Treatment

Definitive management: depends on the severity and etiology of the obstruction and clinical presentation of the patient

• Interventional management

  • Surgery: Transfer the patient to the operating room or admit to a surgical ward depending on the urgency of surgical intervention.

  • Endoscopic intervention: e.g., for the removal or fragmentation of foreign objects that are within reach of an endoscope

  • Stool evacuation

• Nonoperative management: simple bowel obstruction with no evidence of complications (e.g., partial bowel obstruction or postoperative ileus)

• Identify and treat the underlying cause

• Indications

  • Complicated bowel obstruction (i.e., signs of ischemia, perforation, or clinical deterioration)

  • Closed-loop bowel obstruction

  • Suspected bowel obstruction in patients presenting with hemodynamic instability refractory to initial fluid resuscitation

  • Failure of nonoperative management (i.e., no improvement after 3 days of NOM; clinical deterioration/development of complications during NOM)

  • Underlying etiology necessitates surgical intervention (e.g., surgery for inguinal hernia; enterolithotomy fo gall stone ileus)

• Procedure: exploratory laparotomy

  • Management of the obstruction (e.g., adhesiolysis, hernia reduction, cecopexy, tumor resection)

  • Resection of gangrenous bowel with restoration of intestinal transit or creation of a stoma

Endoscopic interventions can be considered for bowel obstruction with no signs of strangulation or perforation. Rigid or flexible sigmoidoscopy, upper GI endoscopy, or colonoscopy under procedural sedation can be used for endoscopic investigation for the following indications.

• Sigmoid volvulus: Attempt endoscopic decompression, detorsion, and reduction.

• Intraluminal bowel obstruction that is within reach of an endoscope: fragmentation or removal

• Inoperable malignant bowel obstruction: Consider placement of stents and decompression tubes.

• Indication: simple bowel obstruction caused by fecal impaction

• Procedures

  • The specific procedure is chosen based on the site of fecal impaction, only after bowel perforation has been definitively ruled out.

    • Manual disimpaction

    • Distal softening or washout with enemas or suppositories

    • Proximal softening or washout with oral solutions such as polyethylene glycol or sodium phosphate

      
      

• Important consideration: Identify and manage the underlying cause of constipation that led to fecal impaction.

• Early postoperative bowel obstruction (i.e., within 6 weeks of abdominal surgery)

• Partial bowel obstruction with no evidence of complications

• Consider in patients with complete SBO and no evidence of complications.

• Complicated bowel obstruction (e.g, peritoneal signs, signs of strangulation)

• Refractory metabolic acidosis

• Significant leukocytosis (> 18,000/mm3)

• Significant cecal dilation

• Bowel rest (NPO)

• Supportive care

  • IV fluid therapy (initial fluid resuscitation followed by maintenance fluid therapy)

  • Electrolyte repletion

  • Parenteral analgesics (nonopioid analgesics are preferred) [36][37]

  • Parenteral antiemetics as needed

Peristalsis-inducing medications (i.e., prokinetic agents such as metoclopramide) are contraindicated in complete mechanical bowel obstruction.

Prophylactic antibiotic therapy is not routinely indicated for simple bowel obstruction that is being managed nonoperatively

• Indications: not routinely required but should be considered in the following situations [39][40]

  • Persistent vomiting

  • Significant upper GI distention

  • Complete bowel obstruction

  • Volvulus

• Contraindications

  • Absolute: midface trauma or recent nasal surgery

  • Relative: coagulopathy, esophageal injury, alkaline ingestion

• No longer than 72 hours

• Some authors suggest trialing NOM for a maximum of 5 days.

• Continuing nonoperative management for > 72 hours does not decrease the need for surgery but does increase surgical morbidity.

• Bowel ischemia

• Bowel perforation

• Peritonitis

A change in the character of pain (colicky pain becoming continuous), rebound tenderness on examination, and/or signs of sepsis in a patient with bowel obstruction indicate the onset of complications and necessitate emergency surgical intervention.

• Mortality rate in untreated intestinal strangulation: 100%

• High risk of recurrence , particularly with chronic or recurring etiologies

• 30-day readmission rate: 16%

• Mortality rate after delayed treatment of closed-loop obstruction: 35%