What are the special considerations when treating a small bowel obstruction?

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Elsevier ClinicalKey Clinical Overview

Treatment Initial medical resuscitation: Resuscitate hemodynamically unstable patients with IV crystalloid solution and correct electrolyte abnormalities Maintain patients on NPO status Administer IV antiemetics (eg, ondansetron, metoclopramide) to reduce nausea, vomiting, and risk of aspiration Decision for nasogastric tube placement depends on each patient; tube is not always required, but it is generally used in the following settings: Significantly distended stomach or proximal small intestine Persistent vomiting Presence of irreducible hernia or volvulus Complete obstruction Generally used for decompression for a period of time followed by administration of enteral contrast material for water-soluble contrast challenge Consult surgeon; promptly refer for findings suggestive of bowel ischemia or strangulation (eg, fever; leukocytosis; tachycardia; constant, noncrampy abdominal pain) Bowel strangulation requires immediate surgery Treat closed-loop small-bowel obstruction as a medical emergency because it can lead to vascular occlusion, mural ischemia, and death (in up to 35% of patients) if diagnosis is delayed Urgent exploration is indicated for patients in whom contrast material fails to appear in the colon within 8 hours and who have mesenteric edema, small-bowel feces sign, and obstipation, or for patients with signs of strangulation Provide antibiotic coverage for intra-abdominal infection if sepsis or perforation is suspected or if surgical exploration is planned Include coverage against gram-negative and anaerobic organisms Management may be nonoperative or operative: Decision to manage relatively stable patients nonoperatively or surgically remains challenging Delay in definitive treatment can result in need for urgent surgical intervention with increased morbidity and mortality compared with patients undergoing prompt intervention

Treatment Decision to manage relatively stable patients nonoperatively or surgically remains challenging Delay in definitive treatment can result in need for urgent surgical intervention with increased morbidity and mortality compared with patients undergoing prompt intervention Patients with simple obstruction who undergo surgery are exposed to inherent surgical risks, longer hospitalizations, and adhesion-related complications (eg, recurrent obstruction) Nonoperative treatment Indications Uncomplicated, partial small-bowel obstruction caused by adhesions in a patient with previous abdominopelvic surgery (high-grade or low-grade) Obstruction as a result of Crohn disease or carcinomatosis Obstruction in early postoperative period Uncomplicated, recurrent small-bowel obstruction; make every attempt to avoid laparotomy in these patients Includes administration of IV fluid and oral water-soluble contrast material (eg, diatrizoate meglumine, diatrizoate sodium) or water-soluble contrast challenge Oral water-soluble contrast material or water-soluble contrast challenge Consider hypertonic contrast material as adjuvant to conservative management in patients with partial small-bowel obstruction Increases pressure gradient across obstruction site by causing fluid shift into intestinal lumen Can aid in differentiating partial from complete obstruction before operative intervention May shorten time to normal bowel function and decrease length of hospital stay, but it does not affect recurrence rate Complications are rare but include anaphylactoid reaction and aspiration Length of nonoperative management depends on obstruction cause and patient course For patients at low risk for ischemia, continue nonoperative management until there is resolution, clinical deterioration, or failure to progress Perform serial abdominal examinations every 4 to 8 hours If nonoperative management is unsuccessful after 12 to 24 hours, initiate the water-soluble contrast challenge Do not continue nonoperative management after 72 hours if obstruction is not resolving, even without clinical deterioration Prolonged nonoperative treatment ( 10-14 days

Treatment Do not continue nonoperative management after 72 hours if obstruction is not resolving, even without clinical deterioration Prolonged nonoperative treatment ( 10-14 days If patient has clinical deterioration or shows signs of peritonitis, emergency surgery is indicated (as opposed to further radiologic studies that delay treatment) Operative treatment (laparoscopic adhesiolysis or laparotomy) Indications Complete bowel obstruction (generally first line treatment) Partial obstruction that is not improving with nonoperative management Signs of ischemia, peritonitis, or bowel strangulation on admission or at any time during nonoperative management Obstruction caused by irreducible hernia or volvulus Timing of surgery based on obstruction cause and presence of complications Emergent surgery is indicated for patients with signs of small-bowel obstruction complicated by ischemia, peritonitis, or strangulation If surgery is required for patients with postoperative adhesive bowel obstruction, plan surgery for sooner than 10 to 14 days after the previous surgery; after this time, adhesions are the most tenacious, poorly defined, and vascular, increasing risk for iatrogenic bowel injury and fistula formation After 10 to 14 days, patients with uncomplicated disease (no signs of peritonitis, perforation, ischemia, or strangulation) may be safer to continue nonoperative management for 6 to 8 weeks with use of nasogastric decompression and total parenteral nutrition After surgical release of obstruction, determine severity of ischemia to inform the need for bowel resection Bowel resection is indicated for necrotic, strangulated, or gangrenous bowel (identified by dark blue to black coloring and possibly a foul odor) to prevent sepsis

Treatment Bowel resection is indicated for necrotic, strangulated, or gangrenous bowel (identified by dark blue to black coloring and possibly a foul odor) to prevent sepsis Resection may not be required for less-severe ischemia, as indicated by a return to normal color after release of obstruction, palpable arterial pulsations, audible Doppler signals on the antimesenteric border, and peristalsis Treatment considerations by obstruction cause: Malignant neoplasm For patients with incurable neoplastic small-bowel obstruction, treatment focus is on maximizing palliation and minimizing complications and hospital stay Provide symptom relief with analgesic, antiemetic, and antisecretory agents in conjunction with other treatment options Surgical treatments include primary resection and reconstruction, internal bypass, or palliative diversion Endoscopic and interventional techniques Decompressive gastrostomy tubes may provide some relief of intractable nausea and vomiting Self-expanding metal stents, passed endoscopically or fluoroscopically, may allow increase in lumen size in a subset of patients Percutaneous endoscopic gastrostomy may be considered if laparotomy is contraindicated In some cases, no available interventions can be performed without significant risk of harm to the patient Hernia Immediate surgery indicated for irreducible or strangulated hernia Resolution of obstruction after manual hernia reduction requires hospital admission for observation and repair before discharge to prevent recurrence Early postoperative adhesions Initial management consists of tube decompression and parenteral nutrition Consider surgical care for patients with postoperative adhesive bowel obstruction if within 10- to 14-day period after primary surgery Adhesions after this time are the most tenacious, poorly defined, and vascular, increasing risk for iatrogenic bowel injury and fistula formation

Treatment Adhesions after this time are the most tenacious, poorly defined, and vascular, increasing risk for iatrogenic bowel injury and fistula formation For patients for whom this time frame has elapsed, consider long-term tube decompression and parenteral nutrition If signs of strangulation or ischemia are present, surgical exploration is indicated Crohn disease In the acute phase, patients can be managed nonoperatively with hydration, nasogastric decompression, and parenteral nutrition For patients with a history of Crohn disease, allow 7 to 10 days of nonoperative treatment before considering surgery Anti-inflammatory medication is indicated for those patients with disease unresponsive to nonoperative treatment Radiation enteropathy In acute setting, generally treated nonoperatively with tube decompression and possibly corticosteroids In chronic cases, laparotomy is typically required, with possible resection of irradiated bowel or bypass of affected area

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Maienza E, Godiris-Petit G, Noullet S, Menegaux F, Chereau N. International Journal of Colorectal Disease. 2023;38(1):224. doi:10.1007/s00384-023-04512-8.

Publish date: September 2, 2023.

BACKGROUND: Postoperative adhesive small bowel obstruction (SBO) is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive SBO can be managed nonoperatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive SBO. Treatment recommendations are still controversial. METHODS: We conducted an observational retrospective monocentric study to test our protocol of management of SBO using Gastrografin, enrolling 661 patients from January 2008 to December 2021. An emergency surgery was performed in patients with abdominal tenderness, peritonitis, hemodynamic instability, major acute abdominal pain despite gastric decompression, or CT scan findings of small bowel ischemia. Nonoperative management was proposed to patients who... (truncated preview)