What is the management for intestinal obstruction secondary to hernia?

From the Guidelines

Management of bowel obstruction secondary to hernia requires immediate surgical intervention as the definitive treatment, as delayed diagnosis can lead to septic complications and high morbidity and mortality rates. Initial management includes bowel rest, intravenous fluid resuscitation with normal saline or lactated Ringer's solution, nasogastric tube decompression, and pain control with medications like morphine 2-4 mg IV every 4 hours as needed 1. Antibiotics such as cefazolin 1-2 g IV every 8 hours should be started if there are signs of infection or strangulation.

Key Considerations

• Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected, as the benefits outweigh the risks of surgery 1.
• Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1.
• Early detection of complicated abdominal hernias may be the best means of reducing the rate of mortality, and delayed diagnosis can lead to high morbidity and mortality rates 1.

Surgical Approach

• The surgical approach depends on the hernia location and may include open or laparoscopic techniques to reduce the hernia and repair the defect.
• In cases of bowel necrosis, resection of the affected segment will be necessary.
• Post-operatively, patients typically require continued bowel rest until bowel function returns, gradual advancement of diet, pain management, and early mobilization.

Monitoring and Follow-up

• Patients should be closely monitored for signs of bowel ischemia including worsening pain, fever, leukocytosis, or peritoneal signs.
• Multidetector computed tomography has emerged as the best imaging test for the diagnosis of mechanical bowel obstruction and its complications, and can help guide management to either conservative or operative management 1.

From the Research

Management of Bowel Obstruction Secondary to Hernia

• The management of bowel obstruction secondary to hernia typically involves urgent surgical consultation when there is a concern for bowel ischemia, strangulation, or complete obstruction 2.
• History and physical examination can vary, but the most reliable findings include prior abdominal surgery, history of constipation, abdominal distension, and abnormal bowel sounds 3.
• Diagnosis typically requires imaging, and though plain radiographs are often ordered, they cannot exclude the diagnosis. Computed tomography and ultrasound are reliable diagnostic methods 3, 4.
• Management includes intravenous fluid resuscitation, analgesia, and determining need for operative vs. nonoperative therapy. Nasogastric tube is useful for patients with significant distension and vomiting by removing contents proximal to the site of obstruction 3, 4.
• Surgery is needed for strangulation and those that fail nonoperative therapy. Surgical service evaluation and admission are recommended 3, 5.
• Laparoscopic techniques are gaining acceptance as a primary modality in the treatment of small bowel obstruction, and can reduce postoperative pain, minimize hospital stay, and may lead to fewer adhesions 5.

Diagnostic Approaches

• Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing small bowel obstruction 4.
• Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds 4.
• Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced small bowel obstruction, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis 4.

Treatment Outcomes

• Overall mortality for small bowel obstruction is 10% but increases to 30% with bowel necrosis/perforation 4.
• Key point in small bowel obstruction is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy 4.
• Treatment of small bowel and colonic perforations generally includes intravenous antibiotics and fluid resuscitation, but the specific management of the bowel depends on the underlying cause of the perforation 6.