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Small Bowel Obstruction

I. Background

Small bowel obstruction remains one of the more common reasons for Emergency General Surgery consultation. Protocolized management has been shown to shorten length of hospital stay and time to operative management.

II. Guideline

A. Initial Evaluation with Concern for Bowel Obstruction

  • Labs

    • CBC
    • BMP
    • Lactate

  • Imaging

    • CT Abdomen/Pelvis with IV Contrast

  • Surgical Evaluation

    • Emergency General Surgery Consultation
    • If due to gastrointestinal malignancy (known or suspected), consult Surgical Oncology
    • If Inflammatory Bowel Disease (Crohn’s or Ulcerative Colitis), consult Colorectal Surgery
    • If due to gynecologic malignancy, consult Gynecologic Oncology

  • Admission

    • Patients with bowel obstruction should preferably be admitted to a surgical service

B. Indications for Urgent Exploration

  • Suspected Ischemia

    • Peritonitis on physical examination
    • Concerning laboratory values
      • Leukocytosis
      • Lactic Acidosis
    • Concerning CT findings
      • Closed-loop obstruction
      • Internal hernia
      • Pneumatosis intestinalis
      • Mesenteric edema

  • Incarcerated Hernia

  • No Prior Abdominal Surgery

    • Strongly consider exploration

C. Nonoperative Management – Small Bowel Follow Through

  • Initial Steps

    • Nasogastric decompression for 2 hours
    • Abdominal X-ray to confirm gastric tube placement

  • Orders

    • Xray Small Bowel Nonfluoro
    • iohexol (OMNIPAQUE) 300 mg/mL, 300 mL
    • X-rays at 0, 2, 8, 24 hours

  • Interpretation

    • If contrast in the colon OR bowel movement within 24 hours → passed small bowel follow through
    • If no contrast in the colon AND no bowel movement within 24 hours → consider exploration

D. Criteria for Discharge

  • Tolerating diet without nausea or vomiting
  • Bowel function
  • Resolution of pain

E. Criteria for Discharge

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III. References

  1. Choi HK, Chu KW, Law WL. Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial. Ann Surg. 2002 Jul;236(1):1–6.
  2. Goussous N, Eiken PW, Bannon MP, Zielinski MD. Enhancement of a small bowel obstruction model using the gastrografin(R) challenge test. J Gastrointest Surg. 2013 Jan;17(1):110–6.
  3. Loftus T, Moore F, VanZant E, et al. A protocol for the management of adhesive small bowel obstruction. J Trauma Acute Care Surg. 2015 Jan;78(1):13–9.
  4. Maung AA, Johnson DC, Piper GL, et al. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S362–9.
  5. Medvecz AJ, Dennis BM, Wang L, et al. Impact of operative management on recurrence of adhesive small bowel obstruction: A longitudinal analysis of a statewide database. J Am Coll Surg. 2020 Apr;230(4):544–551.e1.
  6. Moskowitz EE, McIntyre RC, Burlew CC, et al. Evaluation of a water-soluble contrast protocol for small bowel obstruction: A Southwestern Surgical Congress multicenter trial. Am J Surg. 2019 Dec;218(6):1046–1051.
  7. Zielinski MD, Haddad NN, Cullinane DC, et al. Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2017 Jul;83(1):47–54.

IV. Authors

  • Elizabeth D. Krebs, MD
  • Andrew J. Medvecz, MD, MPH
  • Michael C. Smith, MD

December 18, 2023