Small Bowel Obstruction Management (WSES 2017)

Algorithm Steps

1. ▶

   Start

   START: Suspected Small Bowel Obstruction

   Abdominal pain, distension, vomiting, obstipation

   1. ●

      Action

      Confirm Diagnosis

      Clinical + imaging

      • History: Prior surgery (adhesions), hernias, malignancy
      • Exam: Distension, bowel sounds, tenderness, hernias
      • Labs: CBC, BMP, lactate
      • CT abdomen/pelvis with IV contrast (gold standard)
      1. ◆

         Decision

         Signs of Strangulation or Peritonitis?

         Identify surgical emergency

         • STRANGULATION SIGNS: Constant severe pain, fever, tachycardia, peritoneal signs, elevated lactate, CT signs (mesenteric edema, reduced enhancement, closed loop)
         1. ⚠

            Warning

            EMERGENCY SURGERY

            Do not delay for strangulation

            • Immediate surgical exploration
            • Resuscitation while preparing OR
            • Broad-spectrum antibiotics
            • Risk of bowel necrosis/perforation
            1. ✓

               Outcome

               Discharge

               Resolution of SBO

               • Tolerating regular diet
               • Passing flatus/stool
               • Pain controlled
               • Discuss recurrence risk (up to 30%)
               • Return if symptoms recur
         2. ●

            Action

            Initial Non-Operative Management

            Trial of conservative therapy

            • NPO
            • NG tube decompression
            • IV fluids and electrolyte correction
            • Foley catheter for monitoring
            • Serial abdominal exams
            1. ●

               Action

               Water-Soluble Contrast Challenge

               Gastrografin via NG tube

               • 50-100 mL Gastrografin via NG tube
               • Clamp NG for 2 hours
               • Abdominal X-ray at 4-8 hours and 24 hours
               • Therapeutic: Osmotic effect may resolve partial SBO
               • Diagnostic: Predicts need for surgery
               1. ◆

                  Decision

                  Contrast in Colon at 24 Hours?

                  Predicts resolution

                  • CONTRAST IN COLON: 99% sensitivity for resolution
                  • NO CONTRAST: Unlikely to resolve, surgery indicated
                  1. ●

                     Action

                     SBO Resolving

                     Continue conservative management

                     • Advance diet slowly
                     • Remove NG when tolerating PO
                     • Bowel function returns
                     • Typically resolves in 24-48 hours
                  2. ●

                     Action

                     No Resolution

                     Failed conservative management

                     • No contrast in colon at 24-48h
                     • Worsening clinical status
                     • Complete obstruction on imaging
                     1. ●

                        Action

                        Surgical Intervention

                        Laparoscopy or laparotomy

                        • Laparoscopic approach if feasible
                        • Adhesiolysis
                        • Bowel resection if necrosis
                        • Open if complex or failed laparoscopy