including opioids, anticholinergics, corticosteroids, and antiemetics 1
• Self-expanding metallic stents are preferred over colostomy for palliation of left-sided obstructing colon cancer 1

Chronic Intestinal Dysmotility (Pseudo-obstruction)

Surgery should be avoided in this population due to high risk of iatrogenic injury 4. However, judicious palliative surgical intervention can improve symptoms and quality of life 4.

• Distinguish from mechanical obstruction by looking for absence of transition point on CT, history of multiple failed surgeries 1
• Bypass operations (gastro-enterostomy, duodeno-jejunostomy, jejuno-enterostomy) can reduce vomiting if dilated gut is present 4
• Avoid vagotomy during gastric surgery—this further retards gastrointestinal transit 4
• Any surgical decision requires multidisciplinary team involvement 4
• Nutritional optimization before surgery is essential 4

Outcomes and Recurrence

Recurrence Rates

• After non-operative management: 12% readmission at 1 year, 20% at 5 years 1
• After operative management: 8% recurrence at 1 year, 16% at 5 years 1
• Young patients with multiple prior surgeries are at highest risk for recurrence 1

Complications to Monitor

• Dehydration with renal injury 1
• Electrolyte disturbances 1
• Malnutrition 1
• Aspiration 1
• Surgical site infection (most common postoperative complication at 36.8%) 5
• Pneumonia (23.6% of complications) 5
• Septic shock (21.0% of complications) 5

Special Populations

Young Females

Examine for ovarian masses, endometriosis, or pelvic inflammatory disease as potential causes 1. CT imaging should specifically evaluate for gynecologic pathology 1.

Patients Without Prior Surgery ("Virgin Abdomen")

Adhesions are common even without prior surgery, occurring from congenital bands or unrecognized prior inflammation 1. Non-operative management with water-soluble contrast is appropriate and effective in these cases 1.