Small bowel obstruction
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
complicated or strangulated SBO: surgical candidate
emergency surgery plus fluid resuscitation
In patients with complicated or strangulated SBO, peritonitis is usually present, which mandates immediate resuscitation and prompt surgical intervention by exploratory laparoscopy or laparotomy.
Placement of intravenous lines and administration of intravenous fluid (either Ringer lactate or normal saline) is indicated. Monitor urine output.
preoperative antibiotic prophylaxis
Treatment recommended for ALL patients in selected patient group
Broad-spectrum antibiotics (e.g., cefazolin or cefotetan plus metronidazole) are indicated preoperatively as prophylaxis for wound infection.[44]Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013 Feb;14(1):73-156. https://deepblue.lib.umich.edu/handle/2027.42/140217
Usually antibiotics are administered for up to 24 hours after surgery.
Primary options
cefazolin: children ≥1 year of age: 30 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery, maximum 2000 mg/dose; adults <120 kg body weight: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery; adults ≥120 kg body weight: 3000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery
or
cefotetan: children ≥1 year of age: 40 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery, maximum 2000 mg/dose; adults: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery
-- AND --
metronidazole: children ≥1 year of age: 15 mg/kg intravenously as a single dose within 60 minutes of surgery, maximum 500 mg/dose; adults: 500 mg intravenously as a single dose within 60 minutes of surgery
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefazolin: children ≥1 year of age: 30 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery, maximum 2000 mg/dose; adults <120 kg body weight: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery; adults ≥120 kg body weight: 3000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery
or
cefotetan: children ≥1 year of age: 40 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery, maximum 2000 mg/dose; adults: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery
-- AND --
metronidazole: children ≥1 year of age: 15 mg/kg intravenously as a single dose within 60 minutes of surgery, maximum 500 mg/dose; adults: 500 mg intravenously as a single dose within 60 minutes of surgery
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefazolin
or
cefotetan
-- AND --
metronidazole
preoperative nasogastric decompression
Treatment recommended for ALL patients in selected patient group
The placement of a nasogastric tube to decompress air/fluid in the upper gastrointestinal tract is indicated as part of initial supportive care for patients with SBO. It is also a very effective antiemetic strategy.
analgesia
Treatment recommended for ALL patients in selected patient group
It is essential to provide adequate analgesia in these patients. This can be readily accomplished with the administration of intravenous opioids (e.g., morphine, hydromorphone, fentanyl).
Primary options
morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response; adults: 0.8 to 10 mg/hour intravenous infusion, adjust dose according to response
OR
hydromorphone: children: consult specialist for guidance on dose; adults: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response
OR
fentanyl: children: consult specialist for guidance on dose; adults: 50-100 micrograms intravenously every 1-2 hours when required; adults: 0.5 to 1.5 micrograms/kg/hour intravenous infusion
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response; adults: 0.8 to 10 mg/hour intravenous infusion, adjust dose according to response
OR
hydromorphone: children: consult specialist for guidance on dose; adults: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response
OR
fentanyl: children: consult specialist for guidance on dose; adults: 50-100 micrograms intravenously every 1-2 hours when required; adults: 0.5 to 1.5 micrograms/kg/hour intravenous infusion
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
OR
hydromorphone
OR
fentanyl
correction of the underlying cause
Treatment recommended for ALL patients in selected patient group
Correction of the underlying cause will be required for treatment of the concomitant intestinal obstruction.
Appropriate specific treatment such as Ladd procedure for malrotation (infants), hernia repair, tumor resection, or appendectomy should be performed. In patients with unresectable tumors, surgery also may be a necessary part of palliative treatment.[9]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: small bowel adenocarcinoma [internet publication]. https://www.nccn.org/guidelines/category_1 [43]Santangelo ML, Grifasi C, Criscitiello C, et al. Bowel obstruction and peritoneal carcinomatosis in the elderly: a systematic review. Aging Clin Exp Res. 2017 Feb;29(Suppl 1):73-8. http://www.ncbi.nlm.nih.gov/pubmed/27837464?tool=bestpractice.com
The most frequent causes include adhesions, inguinal hernia, or tumor in adults in whom there is no history of previous surgery.
complicated or strangulated SBO: surgery not indicated
1st line – nasogastric decompression plus fluid resuscitation
nasogastric decompression plus fluid resuscitation
In cases where surgery is deemed not to be in the patient's best interests, the focus of treatment should be on palliation of symptoms.[16]Rami Reddy SR, Cappell MS. A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. Curr Gastroenterol Rep. 2017 Jun;19(6):28. http://www.ncbi.nlm.nih.gov/pubmed/28439845?tool=bestpractice.com Placement of a nasogastric tube is indicated to decompress air/fluid in the upper gastrointestinal tract.
Placement of intravenous lines and administration of sufficient volume of intravenous fluid (either Ringer lactate or normal saline) to resuscitate and maintain hydration is indicated. Monitor urine output.
analgesia
Treatment recommended for ALL patients in selected patient group
Adequate analgesia should be provided to all patients. This can be readily accomplished with the administration of intravenous opioids (e.g., morphine, hydromorphone, fentanyl).
Primary options
morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response; adults: 0.8 to 10 mg/hour intravenous infusion, adjust dose according to response
OR
hydromorphone: children: consult specialist for guidance on dose; adults: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response
OR
fentanyl: children: consult specialist for guidance on dose; adults: 50-100 micrograms intravenously every 1-2 hours when required; adults: 0.5 to 1.5 micrograms/kg/hour intravenous infusion
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response; adults: 0.8 to 10 mg/hour intravenous infusion, adjust dose according to response
OR
hydromorphone: children: consult specialist for guidance on dose; adults: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response
OR
fentanyl: children: consult specialist for guidance on dose; adults: 50-100 micrograms intravenously every 1-2 hours when required; adults: 0.5 to 1.5 micrograms/kg/hour intravenous infusion
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
OR
hydromorphone
OR
fentanyl
antiemetic
Treatment recommended for SOME patients in selected patient group
Antiemetics (e.g., ondansetron) can be a useful adjunct to nasogastric decompression for patients with emesis and/or nausea in cases where surgery is not indicated. Metoclopramide is contraindicated in patients with bowel obstruction.
Primary options
ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required
These drug options and doses relate to a patient with no comorbidities.
Primary options
ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ondansetron
antispasmodic
Treatment recommended for SOME patients in selected patient group
An antispasmodic can be used to reduce abdominal pain or discomfort as part of the management of malignant bowel obstruction.[60]Roeland E, von Gunten CF. Current concepts in malignant bowel obstruction management. Curr Oncol Rep. 2009 Jul;11(4):298-303. http://www.ncbi.nlm.nih.gov/pubmed/19508835?tool=bestpractice.com [61]Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer. 2008 May;44(8):1105-15. http://www.ncbi.nlm.nih.gov/pubmed/18359221?tool=bestpractice.com [62]Madariaga A, Lau J, Ghoshal A, et al. MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer. Support Care Cancer. 2022 Jun;30(6):4711-28. https://pmc.ncbi.nlm.nih.gov/articles/PMC9046338 http://www.ncbi.nlm.nih.gov/pubmed/35274188?tool=bestpractice.com
simple SBO
1st line – fluid resuscitation plus nasogastric decompression
fluid resuscitation plus nasogastric decompression
Typically, conservative therapy may be adopted for 48-72 hours in cases of partial SBO before surgery is performed, except in patients with evidence of complicated SBO (e.g., peritonitis or bowel strangulation/ischemia), where prompt surgical intervention is crucial.[1]Maung AA, Johnson DC, Piper GL, et al; Eastern Association for the Surgery of Trauma. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 suppl 4):S362-9. https://journals.lww.com/jtrauma/Fulltext/2012/11004/Evaluation_and_management_of_small_bowel.14.aspx http://www.ncbi.nlm.nih.gov/pubmed/23114494?tool=bestpractice.com
Placement of intravenous lines and administration of large volumes of intravenous fluid (either Ringer lactate or normal saline) is indicated in all patients. Monitor urine output.
The placement of a nasogastric tube is indicated to decompress air/fluid in the upper gastrointestinal tract.
A surgical consultation (general surgeon) is indicated at this stage to determine the best course of treatment.
Fluid replacement and passage of a nasogastric tube result in the correction of simple adhesive SBO in approximately 70% to 90% of cases. In patients with acute SBO as a result of adhesions, a water-soluble contrast challenge may be used to help estimate whether conservative treatment has been successful. Patients in which the contrast reaches the colon by 24 hours rarely require surgery.[19]American College of Radiology. ACR appropriateness criteria: suspected small-bowel obstruction. 2019 [internet publication]. https://acsearch.acr.org/docs/69476/Narrative [25]Ceresoli M, Coccolini F, Catena F, et al. Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value. Am J Surg. 2016 Jun;211(6):1114-25. http://www.ncbi.nlm.nih.gov/pubmed/26329902?tool=bestpractice.com There is no evidence that the use of oral water-soluble contrast reduces the need for surgical intervention in patients with adhesive SBO.[33]Koh A, Adiamah A, Chowdhury A, et al. Therapeutic role of water-soluble contrast media in adhesive small bowel obstruction: a systematic review and meta-analysis. J Gastrointest Surg. 2020 Feb;24(2):473-83. http://www.ncbi.nlm.nih.gov/pubmed/31485900?tool=bestpractice.com [34]Scotté M, Mauvais F, Bubenheim M, et al. Use of water-soluble contrast medium (gastrografin) does not decrease the need for operative intervention nor the duration of hospital stay in uncomplicated acute adhesive small bowel obstruction? a multicenter, randomized, clinical trial (adhesive small bowel obstruction study) and systematic review. Surgery. 2017 May;161(5):1315-25. http://www.ncbi.nlm.nih.gov/pubmed/28087066?tool=bestpractice.com
correction of the underlying cause
Treatment recommended for ALL patients in selected patient group
Correction of the underlying cause will be required for treatment of the concomitant intestinal obstruction. Appropriate specific treatment such as Ladd procedure for malrotation (infants), hernia repair, tumor resection, or appendectomy should be performed. In patients with unresectable tumors, surgery or conservative measures may be a necessary part of palliative treatment.[9]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: small bowel adenocarcinoma [internet publication]. https://www.nccn.org/guidelines/category_1 [43]Santangelo ML, Grifasi C, Criscitiello C, et al. Bowel obstruction and peritoneal carcinomatosis in the elderly: a systematic review. Aging Clin Exp Res. 2017 Feb;29(Suppl 1):73-8. http://www.ncbi.nlm.nih.gov/pubmed/27837464?tool=bestpractice.com
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]Navaneethan U, Lourdusamy V, Njei B, et al. Endoscopic balloon dilation in the management of strictures in Crohn's disease: a systematic review and meta-analysis of non-randomized trials. Surg Endosc. 2016 Dec;30(12):5434-43. http://www.ncbi.nlm.nih.gov/pubmed/27126619?tool=bestpractice.com [40]Baars JE, Theyventhiran R, Aepli P, et al. Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: a systematic review. World J Gastroenterol. 2017 Dec 7;23(45):8073-81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725302 http://www.ncbi.nlm.nih.gov/pubmed/29259383?tool=bestpractice.com [41]Bettenworth D, Bokemeyer A, Kou L, et al. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn's disease strictures. Aliment Pharmacol Ther. 2020 Oct;52(7):1104-16. http://www.ncbi.nlm.nih.gov/pubmed/32813282?tool=bestpractice.com
There is no evidence that the use of oral water-soluble contrast reduces the need for surgical intervention in patients with adhesive SBO.[33]Koh A, Adiamah A, Chowdhury A, et al. Therapeutic role of water-soluble contrast media in adhesive small bowel obstruction: a systematic review and meta-analysis. J Gastrointest Surg. 2020 Feb;24(2):473-83. http://www.ncbi.nlm.nih.gov/pubmed/31485900?tool=bestpractice.com [34]Scotté M, Mauvais F, Bubenheim M, et al. Use of water-soluble contrast medium (gastrografin) does not decrease the need for operative intervention nor the duration of hospital stay in uncomplicated acute adhesive small bowel obstruction? a multicenter, randomized, clinical trial (adhesive small bowel obstruction study) and systematic review. Surgery. 2017 May;161(5):1315-25. http://www.ncbi.nlm.nih.gov/pubmed/28087066?tool=bestpractice.com
analgesia
Treatment recommended for ALL patients in selected patient group
Adequate analgesia should be provided to all patients. This can be readily accomplished with intravenous administration of opioids (e.g., morphine, hydromorphone, fentanyl).
Primary options
morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response; adults: 0.8 to 10 mg/hour intravenous infusion, adjust dose according to response
OR
hydromorphone: children: consult specialist for guidance on dose; adults: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response
OR
fentanyl: children: consult specialist for guidance on dose; adults: 50-100 micrograms intravenously every 1-2 hours when required; adults: 0.5 to 1.5 micrograms/kg/hour intravenous infusion
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response; adults: 0.8 to 10 mg/hour intravenous infusion, adjust dose according to response
OR
hydromorphone: children: consult specialist for guidance on dose; adults: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response
OR
fentanyl: children: consult specialist for guidance on dose; adults: 50-100 micrograms intravenously every 1-2 hours when required; adults: 0.5 to 1.5 micrograms/kg/hour intravenous infusion
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
OR
hydromorphone
OR
fentanyl
antiemetic
Treatment recommended for SOME patients in selected patient group
For partial SBO an antiemetic (e.g., ondansetron) may be beneficial, but only if nasogastric aspirates are minimal.[32]Chen SC, Lee CC, Yen ZS, et al. Specific oral medications decrease the need for surgery in adhesive partial small-bowel obstruction. Surgery. 2006 Mar;139(3):312-6. http://www.ncbi.nlm.nih.gov/pubmed/16546494?tool=bestpractice.com Metoclopramide is contraindicated in patients with bowel obstruction.
Primary options
ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required
These drug options and doses relate to a patient with no comorbidities.
Primary options
ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ondansetron
surgery
Treatment recommended for ALL patients in selected patient group
An exploratory laparotomy or laparoscopy should be performed in patients who do not improve after 48-72 hours of nonoperative treatment or sooner if there are signs and symptoms of developing bowel ischemia 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 patients with SBO secondary to adhesions, laparoscopic adhesiolysis is more favorable than an open laparotomy.[16]Rami Reddy SR, Cappell MS. A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. Curr Gastroenterol Rep. 2017 Jun;19(6):28. http://www.ncbi.nlm.nih.gov/pubmed/28439845?tool=bestpractice.com 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]Sajid MS, Khawaja AH, Sains P, et al. A systematic review comparing laparoscopic vs open adhesiolysis in patients with adhesional small bowel obstruction. Am J Surg. 2016 Jul;212(1):138-50. http://www.ncbi.nlm.nih.gov/pubmed/27162071?tool=bestpractice.com [36]Wiggins T, Markar SR, Harris A. Laparoscopic adhesiolysis for acute small bowel obstruction: systematic review and pooled analysis. Surg Endosc. 2015 Dec;29(12):3432-42. http://www.ncbi.nlm.nih.gov/pubmed/25840892?tool=bestpractice.com [37]Quah GS, Eslick GD, Cox MR. Laparoscopic versus open surgery for adhesional small bowel obstruction: a systematic review and meta-analysis of case-control studies. Surg Endosc. 2019 Oct;33(10):3209-17. https://www.doi.org/10.1007/s00464-018-6604-3 http://www.ncbi.nlm.nih.gov/pubmed/30460502?tool=bestpractice.com 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]Krielen P, Di Saverio S, Ten Broek R, et al. Laparoscopic versus open approach for adhesive small bowel obstruction, a systematic review and meta-analysis of short term outcomes. J Trauma Acute Care Surg. 2020 Jun;88(6):866-74. http://www.ncbi.nlm.nih.gov/pubmed/32195994?tool=bestpractice.com
preoperative antibiotic prophylaxis
Treatment recommended for ALL patients in selected patient group
Broad-spectrum antibiotics (e.g., cefazolin or cefotetan plus metronidazole) are indicated preoperatively as prophylaxis for wound infection.[44]Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013 Feb;14(1):73-156. https://deepblue.lib.umich.edu/handle/2027.42/140217
Usually antibiotics are administered for up to 24 hours after surgery.
Primary options
cefazolin: children ≥1 year of age: 30 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery, maximum 2000 mg/dose; adults <120 kg body weight: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery; adults ≥120 kg body weight: 3000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery
or
cefotetan: children ≥1 year of age: 40 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery, maximum 2000 mg/dose; adults: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery
-- AND --
metronidazole: children ≥1 year of age: 15 mg/kg intravenously as a single dose within 60 minutes of surgery, maximum 500 mg/dose; adults: 500 mg intravenously as a single dose within 60 minutes of surgery
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefazolin: children ≥1 year of age: 30 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery, maximum 2000 mg/dose; adults <120 kg body weight: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery; adults ≥120 kg body weight: 3000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 4 hours during surgery
or
cefotetan: children ≥1 year of age: 40 mg/kg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery, maximum 2000 mg/dose; adults: 2000 mg intravenously as a single dose within 60 minutes of surgery, may repeat dose every 6 hours during surgery
-- AND --
metronidazole: children ≥1 year of age: 15 mg/kg intravenously as a single dose within 60 minutes of surgery, maximum 500 mg/dose; adults: 500 mg intravenously as a single dose within 60 minutes of surgery
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefazolin
or
cefotetan
-- AND --
metronidazole
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer