What is the appropriate management for an 80‑year‑old woman with a contrast‑enhanced CT showing a complete ileal obstruction, no contrast passage beyond the ileum and cecum, and multiple levels of blockage?

Management of Complete Ileal Obstruction in an 80-Year-Old Woman

This patient requires urgent surgical exploration via laparotomy without delay. The CT findings of complete obstruction at the ileal level with no contrast passage beyond the ileum and cecum, combined with multiple levels of blockage, indicate high-grade complete small bowel obstruction that mandates immediate operative intervention. 1

Immediate Surgical Indications

Complete obstruction with no distal contrast passage is an absolute indication for surgery. The absence of contrast flow beyond the obstruction site on CT imaging predicts failure of non-operative management with near certainty. 1

Critical Decision Points Against Conservative Management

• Multiple levels of obstruction significantly increase the risk of closed-loop obstruction and strangulation, which carry mortality rates up to 25% if not promptly treated. 1, 2
• CT findings showing complete obstruction without distal contrast passage have >90% accuracy in predicting the need for surgery. 1, 3
• In an 80-year-old patient, delays beyond 24 hours dramatically increase mortality: 2% at <8 hours, 9% at 8-16 hours, 17% at 16-24 hours, and 31% at >24 hours. 4, 5

Pre-Operative Assessment Required

Before proceeding to surgery, rapidly assess for signs of bowel ischemia or strangulation on the CT scan:

• Abnormal bowel wall enhancement (either decreased or increased) indicates ischemia requiring immediate surgery. 1, 6
• Mesenteric edema, ascites, or pneumatosis intestinalis are CT signs mandating urgent laparotomy. 1, 6
• Closed-loop obstruction appearance (C-shaped or U-shaped dilated bowel with converging mesenteric vessels) requires emergency surgery. 4, 6
• Free intraperitoneal fluid or air suggests perforation or advanced ischemia. 1, 6

Why Conservative Management is Contraindicated

Water-soluble contrast challenge protocols are only appropriate for partial or incomplete obstruction where some contrast passes distally. 1, 4 In this case:

• No contrast reaching the colon at 24 hours predicts 100% failure of non-operative management. 1, 4
• Multiple obstruction levels suggest adhesive disease or closed-loop obstruction, both requiring surgical intervention. 1, 7
• Advanced age (80 years) increases surgical risk but also increases mortality from delayed intervention, making prompt surgery the safer option. 5

Surgical Approach Considerations

Attempt laparoscopy only if the surgeon has sufficient experience, the patient has <2 prior laparotomies, and a single adhesive band is expected. 1 However, given multiple obstruction levels in this case:

• Laparotomy is likely required due to the complexity of multiple blockage points and the need for thorough exploration. 1, 8
• Prepare for possible bowel resection if ischemic segments are identified intraoperatively. 6, 8
• Intraoperative assessment of bowel viability is critical—resect any segments with questionable perfusion. 6

Critical Pitfalls to Avoid

• Never delay surgery to attempt a trial of nasogastric decompression and nil per os in complete obstruction with no distal contrast passage. This approach is only for partial obstruction or when the diagnosis is uncertain. 1, 4
• Do not wait for clinical deterioration or peritonitis to develop before operating. By that point, mortality increases exponentially. 4, 5
• Do not rely on physical examination or laboratory tests alone to exclude strangulation—they are neither sensitive nor specific enough. 4, 2
• Avoid administering oral contrast in suspected high-grade obstruction, as it delays diagnosis, increases aspiration risk, and can mask abnormal bowel wall enhancement indicating ischemia. 4

Pre-Operative Resuscitation Protocol

While preparing for urgent surgery (not delaying surgery):

• Aggressive IV fluid resuscitation to correct dehydration and electrolyte abnormalities. 1
• Nasogastric tube decompression to reduce aspiration risk during intubation. 1, 4
• Broad-spectrum IV antibiotics to cover enteric pathogens in case of bacterial translocation or occult perforation. 1
• Serial lactate monitoring to detect evolving ischemia—rising lactate mandates even more urgent intervention. 9, 6

Timing of Intervention

Proceed to laparotomy within 2-4 hours of diagnosis confirmation. 4, 5 The combination of complete obstruction, multiple levels, advanced age, and no distal contrast passage creates a surgical emergency where every hour of delay increases morbidity and mortality. 5, 6