From the Guidelines
Conservative management is contraindicated in small bowel obstruction (SBO) when there are signs of peritonitis, strangulation, or bowel ischemia. According to the Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO) 1, non-operative management should always be tried in patients with ASBO, unless there are signs of peritonitis, strangulation, or bowel ischemia. The guidelines emphasize that morbidity from emergency surgical exploration is high, and surgical treatment may significantly reduce post-operative quality of life.
Some key indicators that necessitate immediate surgical intervention include:
- Severe, constant abdominal pain
- Fever above 38°C
- Tachycardia (heart rate >100 beats/minute)
- Hypotension
- Peritoneal signs such as rebound tenderness or guarding
- Leukocytosis (white blood cell count >12,000/mm³)
- Metabolic acidosis
- Elevated lactate levels
- Concerning imaging findings such as pneumoperitoneum, pneumatosis intestinalis, or portal venous gas.
Additionally, complete obstruction, closed-loop obstruction, internal herniation, and failure of conservative management after 48-72 hours are also contraindications, as stated in the guidelines 1. Conservative management typically involves nasogastric tube decompression, IV fluids, electrolyte correction, and bowel rest, but these measures should not delay surgical intervention when indicated. Prompt recognition of these contraindications is crucial as delayed surgery in cases of compromised bowel can lead to increased morbidity and mortality due to sepsis, multiorgan failure, and death.
From the Research
Conservative Management Contraindications in SBO
Conservative management is contraindicated in certain situations in small bowel obstruction (SBO). The following are some of the key points to consider:
- Presence of intestinal ischemia, as indicated by reduced or increased bowel wall enhancement, mesenteric edema or engorgement, fluid or free air in the peritoneal cavity on CT scans 2, 3
- Signs of strangulation, such as severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness 4, 5
- Complete obstruction with no sign of resolution on conservative treatment, especially if there are signs of complications such as bowel ischemia or perforation 4, 6
- Clinical deterioration despite medical therapy, including worsening abdominal pain, nausea, vomiting, and signs of sepsis 5
- Presence of a closed-loop obstruction or a single transition point on imaging studies, which may indicate a higher risk of complications 3
Key Findings
Some key findings from the studies include:
- The importance of early diagnosis and aggressive medical therapy in SBO, including rehydration, antibiotics, and nil per os 5
- The use of abdominal CT with oral and intravenous contrast to detect and characterize SBO, including the presence of complications such as bowel ischemia or perforation 2, 3, 5
- The need for surgical intervention in cases where conservative management is contraindicated, preferentially by laparoscopy 5