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Small Bowel Obstruction

Credits
Megan Fix, MD, Maine Medical Center

Edited By: David Gordon, Duke University, Durham, North Carolina

Small Bowel Obstruction Objectives

Upon completion of this self-study module, you should be able to:

List the common causes of a small bowel obstruction

Describe the classic presentation and physical examination findings of a small bowel obstruction

Discuss the diagnostic modalities available to diagnose a small bowel obstruction

List the classic findings of small bowel obstruction on plain films

Describe the treatment priorities for bowel obstruction

Identify which patients are in need of emergent surgical intervention or surgical consultation

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Management of small bowel obstruction in adults

Authors:Liliana Bordeianou, MD, MPHDaniel Dante Yeh, MDSection Editor:Lillian S Kao, MD, MSDeputy
Editor:Wenliang Chen, MD, PhD

INTRODUCTION

Small bowel obstruction (SBO) occurs when the normal flow of intestinal contents is interrupted. The
management of bowel obstruction depends upon the etiology, severity, and location of the obstruction.
The goals of initial management are to relieve discomfort and restore normal fluid volume and
electrolytes. Bowel compromise (ischemia, necrosis, or perforation) and a surgically correctable cause of
SBO (eg, incarcerated hernia) require immediate surgical exploration; other patients may be candidates
for a trial of nonoperative management. Although 60 to 85 percent of adhesion-related SBOs resolve
without surgery, it is difficult to predict a priori which patients will fail nonoperative management. Non-
adhesion-related SBO is usually secondary to another intra-abdominal process (eg, inflammation,
infection), targeted treatment of which will lead to the resolution of SBO symptoms.
This topic review will focus on the management of SBO. The clinical features and diagnosis of SBO are
discussed separately. (See "Epidemiology, clinical features, and diagnosis of mechanical small bowel
obstruction in adults".)

Hypertonic water-soluble radiologic contrast (eg, Gastrografin) has been widely used therapeutically to
treat adhesion-related SBO. Its use is mentioned here but discussed in depth in another topic. (See
"Gastrografin for adhesive small bowel obstruction

Bowel obstruction should be considered as a potential surgical emergency when a patient presents with
acute abdominal pain. It occurs when the normal flow of intestinal contents is interrupted. The most
common causes are adhesions followed by tumors and hernias. Other causes include strictures,
intussuseption, volvulus, Chrohn’s disease, and gallstones. Obstruction is classified as small bowel
obstruction (SBO) or large bowel obstruction (LBO) based on the level of obstruction. LBO is more
commonly caused by malignancy and will not be discussed in detail in this module.

Small bowel obstruction begins when the normal luminal flow of intestinal contents is interrupted and
the small intestine proximal to the obstruction dilates. Secretions are prevented from passing distally. As
time progresses, the distension leads to nausea and vomiting and inability to take oral intake. Bacteria
may ferment in the proximal intestine and cause feculent emesis. The bowel wall becomes more and
more edematous as the process continues and leads to a transudative loss of fluid into the peritoneal
cavity. This increases the degree of dehydration and electrolyte abnormalities that are present in these
patients. Decreased urine output, tachycardia, azotemia and hypotension can also be seen.

Bowel obstructions can be defined as partial or complete and simple or strangulated. Partial obstruction
is when gas or liquid stool can pass through the point of narrowing and complete obstruction is when no
substance can pass. Partial obstruction is further characterized as high grade or low grade according to
the severity of the narrowing. Complete bowel obstruction typically requires surgery, whereas partial
bowel obstruction is often managed conservatively. Strangulation is the most severe complication of
small bowel obstruction and is a surgical emergency. This occurs when bowel wall edema compromises
perfusion to the intestine and necrosis ensues. This will eventually lead to perforation, peritonitis and
death if not intervened upon.

Classic Presentation

History
The patient with a small bowel obstruction will usually present with abdominal pain, abdominal
distension, vomiting, and inability to pass flatus. In a proximal obstruction nausea and vomiting are more
prevalent. Pain is frequently described as crampy and intermittent with a simple obstruction. If the pain
becomes more severe, it may indicate the development of strangulation or ischemia. Patients also may
complain of diarrhea early in the course of bowel obstruction, with inability to pass flatus and
obstipation occurring after the distal portion of the bowel has emptied (up to 12-24 hours).

A history of prior abdominal surgery is important to ascertain because adhesions are the most common
cause of small bowel obstruction. Also important is a history gastrointestinal disorders such as Crohn’s
disease. A patient who presents with a small bowel obstruction with no history of prior surgery is called
a “de novo small bowel obstruction”. These are caused by tumor until proven otherwise and usually
require a surgical intervention.

Physical Exam

Physical examination findings include: abdominal distension (more prevalent in distal obstructions),
hyperactive bowel sounds (early), or hypoactive bowel sounds (late). Fever, tachycardia and peritoneal
signs may be associated with strangulation. It is also important to look for possible causes of obstruction
such as inguinal hernias so always include a genitourinary examination. Rectal examination is important
as well, because gross blood or hemoccult positive stool suggests strangulation or malignancy.

Diagnostic Testing

Plain radiography

All patients suspected of having a small bowel obstruction should have plain radiographs obtained. It is
essential is to obtain an upright chest film (looking for free air/perforation), an upright abdominal film
(looking for air fluid levels), and a supine abdominal film (looking for distended loops of bowel). The
diagnosis is made when multiple air-fluid levels are seen along with distended loops of small bowel.
Absence of air in the colon or rectum suggests a complete obstruction while the presence of air in the
colon suggests a partial obstruction. Plain radiographs can be misleading in difficult cases. Diagnostic
failure rates of as much as 30% have been reported. In one small study, the sensitivity of plain
radiographs was reported as 75%, and specificity was reported to be 53%. Free air on upright chest film
mandates operative management. The presence of strangulation, however, is very difficult to ascertain
on plain films alone.

Small Bowel Series

The diagnosis and degree of small bowel obstruction can be confirmed by a small bowel follow-through
or enteroclysis (the duodenum is instilled with air and contrast). These studies used to be considered the
gold standard for determining whether an obstruction was partial or complete. More recently, CT has
been replacing small bowel follow-through for definitive diagnosis.

Computerized Tomography

Computerized tomography has been replacing the small bowel series as the study of choice to
differentiate partial versus complete obstruction as well as to identify strangulation early. One small
series reported a sensitivity of 93%, specificity of 100%, and accuracy of 94% in detecting obstruction.

Obstruction is present if the small-bowel loop is greater than 2.5 cm in diameter dilated proximal to a
distinct transition zone of collapsed bowel less than 1 cm in diameter. A smooth beak indicates simple
obstruction without vascular compromise; a serrated beak may indicate strangulation. Bowel wall
thickening, pneumatosis, and portal venous gas all suggest strangulation.

CT can also differentiate between the etiologies of SBO, that is, extrinsic causes such as adhesions and
hernia from intrinsic causes such as neoplasms or Crohn’s disease. Furthermore, it has the ability to
identify a myriad of other causes of acute abdominal pain such as abscess, hernia, tumor, or
inflammation. The CT should be obtained with both PO and IV contrast, unless the patient has renal
failure or IV contrast allergy.

Laboratory studies

Laboratory studies are generally not helpful in making the diagnosis of SBO, but they can be helpful in
patient management, especially in determining the degree of dehydration. The following labs should be
ordered to identify dehydration as well as to prepare for possible operative management: serum
chemistry panel, CBC, type and screen, and coagulation profile. Lactic acid, liver function tests, lipase
and urinalysis are also of value in guiding diagnosis, resuscitation, and post-surgical care.

Serum BUN and creatinine may be elevated. A leukocytosis with a left shift may indicate strangulation.
Metabolic alkalosis can be seen in patients with persistent vomiting. Hematocrit may be elevated in
severe dehydration.
Any patient who has had previous abdominal surgery and presents with abdominal pain, distension,
vomiting and decreased flatus should be considered to have a small bowel obstruction. Use of
abdominal series plain films (upright CXR, upright and supine abdominal films) will reveal the diagnosis
in up to 75% of cases. If there is free intraperitoneal air, an emergent surgical consultation for operative
management is indicated. If the diagnosis is not revealed on plain radiographs, CT scan is indicated to
identify bowel obstruction versus other acute abdominal pathology. Laboratory studies are adjunctive
and will help in treatment and resuscitative measures and correcting electrolyte abnormalities.

How do I make the diagnosis?

Any patient who has had previous abdominal surgery and presents with abdominal pain, distension,
vomiting and decreased flatus should be considered to have a small bowel obstruction. Use of
abdominal series plain films (upright CXR, upright and supine abdominal films) will reveal the diagnosis
in up to 75% of cases. If there is free intraperitoneal air, an emergent surgical consultation for operative
management is indicated. If the diagnosis is not revealed on plain radiographs, CT scan is indicated to
identify bowel obstruction versus other acute abdominal pathology. Laboratory studies are adjunctive
and will help in treatment and resuscitative measures and correcting electrolyte abnormalities.

Treatment

Initial management of small bowel obstruction consists of the following goals:

resuscitation and electrolyte replacement

identifying the severity and cause of the obstruction

GI decompression

symptomatic treatment

determining whether or not surgical intervention is indicated

If the patient is acutely ill and/or has peritoneal signs, an emergent surgical consult and aggressive
resuscitation should ensue. Crystalloid replacement should start with 2 Liters wide open with standard
oxygen and monitoring per protocol. If surgical intervention is acutely needed, prophylactic antibiotics
may be given.

In the stable patient in whom the diagnosis of SBO is made, it is important to consult with surgery to
determine if operative management is warranted. If the patient’s exam or CT scan suggests strangulation
(peritonitis, thickened bowel wall, etc) then operative intervention should ensue. If there are no signs of
impending strangulation, then non-operative management may be appropriate.

Non-operative management consists of GI decompression with a nasogastric tube, intravenous fluid

hydration, bowel rest, and symptomatic treatment. Frequent reassessment is important to make sure
that the patient is not developing signs of strangulation. Intravenous medications for pain control
(morphine, fentanyl) and nausea (zofran) should be given as needed. The patient should be admitted for
observation and serial abdominal examinations. If no improvement is shown, operative management
should ensue. Any patient with a “de novo obstruction” will also likely need surgical intervention.

Disposition

OR

ICU

Floor

Pearls and Pitfalls

Prior surgical adhesions are the most common cause of small bowel obstructions

Abdominal radiographs may miss small bowel obstruction in up to 25% of cases and should be followed
by CT if the diagnosis is not clear

Strangulation is the most lethal complication of small bowel obstruction and can be present without
peritoneal signs on examination.

Early surgical consultation for impending strangulation, resuscitation, GI decompression and

symptomatic control are the mainstays to therapy

References

Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of
small bowel obstruction. J Trauma. Jun 2008;64(6):1651-64.

Cappell MS, Batke M. Mechanical obstruction of the small bowel and colon. Med Clin North Am. May
2008;92(3):575-97, viii.

Bass KN, Jones B, Bulkley GB. Current management of small-bowel obstruction. Adv Surg. 1997;31:1-34.

Horton KM. Small bowel obstruction. Crit Rev Comput Tomogr. 2003;44(3):119-28.
Kahi CJ, Rex DK. Bowel obstruction and pseudo-obstruction. Gastroenterol Clin North Am. Dec
2003;32(4):1229-47.

Tintinalli J, Kelen GD, Stapczynski JS. Intestinal obstruction. In: Tintinalli J, ed. Emergency Medicine
Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill; 2004:523-26.

As the premier organization for high-quality research and educational innovation in emergency care, the
Society for Academic Emergency Medicine (SAEM) creates and promotes scientific discovery,
advancement of education, and the highest professional and ethical standards for clinicians, educators,
and researchers. The Clerkship Directors in Emergency Medicine (CDEM) is an Academy of SAEM.

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Fast Fact and Concept #45: Medical Management of Bowel Obstruction

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Title: Fast Fact and Concept #45: Medical Management of Bowel Obstruction
Author(s): Charles von Gunten, MD PhD and J. Cameron Muir, MD

Malignant bowel obstruction is a common oncologic complication; most common in ovarian and colon
cancer. Symptoms include abdominal pain, colicky and/or continuous, nausea and vomiting. Treatment
options include surgical correction, placement of a venting gastrostomy tube, stent placement across the
obstructed site or medical management. The need to rely solely on medical management is common,
especially when the patient's functional status is poor and expected survival is short. In the past 10 years
there has been significant advances in the medical management of this problem, so that virtually all
patients can avoid dying with the traditional approach of intravenous fluids and nasogastric tubes ("drip
and suck"). The cornerstone of treatment is drug therapy.

Major Drugs

Opioids and anti-emetics (usually dopamine antagonists, e.g. haloperidol) can be administered (IV or SQ)
to relieve pain and nausea. Antimuscarinic/anticholinergic drugs (e.g. atropine, scopolamine) are used to
manage colicky pain due to smooth muscle spasm and bowel wall distension. In the US, scopolamine can
be administered by parenteral (10 ?g/hr sc/iv continuous infusion) or transdermal routes (10ug/hr).
Scopolamine is only available as the hydrobromide salt, which penetrates the CNS with the attendant
potential for significant side effects, notably delirium. An alternative agent is glycopyrrolate, a
quaternary ammonium antimuscarinic with similar clinical effects to scopolamine, but without the CNS
side-effects (0.2-0.4 mg sc q 2-4h).

A recent advance is to use somatostatin analogs, which lack the adverse effects of antimuscarinic agents.
Somatostatin inhibits secretion of GH, TSH, ACTH and prolactin and decreases the release of gastrin, CCK,
insulin, glucagon, gastric acid and pancreatic enzymes. It also inhibits neurotransmission in peripheral
nerves of the GI tract leading to decreased peristalsis and a decrease in splanchnic blood flow.
Octreotide (Sandostatin) is administered as a SQ injection (starting at 50-100 mcg q 8 hours) or as
continuous IV or SC infusion, beginning at 10-20 mcg/hr. The drug is titrated every 24 hours until nausea,
vomiting, and abdominal pain are controlled.

Minor Drugs

Prokinetic drugs (e.g. metoclopramide) may be beneficial if there is a partial obstruction. However, if
there is total obstruction prokinetic agents should be discontinued as they may exacerbate symptoms.
Corticosteroids have been recommended to decrease the inflammatory response and resultant edema,
as well as relieve nausea, through both central and peripheral antiemetic effects.

Care Plan

The goal of medical management is to decrease pain, nausea and secretions into the bowel so to
eliminate the need for an NG tube and IV hydration. During the medication titration phase, IV fluids
should be restricted to 50 cc/hr. When NG output is less than 100cc/day, the NG tube can be clamped for
12 hours and then removed. Once out, patients are instructed that they may drink and even eat,
although, vomiting may occur (note: if a venting gastrostomy tube is already in place, oral intake can be
normal without fear of vomiting). Supplemental parenteral hydration is only indicated if a) patients
remain dehydrated despite oral intake and b) use of hydration to extend life is consistent with the
patients' goals.

References:

Baines, MJ. The pathophysiology and management of malignant intestinal obstruction. In Doyle, D,
Hanks, GWC, MacDonald, N, eds. Oxford Textbook of Palliative Medicine, Oxford University Press,
Oxford, 1998; 526-534.

Riley, J., Fallon, MT., Octreotide in terminal malignant obstruction of the gastrointestinal tract. European
Journal of Palliative Care, 1(1): 23-25, 1994.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only.
Citation for referencing: von Gunten C and Muir, JC Fast Facts and Concepts #45: Medical Management
of Bowel Obstruction July, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U.
Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum
project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health
care providers should exercise their own independent clinical judgment. Some Fast Fact information cites
the use of a product in dosage, for an indication, or in a manner other than that recommended in the
product labeling. Accordingly, the official prescribing information should be consulted before any such
product is used.
Creation Date: 7/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice

Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics,
Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics,
Psychiatry, Surgery

Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Addiction, Cancer, Chronic non-malignant pain, Controlled substance regulations,

Gastrointestinal, Interventional procedures, Pain, Pain assessment, Pain treatment

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For
the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror
version is provided subject to copyright restrictions for educational use within the Inter-Instutional
Collaborating Network on End-of-Life Care (IICN).