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

INITIAL

acutely ill

1st line – supportive measures

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INITIAL
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acutely ill
1st line – 

supportive measures

When diffuse peritonitis occurs in perforation, the priority is to control the source of sepsis, and medical treatment should be started as soon as possible.[5] Patients with sepsis may also require hemodynamic support with vasopressors. See Sepsis in adults. The patient should fast until the underlying cause is resolved. Supplemental oxygen is given.

Intravenous fluids should replace previous losses, and any electrolyte imbalances should be corrected.

Blood transfusion or blood products may be required to correct anemia or coagulopathy.

Patient may require urinary catheterization and monitoring of urinary output.

Central venous pressure monitoring can be considered.

Nasogastric decompression is part of the initial management of any cause, to decompress the intestinal tract and reduce flow of gastric contents or air toward the obstruction.

Antibiotics are given preoperatively. [ Cochrane Clinical Answers logo ] [Evidence A] Broad-spectrum antibiotics that cover likely pathogens, including amoxicillin, metronidazole, and gentamicin, or a penicillin/beta-lactamase inhibitor combination are recommended according to local protocols.

Where impending perforation is not suspected, and in the absence of any cause that mandates surgical intervention, a period of conservative management may be indicated with further workup and/or treatment of the underlying cause. However, patients with large bowel obstruction will more frequently require operative intervention compared with those with small bowel obstruction.[12]

Plus – emergency surgery

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INITIAL
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acutely ill
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suspected or impending perforation
Plus – 

emergency surgery

Treatment recommended for ALL patients in selected patient group

Emergency surgery is mandatory in patients with colonic perforation due to obstruction, unless there are additional factors (e.g., limitations on goals of care or the patient not expected to survive surgery).[4]

Objectives of surgical intervention are to deal with any intra-abdominal contamination by thorough irrigation, resect the perforated segment, and ideally address the underlying cause.

ACUTE

sigmoid volvulus

1st line – flexible or rigid sigmoidoscopy

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ACUTE
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sigmoid volvulus
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no peritonitis or mucosal gangrene
1st line – 

flexible or rigid sigmoidoscopy

Urgent intervention is required due to risk of perforation from either ischemia of the affected segment or obstruction. Patients without hemodynamic instability, peritonitis, or evidence of perforation should typically undergo flexible sigmoidoscopy to assess sigmoid colon viability, detorse the anatomy, and decompress the colon.[3][8]​​[13]​​

Endoscopic detorsion through flexible or rigid sigmoidoscopy is effective in 60% to 95% of patients.[3] It is considered first-line therapy in stable patients without colonic ischemia or perforation.[3] After successful detorsion of the sigmoid colon, a decompression tube may be left in place to allow for continued colonic decompression, to decrease the risk of recurrent volvulus, and to facilitate preoperative mechanical bowel preparation, as needed.[3][13] Underlying medical conditions should be addressed and a later colonoscopy arranged to exclude more proximal pathology. Patients who undergo successful endoscopic detorsion should be considered for sigmoid colectomy during the same hospital admission to prevent recurrent volvulus.[3] Although minimally invasive and open approaches have been described in the management of volvulus, surgeon and patient factors influence the selection of the operative plan. The redundancy and mobility of the colon and the associated mesentery usually allow for colectomy via a minilaparotomy.[3] 

2nd line – surgery

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ACUTE
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sigmoid volvulus
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no peritonitis or mucosal gangrene
2nd line – 

surgery

Of the variety of elective and semi-elective operations that have been described for sigmoid volvulus, sigmoid colectomy (with or without colorectal anastomosis) is the most effective at preventing recurrent volvulus.[3][8]​ Stoma creation in the nonemergent setting is not usually necessary, and should be individualized based on the operative findings and unique patient factors.[3]

Alternative surgical strategies to resection include detorsion alone, sigmoidopexy, and mesosigmoidoplasty. However, these are inferior to sigmoid colectomy for the prevention of recurrent volvulus.[3][8]​ Endoscopic fixation of the sigmoid colon may be considered in selected patients in whom operative intervention presents a prohibitive risk.[3][8]

1st line – surgery

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ACUTE
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sigmoid volvulus
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peritonitis or mucosal gangrene
1st line – 

surgery

Patients who present with colonic ischemia or perforation, peritonitis, or septic shock, or in whom endoscopic detorsion fails, all require urgent sigmoid resection.[3] After the volvulized segment has been resected, the decision to perform a primary colorectal anastomosis, end colostomy, or defunctionalized colorectal anastomosis with diverting ileostomy should be individualized after considering a patients’ clinical status at the time of surgery, health of the remaining colon, and comorbidities.[3] The Hartmann procedure, the most commonly performed operation for patients who have sigmoid volvulus with a nonviable colon and peritonitis, has an associated mortality rate of around 12% but can be up to 57% in some cases, according to retrospective studies.[8]​​[50][51]​​​​​[52]​ Resection with primary anastomosis had a leak rate of up to 12% and a mortality rate of 5% to 10% in international retrospective studies.[8][53]​​​ End colostomy may be the safest and most appropriate choice for higher-risk patients (e.g., patients with higher American Society of Anesthesiologists [ASA] class, acidosis, sepsis, coagulopathy).[3]

Frequently, the colostomy is on a permanent basis.

As proximal colonic obstruction occurs with sigmoid volvulus, rapid cecal dilation, and ischemia can place the cecum at risk of perforation, and the cecum must be carefully inspected at the time of surgery.

cecal volvulus

1st line – surgery

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ACUTE
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cecal volvulus
1st line – 

surgery

Nonviable or gangrenous cecum is present in 18% to 44% of patients with cecal volvulus and is associated with a significant mortality rate.[3] Segmental resection is the preferred treatment for cecal volvulus.[3] Attempts at endoscopic reduction of cecal volvulus are generally not recommended, given the low probability of success and the potential for procedure-related perforation.[3][13] End stoma creation should be considered in higher-risk patients and in patients with a nonviable bowel, although the data regarding this option are limited.[3]

For cecal volvulus with a viable bowel, the use of nonresectional operative procedures should be limited to patients who are considered unfit for resection.[3]

colorectal malignancy

1st line – surgery

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ACUTE
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colorectal malignancy
1st line – 

surgery

Surgical care aims to relieve obstruction and resect the lesion in most cases.[54]

The American Society of Colon and Rectal Surgeons has issued the following recommendations.[55]

For patients with an obstructing left-sided colon cancer and curable disease, the choice of endoscopic stent decompression, diverting colostomy with interval colectomy, or initial treatment with oncologic segmental colectomy should be individualized based on patient factors and available expertise.

For patients with an obstructing right or transverse colon cancer and curable disease, initial colectomy or initial endoscopic stent decompression with subsequent interval colectomy may be performed.

In the setting of perforation or impending perforation of the colon, resection following established oncologic principles with a low threshold for performing a staged procedure is recommended when feasible.

In patients with an obstructing colon cancer and incurable metastatic disease, or in other scenarios in which palliation is preferred over an attempt at cure, endoscopic stent placement or fecal diversion is preferable to colectomy when life expectancy is <1 year.

See Colorectal cancer. 

Consider – endoscopic stenting

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ACUTE
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colorectal malignancy
Consider – 

endoscopic stenting

Treatment recommended for SOME patients in selected patient group

In patients with an obstructing colon cancer and incurable metastatic disease, or in other scenarios in which palliation is preferred over an attempt at cure, endoscopic stent placement or fecal diversion is preferable to colectomy when life expectancy is <1 year.[55]

diverticular disease

1st line – surgery

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ACUTE
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diverticular disease
1st line – 

surgery

A persistent obstruction due to diverticular disease will likely merit surgical intervention as outcomes with endoscopic stenting are poor.[56] In addition, it may be difficult to exclude a malignant etiology. The criteria for recommending elective colectomy for nonobstructing recurrent disease are not clear cut. Any judgment should be made on an individual basis depending on age, frequency and severity of recurrent symptoms, previous complications, comorbidities, and patient preferences and values.[57][58][59][60] See Diverticular disease.

foreign body ingestion

1st line – transluminal removal or laparotomy

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ACUTE
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foreign body ingestion
1st line – 

transluminal removal or laparotomy

Management of a foreign body should be handled on a case-by-case basis and may be done with endoscopy. However, emergency surgery is mandatory in patients with perforation due to obstruction. Objectives of surgical intervention are to deal with intra-abdominal contamination by thorough irrigation, resect the perforated segment, and ideally address the underlying cause. See Foreign body ingestion.

benign strictures

1st line – treat underlying cause

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ACUTE
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benign strictures
1st line – 

treat underlying cause

Should be treated based on the severity of symptoms, the underlying disease process, and the patient's general condition.

endometriosis

1st line – resection

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ACUTE
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endometriosis
1st line – 

resection

May require the diseased segment to be resected if there is an obstruction.

Depending on the severity of the endometriosis, medical therapy may need to be initiated by a gynecologist. See Endometriosis.

pelvic abscess

1st line – percutaneous or transrectal drainage

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ACUTE
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pelvic abscess
1st line – 

percutaneous or transrectal drainage

Percutaneous or transrectal drainage may be performed, though there is a risk that an underlying malignancy will be missed.

Consider – resection

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ACUTE
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pelvic abscess
Consider – 

resection

Treatment recommended for SOME patients in selected patient group

Resection of the diseased segment may be considered at a later date depending on the patient's progress.

currently receiving palliative care

1st line – initial supportive care

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ACUTE
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currently receiving palliative care
1st line – 

initial supportive care

Bowel obstruction may occur in patients already receiving palliative care.

In these situations, management decisions should be made with the appropriate multidisciplinary team and the patient and/or their caregivers should be involved where possible.

Careful consideration as to whether or not surgery is indicated for the individual patient receiving palliative care is needed; take into account the patient’s condition and their preferences, as well as the benefits and risks when considering surgery.

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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

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