Recommendations
Key Recommendations
Be aware that SBO is a medical emergency. Diagnosis requires immediate resuscitation and management strategies vary depending on the cause. Adhesive or Crohn disease obstruction may resolve nonoperatively, while obstruction due to hernia usually requires reduction of the hernia and/or repair, and urgent surgery is indicated when there is suspected bowel ischemia or complicated SBO.
In general:
Patients with peritonitis or suspicion for bowel ischemia require emergency surgery.
Patients with simple, adhesive SBO may benefit from nasogastric decompression and close observation. Surgery will likely be required if the patient does not improve with nonoperative management after 48-72 hours.
Patients should initially be treated in the emergency room with fluid resuscitation, bowel decompression, and administration of analgesia. Early surgical consultation with a general surgeon should take place. Operative treatment is indicated in patients with complicated SBO, peritonitis, evidence of strangulation, and those who do not improve with nonoperative treatment.
Correction of the underlying cause will be required for treatment of the concomitant intestinal obstruction.
All patients
Nonoperative treatment
Fluid resuscitation: placement of intravenous lines and administration of intravenous fluids (either Ringer lactate or normal saline) is indicated in all patients. Monitor urine output.
Bowel decompression: the placement of a nasogastric tube is indicated to decompress air/fluid in the upper gastrointestinal tract, although there is evidence to suggest it may not be needed in all patients.[30][31] A surgical consultation (general surgeon) is indicated at this stage.
Antiemetics: although patients with complete SBO often have severe nausea, antiemetics are generally not administered as they do not provide significant relief. The most effective antiemetic strategy is nasogastric decompression. For partial SBO an antiemetic may be beneficial, but only if nasogastric aspirates are minimal.[32] Metoclopramide is contraindicated in patients with bowel obstruction.
Analgesia: it is essential to provide adequate analgesia in patients with partial or complete SBO. This can be readily accomplished with opioids.
Antibiotics: there is insufficient evidence that broad-spectrum antibiotics are routinely beneficial in these patients. However, preoperative antibiotic prophylaxis is indicated if surgery is needed and is usually continued for up to 24 hours postoperatively.
The administration of intravenous fluids and passage of a nasogastric tube result in the correction of adhesive SBO in approximately 70% to 90% of cases. A water-soluble contrast challenge may be used to help estimate whether conservative treatment has been successful in these patients. If the contrast reaches the colon by 24 hours the patient rarely requires surgery.[19][25] There is no evidence that the use of oral water-soluble contrast reduces the need for surgical intervention in patients with adhesive SBO.[33][34] In patients with Crohn disease, medical management of the inflammatory process may be beneficial. However, if there is evidence of bowel strangulation, prompt surgical intervention is crucial. The optimal duration of nonoperative therapy is not completely defined but expert opinion suggests a 72 hour window is safe, unless there are signs and symptoms of developing bowel ischemia.[1][21]
Correction of the underlying cause will be required for treatment of the concomitant intestinal obstruction. Appropriate specific treatment such as Ladd procedure for malrotation, hernia repair, tumor resection, or appendectomy should be performed. The most frequent causes include adhesions, inguinal hernia, or tumor in adults in whom no previous surgery is present.
If surgery is required, laparoscopic adhesiolysis is more favorable than an open laparotomy but may require specific surgical expertise.[16] Systematic reviews and meta-analyses found that the morbidity, mortality, infection rates, and hospital stay were all more favorable in the laparoscopic group when compared with an open laparotomy.[35][36][37] Laparoscopic adhesiolysis is associated with similar short term outcomes (postoperative mortality, iatrogenic bowel perforations, length of postoperative stay, severe postoperative complications and early readmission) as open surgery.[38]
In patients with SBO as a result of stricturing secondary to Crohn disease, endoscopic balloon dilation and double-balloon enteroscopy-assisted dilation are safe and effective alternatives to surgery.[39][40][41]
Where SBO has resulted from advanced malignancy, the benefits of surgery must be weighed up against the risk of complications and increased morbidity.[42]
[ 
]
Such patients may benefit more from palliation of their symptoms through conservative treatment to decompress the bowel if possible, combined with antiemetics, antispasmodics, and adequate analgesia.[16] Nonetheless, surgery may be a necessary part of the palliative treatment to manage the patient’s symptoms.[9][43]
Patients with complicated SBO, peritonitis, strangulation, or failed nonoperative treatment
Operative treatment
The nature of the obstruction determines the type and extent of surgery. An exploratory laparotomy or laparoscopy should be performed in any patient with documented peritonitis or evidence of strangulation; and in patients with SBO who do not improve within 48-72 hours of nonoperative treatment as manifest by persistent abdominal pain, leukocytosis, or evidence of ongoing obstruction with water-soluble contrast imaging, or in an inconsolable infant with documented malrotation. In complicated SBO, peritonitis is usually present (rebound, guarding), which mandates immediate resuscitation and prompt surgical intervention.[1]
Antibiotic prophylaxis
Patients undergoing surgery for SBO will require broad-spectrum antibiotics (e.g., cefotetan or cefazolin plus metronidazole) as prophylaxis for wound infection.[44]
Ultrasound-guided insertion of a non-tunnelled central venous catheter (CVC) into the right internal jugular vein using the Seldinger insertion technique.
How to insert a peripheral intravascular catheter into the dorsum of the hand.
How to insert a urethral catheter in a female patient using sterile technique.
How to insert a urethral catheter in a male patient using sterile technique.
How to insert a fine bore nasogastric tube for feeding.
Use of this content is subject to our disclaimer