Recommendations
Urgent
Is the patient stable? Use an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to manage shock empirically.[42] Ensure a patent airway and give oxygen if needed. See our topic Shock.
Emergency surgery is necessary for a suspected or imminent perforated bowel. Emergency surgery for large bowel obstruction is associated with a high morbidity and mortality.[3]
Think 'Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[25][26][27]
Use a systematic approach, alongside your clinical judgement, for assessment; urgently consult a senior clinical decision-maker (e.g., ST3 level doctor in the UK) if you suspect sepsis.[25][26][28][29]
Refer to local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
Key Recommendations
Treat initially in the accident and emergency department with intravenous fluid resuscitation, nasogastric tube placement in some patients, and urethral catheterisation.[3]
Consult the surgical team early, as emergency surgery may be required. The type of surgery necessary will depend on the site and cause of the obstruction.
A consultant review should take place in all patients diagnosed with acute bowel obstruction as soon as clinically indicated and at the latest within 14 hours of admission to hospital.[3][6][23]
Further treatment will depend on the underlying cause, such as: malignancy, benign stricture, volvulus, or any other more unusual mechanism.
Is the patient stable? Use an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to manage shock empirically.[42] Ensure a patent airway and give oxygen if needed.
Treat the underlying cause as early as possible.
Escalate all patients with shock to a senior clinician.
See our topic Shock.
Manage peritonitis with urgent resuscitation and surgery within 6 hours.[3]
When peritonitis is related to perforation proximal to a tumour site, patients are at higher risk of developing sepsis compared with patients where the perforation is at the tumour site.[5]
Identify and manage any other complications from bowel obstruction, such as sepsis, urgently.[3] See Sepsis in adults.
Practical tip
Sepsis
Think 'Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[25][26][27]
The patient may present with non-specific or non-localised symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multi-organ dysfunction and shock.[25][26][27]
Remember that sepsis represents the severe, life-threatening end of infection.[30]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[25][26][27][28][31] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[29]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
A patient is also at high risk of severe illness or death from sepsis if they have a NEWS2 score below 7 and a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk.
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6) or within 1 hour of any intervention for suspected sepsis (antibiotics/fluid resuscitation/oxygen) if there is no improvement in the patient’s condition.
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[29][31]
In the community and in custodial settings: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[26]
Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis.
See Sepsis in adults.
Admit to hospital all patients with intestinal obstruction.[3][6][23] Large bowel obstruction is a surgical emergency.[3] Urgent surgery may be required.
The patient should be under the care of a colorectal surgeon within 24 hours of admission.[3][23]
A consultant review should take place in all patients diagnosed with acute bowel obstruction as soon as clinically indicated and at the latest within 14 hours of admission to hospital.[3][6][23]
The patient should have their risk of morbidity and mortality assessed and recorded in their medical records by a senior surgeon within 4 hours of admission or transfer.[43]
Discuss ‘high-risk’ patients with a consultant within 1 hour.[6][23] ‘High risk’ is defined as where the risk of mortality is greater than 10%, or where a patient is unstable and not responding to treatment.[23]
Consult anaesthetic, critical care, and palliative care teams as well as surgery if needed.[33] Bowel obstruction can be complex to manage. Multidisciplinary input is needed.[33]
Consult anaesthetic, critical care, and palliative care teams as well as surgery if needed.[33] Bowel obstruction can be complex to manage. Multidisciplinary input is needed.[33] Some hospital trusts offer a service for surgeons to liaise with geriatricians in order to optimise an older patient for surgery and reduce postoperative complications.
Treat initially in the accident and emergency department with intravenous fluid resuscitation, nasogastric tube placement, and urethral catheterisation.[3] Further management depends on the underlying cause of the obstruction. Maintain the patient as nil by mouth.
Fluid management
Measure and document the patient’s hydration status at presentation and throughout the admission.[6][23] Aim to minimise the risk of acute kidney injury.[6] See our topic Acute kidney injury.
Use intravenous fluids to treat patients with signs of shock or severe dehydration, or for maintenance in patients unable to tolerate oral fluids.
Indicators that the patient may need urgent fluid resuscitation include:[44]
Systolic blood pressure less than 100 mmHg
Heart rate more than 90 beats per minute
Cold peripheries
Capillary refill time more than 2 seconds
Respiratory rate more than 20 breaths per minute
National Early Warning Score (NEWS2) of 5 or more NEWS2 Opens in new window
Passive leg-raising suggests fluid responsiveness.
Check local protocols for specific recommendations on fluid choice.
In patients receiving fluid resuscitation, place a catheter to monitor urine output.[3]
Analgesia
Assess pain at presentation and throughout the admission.[6][23] Provide analgesia in line with your local protocol.[3][23]
Use opioid analgesia (e.g., morphine) for acute abdominal pain.[3][45]
Check your local protocols for specific advice on choice of drugs and doses.
Refer to the acute pain team if the patient’s pain is difficult to manage, but ensure that this does not delay definitive treatment.[6][23]
Bowel decompression via nasogastric tube
Consider decompressing the bowel upstream of the obstruction via a nasogastric tube. This is generally required for patients with a distended small bowel or who are vomiting.
Place a nasogastric tube to decompress air/fluid in the upper gastrointestinal tract.[3]
This may prevent aerophagia and relieve nausea and vomiting.
Follow your local protocol for this procedure. Aspirate the tube regularly to reduce the risk of aspiration.[3]
Once the obstruction has been resolved, remove the tube as the patient’s clinical condition improves and as nasogastric aspirates decrease.
How to insert a fine bore nasogastric tube for feeding.
Screening and monitoring
Monitor the patient using an early warning score, such as the NEWS2 score. NEWS2 Opens in new window NEWS2 measures:[27]
Respiration rate
Oxygen saturation
Systolic blood pressure
Pulse rate
Level of consciousness or new-onset confusion
Temperature.
Undertake a nutritional screen, such as the Malnutrition Universal Screening Tool (MUST) score, and act on the results.[6][23][48] MUST calculator Opens in new window Provide nutritional support, if indicated.[6][48] Arrange review by a dietitian or the nutrition team.[23] Consider nutritional support if the patient has not eaten for 5 days and/or may not be able to resume their usual diet within the next 5 days, or if the patient has a poor absorptive capacity.[48]
Assess frailty using a score, such as the Rockwood frailty score.[6][23][49] Clinical Frailty Scale Opens in new window
Discuss patients with a high frailty score with the multidisciplinary team.
Establish a treatment escalation plan and record resuscitation status.
Arrange a risk assessment, with input from critical care where necessary.[23]
Treat a suspected or imminent perforated bowel with emergency surgery without delay. Emergency surgery for large bowel obstruction is associated with a high morbidity and mortality.[3]
Practical tip
Bear in mind that closed loop obstruction can result in perforation and so should be treated as a surgical emergency.
Closed loop obstruction is when a single segment of bowel is obstructed at two sites. With gas trapped inside the bowel and continuing to enter the colon, pressure within the large bowel will continue to increase and cannot flow back into the small bowel. It leads to a rapid increase in distension and intraluminal pressure, with early vascular occlusion.[1]
The caecum is usually the site of perforation as it has the thinnest bowel wall.[1]
Pre-surgical assessment
Prior to surgery, identify and treat any correctable comorbidities so that surgery is not delayed.
Assess the patient’s bleeding and venous thromboembolism (VTE) risk prior to surgery.[50]
Use a validated VTE prophylaxis tool. The National Institute for Health and Care Excellence in the UK states that a commonly used risk assessment tool for surgical patients is the UK Department of Health VTE risk assessment tool.[50] Department of Health VTE risk assessment tool Opens in new window
Follow your local trust protocol for thromboprophylaxis.
Arrange a group and save.
Reassess the risk of bleeding and venous thromboembolism at the point of consultant review or if the patient’s clinical condition changes.
Assess the patient’s risk using appropriate risk prediction tools and your clinical judgement.[23][43]
The patient should have their risk of morbidity and mortality assessed and recorded in their medical records by a senior surgeon within 4 hours of admission or transfer.[43]
Use a risk score recommended by your local protocol, such as the National Emergency Laparotomy Audit (NELA) risk model in the UK, to calculate a patient’s morbidity and mortality risk before surgery.[23][51]
The risk score can be used as a way to explain the risks of surgery to patients and their relatives, which enables shared decision-making and informed consent.
Give antibiotic prophylaxis in line with your local hospital protocol if surgery is needed.[52]
[ 
]
[Evidence A] This is to reduce the risk of postoperative complications.
Surgical procedures
The aim of all operations for large bowel obstruction is to restore the flow of the faecal stream and to remove the obstructing lesion, if possible. This is often achieved through the formation of a stoma, either to defunction a downstream obstructing lesion or to avoid the risks inherent to anastomosis.
When deciding whether to make a stoma or form an anastomosis, the surgical team must take into account the severity of the illness and the patient’s condition under anaesthesia.
Bear in mind the morbidity and mortality risks of emergency colonic surgery.
Wherever possible, respect the patient’s wishes with regard to the formation of a stoma.
To treat an obstruction, the three main types of procedure are:
Right hemicolectomy: any operation that removes the ileocaecal valve and the caecum. The colonic resection can be limited to the caecum or extended to the descending colon
Hartmann’s procedure: involves the removal of the sigmoid colon with formation of a left iliac fossa colostomy. The rectal stump is closed. Theoretically reversible, but many patients opt not to undergo another major abdominal operation and, instead, keep their colostomy
Subtotal/total colectomy: carried out for obstructing lesions in the descending or sigmoid colon when the caecum has torn. For these lesions, it is not safe to just remove the obstruction, so subtotal colectomy is undertaken. An ileosigmoid or ileorectal anastomosis can be fashioned if the patient is well enough. Alternatively, an end ileostomy can be formed and the rectal stump oversewn.
Where a malignancy is causing obstruction, the management options are usually emergency surgery or stenting, or medical management (palliative care).[53][54][55]
See Emergency surgery above.
See our topic Colorectal cancer.
The surgeon will provide information on all of the treatment options available, such as surgery and palliative care, including the benefits, risks, and side effects.[53]
The surgeon will explain that open or laparoscopic surgery and a stoma may be required.
Side effects after surgery for colorectal cancer include pain; nerve damage; altered bowel, urinary, or sexual function; and anal discharge or bleeding.[53]
Arrange for a trained stoma professional to provide information to the patient on the care and management of stomas and to mark the prospective site, if a stoma is required.[53]
Stenting
Colonic stenting is an option for the management of malignant obstruction.[2][3][56] Use in the absence of:[37][56]
Signs of sepsis or ischaemia
Perforation
Peritonitis
Closed loop obstruction
Intra-abdominal abscess
Caecum dilated more than 9 cm
Distal rectal lesions
Persistent coagulopathy.
Practical tip
Closed loop obstruction
Bear in mind that closed loop obstruction can result in perforation and so should be treated as a surgical emergency.
Closed loop obstruction is when a single segment of bowel is obstructed at two sites. With gas trapped inside the bowel and continuing to enter the colon, pressure within the large bowel will continue to increase and cannot flow back into the small bowel. It leads to a rapid increase in distension and intraluminal pressure, with early vascular occlusion.[1]
The caecum is usually the site of perforation as it has the thinnest bowel wall.[1]
Consider stenting for patients with acute left-sided malignant large bowel obstruction who are to be given palliative care.[2][53]
For patients in whom curative surgery is planned, stenting may allow time to fully assess the patient and stabilise any comorbidities before proceeding.[2][53] This is described as using a stent to provide a 'bridge' to an elective procedure with less risk than emergency surgery.[2]
Evidence: Use of colonic stenting as a bridge to surgery
Colonic stenting as a bridge to definitive surgery is an alternative option to emergency surgery for the management of acute left-sided large bowel obstruction in adults with suspected colorectal cancer. Stenting allows for optimisation of the patient’s condition pre-surgery and reduces the need for stoma formation; however, it may not always be technically successful and there is a risk of perforation.
In January 2020 the UK National Institute for Health and Care Excellence (NICE) updated its guideline on colorectal cancer to include evidence on the effectiveness of stenting compared with emergency surgery for adults with suspected colorectal cancer causing acute large bowel obstruction where curative surgery is planned.[54]
NICE found seven randomised controlled trials (RCTs, n=469), two with follow-up studies, comparing stenting as a bridge to surgery with emergency surgery.
NICE included studies that all had low numbers of participants; the largest was the Enteral Stents for Colonic Obstruction (ESCO) trial with 115 participants. Two RCTs were stopped early - one due to excess morbidity in the emergency surgery arm and the other due to bowel perforation in the stenting arm.
Clinically successful bowel decompression was achieved in 69% of patients with stenting as a bridge to surgery (five RCTs, n=177, very low-quality evidence as assessed by GRADE).
There was a clinically important decrease in stoma rate post-procedure and at last follow-up (GRADE moderate). However, there was no clinically important difference in 30-day mortality (five RCTs, n=340, GRADE very low), disease-free survival at 4 to 5 years follow-up (two RCTS, n=106, GRADE low) or 3-year progression-free survival (one RCT, n=115, GRADE moderate).
Bowel perforation occurred in 10% of patients undergoing stenting (three RCTs, n=133, GRADE moderate) and stent failure in 18% (two RCTs, n=76, GRADE low).
The pre-publication results from the phase 3 UK ColoRectal Endoscopic Stenting Trial (CReST) were shared in confidence with the NICE guideline committee.
The results were consistent with the published evidence.
The NICE guideline committee concluded that the balance of benefits and harms was less clear for people where there was curative (as opposed to palliative) intent. However, the guideline committee also noted that stenting allows time to fully assess the patient and stabilise any comorbidities, thus reducing operative morbidity. This resulted in a strong recommendation to offer the option of either stenting or emergency surgery for people with acute left-sided large bowel obstruction if curative treatment is a possibility.
Also consider stenting for patients where extra-colonic tumours are causing bowel obstruction, such as in advanced gastric or ovarian cancer.[56]
Stenting should be performed only by an experienced endoscopist.[57]
Additional examination and imaging may be required to aid correct stent placement.[56]
Bowel preparation and sedation will be required prior to the procedure.
General anaesthesia may be required for stent placement in an obstructive emergency.[56]
After stent placement, prescribe stool softeners to prevent faecal impaction within the stent.[56]
Risks associated with stenting include stent migration, stent obstruction, perforation, haemorrhage, and pain.[56]
Ongoing care
Explain to the patient that they may experience emotional changes, feel anxious or depressed, or experience changes to their self-perception after cancer treatment, and signpost where they can receive help.[53]
Prior to discharge, advise on:[53]
Adapting physical activity as needed
Diet - in particular, advice on foods that may cause diarrhoea, flatulence, incontinence, or difficulty emptying the bowels
Weight management
Smoking and alcohol use
Expectations for recovery
How to seek help for any side effects.
Treat urgently, because of the risk of perforation due to ischaemia or due to the obstruction itself. Emergency surgery is the primary treatment option where perforation or peritonitis is suspected.[3][9][32] See Emergency surgery above.
Otherwise, treat with endoscopic decompression using a flexible sigmoidoscope and refer for surgery if decompression fails.[3][9][32]
Often endoscopic decompression using flexible sigmoidoscopy allows the twist in the bowel to be untwisted and the obstruction to be relieved.
Be aware that this can introduce more gas into the large bowel and increase the distention in the case of a stricture.
Continue appropriate supportive care such as fluid resuscitation to prevent or treat any adverse consequences, such as high intestinal fluid accumulation, electrolyte disturbances, and hypoproteinaemia.[32] Recurrence can occur and, if so, the sigmoidoscopy can be repeated.[32]
Consider whether elective resection is indicated after endoscopic decompression.[3][9]
Refer patients with benign strictures causing large bowel obstruction for emergency surgery.[3] Base further treatment for benign strictures on the severity of symptoms, the underlying disease process, and the patient's general condition.
Use medical management for uncomplicated disease.[3]
Admit the patient for intravenous antibiotics and fluids.[3]
In a patient with mild disease, consider management in an emergency ambulatory setting, where service provision allows, and providing real-time imaging and senior clinical input are available. In this setting, treat with oral antibiotics, fluids, and stool softeners. Review the patient regularly.[3]
Complications requiring further investigation and treatment include bleeding, abscess, obstruction, perforation, and fistulae. The presence of complications warrants a surgical consultation.
The options for treatment for patients with complicated disease or who fail to respond to conservative treatment need to be decided on an individual basis.[3] Treatment options include: emergency surgery, laparoscopic lavage, and abscess drainage.
See our topic Diverticular disease.
Bowel obstruction may occur in patients already receiving palliative care.
Make management decisions with the appropriate multidisciplinary team and involve the patient and/or their carers where possible. Regarding any acute care, consider the patient’s resuscitation status and any agreed ceilings of care in place.
If the patient is at the end of life, take treatment and monitoring decisions in accordance with an end-of-life care pathway.
Consider whether or not surgery is indicated for the individual patient receiving palliative care. Bear in mind the patient’s condition and their preferences, as well as the benefits and risks when considering surgery.[33]
Factors that may suggest surgery is not indicated:[33][55]
Known diffuse intra-abdominal cancer (seen during surgery or on imaging)
Diffuse, palpable intra-abdominal masses
Massive ascites that recurs rapidly after drainage
High obstruction involving the proximal stomach
Extensive metastatic disease outside the abdomen
Patient with poor performance or nutritional status
Previous radiotherapy to the abdomen or pelvis
Small bowel obstruction at multiple sites.
If an acute problem, consider conservative management and watchful waiting.[33] Ensure the patient is nil by mouth in order to rest the bowel. Relieve symptoms with:[33][55][58]
Laxatives for constipation
A nasogastric tube as a short-term measure to control vomiting
Ice to suck to moisten the mouth and lips, and to manage a sense of thirst.
In a dehydrated patient, use intravenous rehydration initially and subcutaneous rehydration for longer-term management.[33][55]
Consider stenting to treat a localised obstruction in the colon.[33][55][58]
Treat a mechanical obstruction or an obstruction due to peristaltic failure with medication.
For peristaltic failure:[33][55][58]
Stop any medications that the patient is taking that reduce peristalsis, such as cyclizine, hyoscine, 5HT3 antagonists, or amitriptyline
Treat constipation with laxatives
Use a prokinetic antiemetic, such as metoclopramide
Stop the medication if colic develops
Use prolonged higher doses with caution and monitor for extrapyramidal side effects
Consider a fentanyl transdermal patch for pain control as it is less constipating than morphine or oxycodone.
For mechanical obstruction:[33][58]
Treat constipation with laxatives
Avoid stimulant laxatives if the patient has colic
Stop all laxatives in complete obstruction
Consider parenteral dexamethasone to reverse partial obstruction.
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