Small Bowel Obstruction Guideline
Small bowel obstruction is a commonly encountered problem with about 300,000 annual hospital admissions in North America. SBO is distinct from ileus, which includes obstipation and intolerance to oral intake resulting from non-mechanical insult that disrupts the normal coordinated propulsive motor activity of GI tract. In ileus, small bowel functions returns first (within 0-24 hours), stomach second (24-48 hours) and colon last (48-72 hours). While both ileus and SBO may demonstrate distention, obstipation, vomiting and dilated bowel loops on imaging, SBO is usually associated with more pain, more tenderness on exam, high-pitched rather than quiet bowel sounds and more complications. The most feared complication of SBO is strangulation, complicating 7-42% of bowel obstructions, and diagnostics should be directed at identifying these patients. Patients with no signs of strangulation, partial obstruction on the admission radiograph indicates resolution with conservative management alone 80% of time. Guidelines for SBO diagnosis and management are as follows:
Diagnosis*
1. All patients being evaluated for SBO should have (at least) plane films.
2. All patients with inconclusive plain films for complete or high grade SBO should undergo CT.
3. Multiple signs on CT suggesting strangulation should suggest a low threshold for operation.
4. MRI and ultrasound are an alternative to CT with similar sensitivity and identification of etiology, but have several logistical limitations.
5. Variety of literature show that contrast studies should be considered in patients who fail to improve after 48 hours of conservative management.
6. Nonionic low osmolar weight contrast is an alternative to barium for contrast studies.
Therapy*
1. Patients with plain film finding of SBO and clinical markers or peritonitis on PE warrant exploration
2. Patients without the above clinical picture and a partial SBO or complete SBO can undergo non-operative management safely.
3. Patients without resolution of the SBO by day 3-5 of non-operative management should undergo water soluble study or surgery.
4. There is no significant difference with regard to decompression achieved, success of nonoperative treatment, or the morbidity rate after surgical intervention comparing long tube decompression with NG tube.
5. Water soluble contrast (Gastrografin) given in the setting of pSBO can improve bowel function, decrease length of stay, and is therapeutic and diagnostic. Exercise caution in SBO related to ventral hernia and in patients who have had bariatric surgery. These pathologies are DISTINCT AND REQUIRE SPECIAL MANAGEMENT.
6. In a highly select group of patients the laparoscopic treatment of SBO should be considered and leads to a shorter hospital stay
*Eastern Association for the Surgery of Trauma (EAST) published in 2007
Additional references:
1. BT Fevang et al. Early Operation or Conservative Management of Patients with Small Bowel Obstruction. Eur J Surg 2002.
2. Pickleman, et al. Small Bowel Obstruction. Ann. Surg. Aug 1989.
3. Zielinski, et al. Small Bowel Obstruction – who needs an operation? A Multivariate Prediction Model. World J Surg 2010.
4. Jones, et al. Can a computed tomography scoring system predict the need for surgery in small-bowel obstruction? The American Journal of Surgery. 2007.
5. Goussous et al. Enhancement of a Small Bowel Obstruction Model Using the Gastrografin Challenge Test. J Gastriointest Surg. 2012.
6. Di Saverio et al. Water Soluble Contrast Medium Value in Adhesive Small Intestine Obstruction: A Prospective, Randomized, Controlled, Clinical Trial. World J Surg. 2008.
Posted 3/1/13; Reviewed 9/26/24 (A Bernard)
