Small-Bowel Obstruction, Evaluation and Management of

Published 2012

Diagnosis

Level 1

CT scan of abdomen and pelvis should be considered in all patients with SBO because it can provide incremental information over plain films in differentiating grade, severity, and etiology of SBOs that may lead to changes in management.

Level 2

Water-soluble contrast study should be considered in patients who fail to improve after 48 hours of nonoperative management because a normal contrast study can rule out operative SBO.

Level 3

  1. If available, multidetector CT scanner and multiplanar reconstruction should be used because they aid in the diagnosis and localization of SBOs.
  2. Magnetic resonance imaging (MRI) and ultrasound are potential alternatives to computed tomography but may have several logistical limitations.
  3. CT scan should be considered to aid in the diagnosis of small-bowel volvulus. Findings include multiple transition points, posterior location, and the “whirl” sign.

Management

Level 1

  1. Patients with SBO and generalized peritonitis on physical examination or with other evidence of clinical deterioration such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain should undergo timely surgical exploration.
  2. Patients without the previously mentioned clinical picture can safely undergo initial nonoperative management for both partial and complete SBO, although complete obstruction has a higher level of failure.

Level 2

  1. CT findings consistent with bowel ischemia should suggest a low threshold for operative intervention.
  2. Laparoscopic treatment of SBO is a viable alternative to laparotomy in selected cases. When successful, it may be associated with decreased morbidity and a shorter length of stay.
  3. Water-soluble contrast should be considered in the setting of partial SBO that has not resolved in 48 hours because it can improve bowel function (time to bowel movement), decrease length of stay, and is both therapeutic and diagnostic.

Level 3

  1. Patients without resolution of the SBO by days 3 to 5 of nonoperative management should undergo water-soluble contrast study or surgery.
  2. Patients with SBO should generally be admitted to a surgical service because this has been shown to be associated with a shorter length of stay, less hospital charges, and lower mortality compared with admission to a medical service.