PRACTICE MANAGEMENT GUIDELINES
FOR SMALL BOWEL OBSTRUCTION
EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction

Jose J. Diaz, Jr. MD; Co-Chair
Vanderbilt University Medical Center
Nashville, TN
E-mail: jose.diaz@vanderbilt.edu

Faran Bokhari, MD; Vice-Chair
Stroger Hospital of Cook County
Chicago, IL
fbokhari2000@yahoo.com

Nathan T. Mowery, MD
Vanderbilt University Medical Center
Nashville, TN
nate.mowery@vanderbilt.edu

Jose A. Acosta, MD
San Diego, CA
macosta@centennialpr.net

Ernest F.J, Block, MD
Orlando Regional Healthcare System
Orlando, FL
eblock@orhs.org

William J. Bromberg, MD
Memorial Health University Medical Center
Savannah, GA
brombwi1@memorialhealth.com

Bryan R. Collier, DO
Vanderbilt University Medical Center
Nashville, TN
Bryan.collier@vanderbilt.edu

Daniel C. Cullinane, MD
Mayo Clinic
Rochester, MN
cullinane.daniel@mayo.edu

Kevin M. Dwyer, MD
Inova Fairfax Hospital
Falls Church, VA
kevin.dwyer@inova.com

Margaret M. Griffen, MD
SHANDS – Jacksonville
Jacksonville, FL
maggie.griffen@jax.ufl.com

John C. Mayberry, MD
Oregon Health & Science University
Portland, OR
mayberrj@ohsu.edu

Rebecca Jerome
Vanderbilt University Medical Center
Nashville, TN
rebecca.jerome@vanderbilt.edu


Practice Management Guidelines for Small Bowel Obstruction

I. Statement of the Problem
The description of patients presenting with small bowel obstruction dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management of these patients with attempted reduction of hernias, laxatives, ingestion of heavy metals (e.g., lead or mercury), and leeches to remove toxic agents from the blood was the rule until the late 1800s, when antisepsis and aseptic surgical techniques made operative intervention safer and more acceptable. A better understanding of the pathophysiology of bowel obstruction and the use of isotonic fluid resuscitation, intestinal tube decompression, and antibiotics have greatly reduced the mortality rate for patients with mechanical bowel obstruction.1, 2 However, the means for determining when a period of observation is warranted versus early surgical intervention continues to be an area of debate. With the advances in imaging techniques additional information can be supplied to the clinical information obtained from the history and physical. The question of whether these technological advancements have allowed a more sophisticated evaluation of these patients is yet to be determined. In addition which tests supply the most information has yet to be clearly described.
Additionally the optimal length of observation continues to be debated. In the era of a push toward shorter hospital stays correctly identifying patients who are to fail observation is even more important. It is important to determine if clinical or radiographic clues can increase our sensitivity in determining such patients.
Finally, as minimally invasive surgery grows and finds new applications are there reproducible benefits to the patients in pursuing these intervention as both a diagnostic and therapeutic intervention.

II. Process
A computerized search of the National Library of Medicine MEDLINE database was undertaken using the PubMed Entrez interface. English language citations during the period of 1991 through 2006 using the primary search strategy:

intestinal obstruction[mh] AND intestine, small[mh] AND humans[mh] NOT (case reports[pt] OR letter[pt] OR comment[pt] OR news[pt])

Review articles were also excluded. The PubMed Related Articles algorithm was also employed to identify additional articles similar to the items retrieved by the primary strategy. Of approximately 550 articles identified by these two techniques, those dealing with either prospective or retrospective studies examining small bowel obstruction were selected, comprising 131 institutional studies evaluating diagnosis and management of adult patients with suspected or proven small bowel obstruction. The articles were reviewed by a group of eleven trauma / critical care surgeons who collaborated to produce this practice management guideline. (Table 1)

The correlation between the evidence and the level of recommendations is as follows:
Level 1: This recommendation is convincingly justifiable based on the available scientific information alone. It is usually based on Class I data, however, strong Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, weak or contradictory Class I data may not be able to support a level 1 recommendation.
Level 2: This recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert critical care opinion. It is usually supported by Class II data or a preponderance of Class III evidence.
Level 3: This recommendation is supported by available data but adequate scientific evidence is lacking. It is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future studies.3

III. Recommendations (Figure 1 – Flow diagram)
Diagnosis:
1. All patients being evaluated for small bowel obstruction should have plain films due to the fact that plain films are as sensitive as CT to differentiate obstruction vs. non-obstruction. LEVEL III
2. All patients with inconclusive plain films for complete or high grade SBO should have a CT as CT scan gives incremental information over plain films in regard to differentiating grade of obstruction and etiology of small bowel obstruction leading to changes in planned management. LEVEL I
3. Multiple signs on CT suggesting strangulation should suggest a low threshold for operative intervention (Table 2). LEVEL II
4. MRI and ultrasound are an alternative to CT with similar sensitivity and identification of etiology, but have several logistical limitations. LEVEL III
5. There is a variety of literature that contrast studies should be considered in patients who fail to improve after 48 hours of conservative management as a normal contrast study can rule out operative small bowel obstruction. LEVEL II
6. Nonionic low osmolar weight contrast is an alternative to barium for contrast studies to evaluate for SBO for diagnostic purposes. LEVEL I

Management:
1. Patients with plain film finding of small bowel obstruction and Clinical markers (fever, leukocytosis, tachycardia, metabolic acidosis and continuous pain) or peritonitis on physical exam warrant exploration. LEVEL I
2. Patients without the above mentioned clinical picture, and a partial SBO or a complete SBO can undergo non-operative management safely; although, complete obstruction has a higher level of failure. LEVEL I
3. Patients without resolution of the there SBO by day 3-5 of non-operative management should undergo water soluble study or surgery. LEVEL III
4. There is no significant difference with regard to the decompression achieved, the success of nonoperative treatment, or the morbidity rate after surgical intervention comparing long tube decompression with the use of nasogastric tubes. LEVEL I
5. Water soluble contrast (Gastrograffin) given in the setting of partial SBO can improve bowel function (time to BM), decrease length of stay, and is both therapeutic and diagnostic. LEVEL II
6. In a highly selected group of patients the laparoscopic treatment of small bowel obstruction should be considered and leads to a shorter hospital length of stay. LEVEL II

Scientific Foundation
A. Historical Background
Mechanical small-bowel obstruction is the most frequently encountered surgical disorder of the small intestine. Although a wide range of etiologies for this condition exist, intra-abdominal adhesions related to prior abdominal surgery is the etiologic factor in up to 75% of cases of small-bowel obstruction. More than 300,000 patients are estimated to undergo surgery to treat adhesion-induced small-bowel obstruction in the United States annually.4
B. Diagnostic Evaluation of Small Bowel Obstruction
The diagnostic evaluation should focus on the following goals: distinguishing mechanical obstruction from ileus; determining the etiology of the obstruction; discriminating partial (low grade) from complete (high grade) obstruction; and discriminating simple from strangulating obstruction.
Important elements to obtain on history include prior abdominal operations (suggesting the presence of adhesions) and the presence of abdominal disorders (e.g., intra-abdominal cancer or inflammatory bowel disease) that may provide insights into the etiology of obstruction. Upon examination, a meticulous search for hernias (particularly in the inguinal and femoral regions) should be conducted. The stool should be checked for gross or occult blood, the presence of which is suggestive of intestinal strangulation.

Plain Films
The diagnosis of small-bowel obstruction is usually confirmed with radiographic examination. The abdominal series consists of a radiograph of the abdomen with the patient in a supine position, a radiograph of the abdomen with the patient in an upright position, and a radiograph of the chest with the patient in an upright position. There is class III evidence to suggest that plain films are as sensitive as CT for the detection of a high grade bowel obstruction (86% vs. 82%).5 Data also suggests that plain films are less sensitive in the setting of low grade or partial bowel obstruction. The sensitivity of abdominal radiographs in the detection of small-bowel obstruction ranges from 70 to 86%.6, 7 Despite these limitations, abdominal radiographs remain an important study in patients with suspected small-bowel obstruction because of their widespread availability and low cost.

Computed tomographic (CT)
There is numerous Class II data to suggest that CT provides incremental information over other imaging forms to the level, etiology and accuracy at differentiating low grade from high grade bowel obstruction leading to changes in planned management.8-10 Computed tomographic (CT) scanning is 80 to 90% sensitive and 70 to 90% specific in the detection of small-bowel obstruction.11 The findings of small-bowel obstruction include a discrete transition zone with dilation of bowel proximally, decompression of bowel distally, intraluminal contrast that does not pass beyond the transition zone, and a colon containing little gas or fluid.
There is class II data to suggest that CT is 85 -100% sensitive for ischemia and strangulation later confirmed by surgery.12-15 Ischemia was suggested on CT with: serrated beak, unusual course of mesenteric vasculature, mesenteric haziness, reduced wall enhancement, wall thickening, mesenteric fluid, mesenteric venous congestion, and ascites.16-18 CT scanning also offers a global evaluation of the abdomen and may therefore reveal the etiology of obstruction.19-21 The global picture afforded is especially relevant when evaluating the acute abdomen when multiple etiologies are on the differential diagnosis.



Enteroclysis
A limitation of CT scanning is its low sensitivity (<50%) in the detection of low-grade or partial small-bowel obstruction. A subtle transition zone or unsuspected closed loop obstruction may be difficult to identify in the axial images obtained during CT scanning. In such cases, contrast examinations of the small bowel, either small-bowel series (small-bowel follow-through) or enteroclysis, can be helpful.22 Nonionic low osmolar weight contrast is an alternative to barium for contrast studies to evaluate for SBO.23 These examinations are more labor intensive and less-rapidly performed than CT scanning, but may offer greater sensitivity in the detection of luminal and mural etiologies of obstruction, such as primary intestinal tumors, with sensitivity and specificity approaching 100% when coupled with CT.24 Enteroclysis is rarely performed in the acute setting, but offers greater sensitivity than small-bowel series in the detection of lesions that may be causing partial small-bowel obstruction.25

Ultrasound
Class II data suggests ultrasound is comparable to plain film for the diagnosis, etiology and strangulation in small bowel obstruction and can better identify free fluid which may signal the need for operative intervention.26-30

MRI
Class II data reports the accuracy MRI at least approaches that of CT with both differentiating obstruction vs no obstruction at an almost 100% sensativity.31 MRI has also been shown to be effective in defining location and etiology of obstruction with at least equivalent accuracy of CT.32-34 Limitations of MRI include: lack of availability after hours, poor definition of mass lesions, and poor visualization of colonic obstructions did not show inflammation as well as CT, and does not show viability.35, 36


C. Evaluation of the Evidence Supporting Early Operative Management
The standard therapy for small-bowel obstruction is expeditious surgery. The rationale for this approach is to minimize the risk for bowel strangulation, which is associated with an increased risk for morbidity and mortality. The literature would suggest that clinical signs supported by simple imaging studies can identify the vast majority of patients presenting with surgical small bowel obstruction.37, 38 Early operative intervention in patients with fever, leukocytosis, peritonitis, tachycardia, metabolic acidosis, and continuous pain will identify strangulation 45% of the time39-41 Complete SBO should be operated on early as the primary mode of therapy. Studies would suggest that 31-43% of patients with complete SBO or peritonitis will resolve without requiring some form of bowel resection. 42, 43
Other reported benefits of the operative management of SBO is the description by class II data that reports lower reoccurrence rate and longer disease free intervals with operative intervention when compared to conservative management. 44-47


D. Evaluation of the Evidence Supporting Conservative Management
Exceptions to the recommendation for expeditious surgery for intestinal obstruction include partial small-bowel obstruction, obstruction occurring in the early postoperative period, intestinal obstruction as a consequence of Crohn's disease, and carcinomatosis.
Progression to strangulation (3-6% with conservative management) is unlikely to occur with partial small-bowel obstruction, and an attempt at nonoperative resolution is warranted.48 Level II data suggests that nonoperative management has been documented to be successful in 65 to 81% of patients with partial small-bowel obstruction or in patients without peritonitis. Of those successfully treated non-operatively, only 5 to 15% have been reported to have symptoms that were not substantially improved within 48 hours after initiation of therapy.49-52 Therefore, most patients with partial small obstruction whose symptoms do not improve within 48 hours after initiation of nonoperative therapy should undergo surgery. There has been some level III data to suggest that this time period can be safely lengthened to 5 days without increase the likelihood of strangulation necessitating bowel resection although definite data to support these claims is not available. Patients undergoing non-operative therapy should be followed with serial abdominal exams for signs of peritonitis which would necessitate immediate operative intervention.
Adjuncts to Conservative Management
Hypertonic contrast in PSBO
The administration of hypertonic water-soluble contrast agents, such as Gastrografin used in upper GI and small-bowel follow-through examinations, causes a shift of fluid into the intestinal lumen, thereby increasing the pressure gradient across the site of obstruction. Level II data suggests that this effect may speed the return of bowel function (time to bowel movement) and decrease the length of stay of patients undergoing non-operative management of partial small bowel obstruction.53-58
E. Operative Approach
Successful laparoscopic surgery for bowel obstruction is being reported with greater frequency. Reported data suggest that up to 60% of small-bowel obstruction cases caused by adhesions may be amenable to laparoscopic therapy.59 The reported conversion rate is 20-51.9%60-67 and the complication rate (bowel injury) is 6.5-18.0%.60, 68 Conversion to open procedure have been reported secondary to density of adhesions, inability to fix the obstruction, cause of obstruction not amenable to laparoscopic therapy, intestinal necrosis, and intestinal perforation. Factors that favor laparoscopic success are SBO post appendectomy, with bands as cause, with less then two previous surgeries, and shorter time of symptoms.69 It has been reported that conversion rate can be decreased to as low as 6.9% when the surgery is guided by preoperative enteroclysis.70 The laparoscopic treatment of small bowel obstruction appears to be effective and leads to a shorter hospital stay in a highly selected group of patients.71, 72 There has also been literature to support that patients treated with laparoscopic intervention have lower hernia rate and SBO but require the same amount of operative intervention.73 Patients fitting the criteria for consideration of laparoscopic management include those with (1) mild abdominal distention allowing adequate visualization, (2) a proximal obstruction, (3) a partial obstruction, and (4) an anticipated single-band obstruction. Currently, patients who have advanced, complete, or distal small bowel obstructions are not candidates for laparoscopic treatment. Unfortunately, the majority of patients with obstruction are in this group. Similarly, patients with matted adhesions or those who remain distended after nasogastric intubation should be managed with conventional laparotomy. Therefore, the future role of laparoscopic procedures in the treatment of these patients remains to be defined.

F. Adjuncts to Surgery
Antibiotics
Broad-spectrum antibiotics are commonly administered because of concerns that bacterial translocation may occur in the setting of small-bowel obstruction; however, there are no controlled data to support or refute this approach.74
Long Tube
Prospective randomized trials demonstrated no significant differences with regard to the decompression achieved, the success of nonoperative treatment, or the morbidity rate after surgical intervention compared with the use of nasogastric tubes. Furthermore, the use of these long tubes has been associated with a significantly longer hospital stay, duration of postoperative ileus, and postoperative complications in some series. Therefore, it appears that long intestinal tubes offer no benefit in the preoperative setting over nasogastric tubes.75, 76

Hyaluronic acid-carboxycellulose membrane (Seprafilm)
The overall rate of post-operative SBO showed no difference with or without Seprafilm. However, Seprafilm did have lower (1.8 vs 3.4%) of SBO requiring reoperation.77-80


V. Summary
To summarize, plain abdominal radiographs are usually diagnostic of bowel obstruction in more than 60% of the cases, but further evaluation (possibly by CT or barium radiography) may be necessary in 20% to 30% of cases. CT examination is particularly useful in patients with a history of abdominal malignancy, in postsurgical patients, and in patients who have no history of abdominal surgery and present with symptoms of bowel obstruction. Barium studies are recommended in patients with a history of recurring obstruction or low-grade mechanical obstruction to precisely define the obstructed segment and degree of obstruction.

VI. Future Investigations
Future studies should be conducted in a prospective, randomized fashion concentrating on the timing of operative intervention for small bowel obstruction.

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Evidentiary Tables

            Practice Management Guidelines for Management of Small Bowel Obstruction in the Setting of Previous Abdominal Surgery

1991 – Present