Bowel obstruction Non-operative management

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

Many patients without indications for surgery may initially undergo non-operative management of bowel obstruction. Non-operative treatment includes gastrointestinal decompression and water-soluble contrast. Success rates vary by etiology of bowel obstruction. Bowel obstruction caused by adhesion has a high success rate of resolving non-surgical, where as complete obstruction have low success rates.

Indications

  • Non-operative management indications include:[1][2][3][4][5]
    • Early postoperative bowel obstruction
      • Bowel obstructions that occur early on post-operatively are less likely to be strangulations
    • Inflammatory bowel disease
      • Must not be fulminant or having a history of refractory strictures
    • Gallstone ileus
      • The stone may pass during a period of observation
    • Infectious small bowel disease
      • Such as those caused by tuberculosis and Crohn's disease
    • Colonic diverticular disease
      • May benefit from lone antibiotic therapy

Non-operative management

Gastrointestinal decompression

  • Patients with excessive distension and severe symptoms of nausea and vomiting, nasogastric decompression may be carried out to relief symptoms.
  • Patients with chronic or recurrent bowel obstruction, long tube decompression may be useful in conservative management.

Water-soluble contrast

  • Gastrograffin is introduced into the bowel in an attempt to relieve partial small bowel obstruction.
  • Gastrograffin is hypertonic drawing fluid to it in order to relieve edema of the bowel wall and to stimulate peristalsis.
  • Plain x-rays of the abdomen are taken within a 24 hour period of administration.
  • If gastrograffin is seen to reach the colon, then this is a good indication of success of non-operative management, otherwise surgery may be considered.
    • Dosage: 7.5 mL over 30 minutes, up to 22.5 mL over 2 hours
      • Dosing can be repeated if ineffective initially, up to 100ml
  • Water-soluble contrast study has been found to predict resolution of bowel obstruction upon non-operative management with a sensitivity of 92% and a specificity of 93%.

Observation

  • Patients are observed for a period not exceeding 12 - 24 hours after non-operative management has taken place.
  • If no improvement is noted, then the patient is recommended to be explored surgically.

Failure of non-operative management

  • A failure is categorised as an obstruction that persists for more than 5 days.
  • The decision to move forward with surgery is based upon individual clinical status.




References

  1. Oyasiji T, Angelo S, Kyriakides TC, Helton SW (2010). "Small bowel obstruction: outcome and cost implications of admitting service". Am Surg. 76 (7): 687–91. PMID 20698371.
  2. Brolin RE, Krasna MJ, Mast BA (1987). "Use of tubes and radiographs in the management of small bowel obstruction". Ann. Surg. 206 (2): 126–33. PMC 1493109. PMID 3606237.
  3. Di Saverio S, Catena F, Ansaloni L, Gavioli M, Valentino M, Pinna AD (2008). "Water-soluble contrast medium (gastrografin) value in adhesive small intestine obstruction (ASIO): a prospective, randomized, controlled, clinical trial". World J Surg. 32 (10): 2293–304. doi:10.1007/s00268-008-9694-6. PMID 18688562.
  4. Catena F, Di Saverio S, Coccolini F, Ansaloni L, De Simone B, Sartelli M, Van Goor H (2016). "Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention". World J Gastrointest Surg. 8 (3): 222–31. doi:10.4240/wjgs.v8.i3.222. PMC 4807323. PMID 27022449.
  5. Azagury D, Liu RC, Morgan A, Spain DA (2015). "Small bowel obstruction: A practical step-by-step evidence-based approach to evaluation, decision making, and management". J Trauma Acute Care Surg. 79 (4): 661–8. doi:10.1097/TA.0000000000000824. PMID 26402543.


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