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Overviewofmanagementofmechanicalsmallbowelobstructioninadults
OfficialreprintfromUpToDate
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Overviewofmanagementofmechanicalsmallbowelobstructioninadults
Authors
LilianaBordeianou,MD,MPH
DanielDanteYeh,MD

SectionEditor
DavidISoybel,MD

DeputyEditor
WenliangChen,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:May18,2016.
INTRODUCTIONSmallbowelobstruction(SBO)occurswhenthenormalflowofintestinalcontentsisinterrupted.
Themanagementofbowelobstructiondependsupontheetiology,severity,andlocationoftheobstruction.Thegoals
ofinitialmanagementaretorelievediscomfortandrestorenormalfluidvolumeandelectrolytesinpreparationfor
possiblesurgicalintervention.Somepatientsmaybecandidatesforatrialofnonoperativemanagement.Highquality
datatoguidemanagementofSBOaresparse,andclinicalpracticeishighlyvariablehowever,guidelinesbasedupon
theavailableevidenceareavailablefromtheEasternAssociationfortheSurgeryofTrauma(EAST)[1,2],andfromthe
WorldSocietyofEmergencySurgery(Bolognaguidelines).Thelatterfocusesonthemanagementofadhesionrelated
smallbowelobstruction[3,4].
Thistopicreviewwillfocusonthemanagementofmechanicalsmallbowelobstruction.Theclinicalfeaturesand
diagnosisofmechanicalsmallbowelobstructionarediscussedseparately.(See"Epidemiology,clinicalfeatures,and
diagnosisofmechanicalsmallbowelobstructioninadults".)
INITIALMANAGEMENTPatientswithclinicalfeaturesofsmallbowelobstruction(SBO)whoarediagnosedwith
acutemechanicalsmallbowelobstructiongenerallyrequireadmissiontothehospitalforinitialmanagementthat
includesintravenousfluidtherapyandelectrolytereplacementinpreparationforsurgery,ifindicated,orasanelement
ofnonoperativemanagement.Patientswithchronicand/orintermittentmechanicalsmallbowelobstruction,suchas
patientswithsmallbowelstricturesrelatedtoCrohnsdisease,radiationenteritis,orotheretiologiesthatcancause
partialbowelobstruction,maybemanagedexpectantlyonanoutpatientbasis.Suchpatientsshouldlimittheiroral
intaketofluids,andaslongashydrationandnormalelectrolytebalancecanbemaintained,whichmayrequire
outpatientfluidtherapy,hospitalizationmaybeavoided.Inareviewof129patients,placementofanasogastrictubeto
managenauseaandemesispredictedtheneedforadmission,whichoccurredinabouthalfofpatientswhopresented
totheemergencyroomwithvaryingdegreesandetiologiesforsmallbowelobstruction[5].
SurgicalconsultationForpatientswithsymptomsthataresevereenoughtorequireadmissionforsymptomsof
abdominalpain,nausea,andvomiting,wesuggestpromptsurgicalconsultationtoaidindeterminingifimmediate
surgicalinterventionisneeded.(See'Indicationsforsurgicalexploration'below.)
Ifsurgeryisnotimmediatelyindicated,wesuggestadmissiontoadedicatedsurgicalserviceunlesssuchaserviceis
notavailableorthepatientisnotacandidatefor,orisunwillingtoconsider,anoperation.(See'Medicaltherapies'
below.)
Patientswithsmallbowelobstructionadmittedtoasurgicalservicehaveshorterlengthofstay,fewerhospital
charges,ashortertimetosurgery,andlowermortalitythanpatientsadmittedtomedicalservice[1].Forpatientswho
areadmittedtoamedicalserviceforthemanagementofSBO,theuseofclearcutSBOmanagementprotocols
reportedlydecreasestimetosurgicalconsultation,decreasestimetooperativeintervention,andshortenshospital
lengthofstay[6].
FluidtherapyPatientswithbowelobstructioncanhaveseverevolumedepletion,metabolicacidosisoralkalosis,
andelectrolyteabnormalities.Thisisparticularlytrueforpatientswithcopiousemesisfromproximalsmallbowel
obstruction,thosewithsymptomslastingseveraldayspriortopresentation,orobstructionthatcauseslargevolume
intraluminalfluidsequestration.(See"Epidemiology,clinicalfeatures,anddiagnosisofmechanicalsmallbowel
obstructioninadults",sectionon'Pathophysiology'.)
Uponadmission,adequateintravenous(IV)accessintheformoftwolargeboreperipherallinesshouldbeobtainedfor
fluidresuscitation.Lactatedringersornormalsalinemaybeappropriateforintravenousfluidtherapy.Aggressive
potassiumrepletionmaybeneeded,butitisimportanttobecertainthepatientdoesnothaveacutekidneyinjury
(acuterenalfailure)fromseveredehydration,inwhichcasepotassiumsupplementationshouldbegivencautiously
untilrenalfunctioncanbeimproved.(See"Maintenanceandreplacementfluidtherapyinadults"and"Overviewofthe
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managementofacutekidneyinjury(acuterenalfailure)".)
Althoughsuspectedstrangulationwarrantsoperativeinterventionassoonaspossible,fluidresuscitationandrepletion
ofelectrolytespriortosurgeryhelpsminimizecomplications(eg,hypotension)relatedtosomeanesthesiainduction
agents.(See"Generalanesthesia:Induction",sectionon'Selectionofinductiontechnique'.)
DietIngeneral,allpatientswithmechanicalbowelobstructionshouldbemadenilperos(NPO)tolimitbowel
distensionhowever,asmallsubsetofpatientswithpartialbowelobstructionmaytolerateasmallamountofliquids.
GastrointestinaldecompressionTheneedforgastrointestinaldecompressioninthesettingofsmallbowel
obstructionmayvaryfrompatienttopatientandremainsamatterofclinicaljudgment.Forpatientswithsmallbowel
mechanicalbowelobstructionthatisassociatedwithsignificantdistension,nausea,and/orvomiting,werecommend
nasogastrictubedecompression[13].Inpatientswithcompleteorhighgradesmallbowelobstruction,decompression
ofthedistendedstomachimprovespatientcomfortandalsominimizesthepassageofswallowedair,whichcan
worsendistension.Theplacementandmanagementofnasogastrictubesisdiscussedelsewhere.(See"Nasogastric
andnasoenterictubes".)
Forpatientswithrecurrentsmallbowelobstructionwhohaveundergonemultipleprioroperations,andinwhomanother
operationisfelttobeparticularlyrisky,onecanattemptlongtubedecompressionasacomponentofconservative
managementtoavoidfurthersurgery.However,therearefewdatatosupportthispracticeovertheuseofstandard
nasogastricdecompression,andassuch,wedonotadvocatetheroutineuseoflongtubesinpatientswithsmall
bowelobstruction.Oldertrialscomparingstandardnasogastrictubesandlongtubesweightedwithamercuryfilled
balloon(eg,MillerAbbotttube,Andersontube,Dennistube[7,8]),foundnosignificantdifferenceinthepercentageof
patientsultimatelyrequiringsurgicalintervention[3,9].However,alaterrandomizedtrialcomparing90patients
managedwithanendoscopicallyplacedlonghydrophilicsilicontubewith96patientsmanagedwithanasogastrictube
foundasignificantlydecreasedtimetoreliefofclinicalsymptomsinthegroupmanagedwiththelongtubecompared
withthenasogastrictube(4.1versus8.5days)[7].Overalleffectiveness(ie,noneedforsurgery)wasnearlydoubled
inthelongtubegroup(90versus47percent).Theimprovedoutcomesseeninthisonestudywillneedtobereplicated
infuturestudiesbeforeroutineimplementationconcernsremainoverthepotentialrisksoflongtubes,suchasknot
formation.
PainmanagementIngeneral,painfrommechanicalbowelobstruction,whichiscrampyinnature,isoftennot
amenabletotreatmentwithanalgesics,particularlyopioids.Ifthepatientspainissevereandunrelenting,theremay
beastrangulatingmechanismthatwouldindicatetheneedforsurgicalintervention.However,painmanagementwith
opioidsandotherpharmacologicagentsisreasonableinpalliativecarepatients.(See'Medicaltherapies'below.)
INDICATIONSFORSURGICALEXPLORATIONAllpatientssuspectedofhavingcomplicatedbowelobstruction
(completeobstruction,closedloopobstruction,bowelischemia,necrosis,orperforation)baseduponclinicaland
radiologicexaminationshouldbetakentotheoperatingroomforabdominalexploration[1,2].Althoughsomesurgeons
maybereluctanttooperateonpatientswithahistoryofpriorsurgeryforintraabdominalmalignancybecausethey
believethatobstructionduetometastaticcancerisnotlikelytoberelievedbysurgery,thisisnotnecessarilythecase
asmanyareduetoadhesions.Nonoperativetherapyformalignantobstructionisassociatedwithahighfailurerate
andhighmortality,butontheotherhand,palliativesurgeryforthoseinwhomtheobstructioncannotberelievedisalso
associatedwithoverallpooroutcomes[1014].(See'Patientswithmalignancy'below.)
Theincidenceofcomplicationswithadhesiveobstructionisoveralllow[1525].Amongpatientswhopresentwith
smallbowelobstruction,incarceratedherniascausethemajorityofcomplications[26].
Thedevelopmentofcomplicatedobstructionduringatrialofconservative,nonoperativemanagementshouldalso
promptsurgicalexploration[2].Approximatelyonefourthofpatientsadmittedwithsmallbowelobstructionwillrequire
surgery.(See'Trialofnonoperativemanagement'below.)
Clinicalfeaturesofsmallbowelobstructionindicativeofcomplicatedobstructionarepresentedseparately.(See
"Epidemiology,clinicalfeatures,anddiagnosisofmechanicalsmallbowelobstructioninadults",sectionon'Complete
obstructionandclosedloopobstruction'and"Epidemiology,clinicalfeatures,anddiagnosisofmechanicalsmallbowel
obstructioninadults",sectionon'Bowelischemiaandperforation'.)
Itisdifficulttoaccuratelypredictbowelischemiabaseduponclinicalparametersalone[27,28].Inonestudy,
experiencedclinicianswerewrongintheirpreoperativeassessmentmorethanhalfthetimeinpatientseventually
foundtohavegangrenousbowel[28].Clinicalsignsandsymptomsthatareassociatedwithbowelischemiainclude
thefollowing,buteachoftheseclinicalsignsisnonspecificandcannotbeusedinisolation[2932]:[33]

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Fever
Leukocytosis
Tachycardia
Continuousorworseningabdominalpain
Metabolicacidosis
Peritonitis
Systemicinflammatoryresponsesyndrome(SIRS)(See"Sepsissyndromesinadults:Epidemiology,definitions,
clinicalpresentation,diagnosis,andprognosis".)

Inadditiontolaboratoryandclinicalsigns,thefollowingradiologicsignswillidentify70to96percentofpatientswho
willbenefitfromimmediatesurgery[27,28,3438]:
Freeaironplainradiographsorabdominalcomputedtomography(CT)indicatingbowelperforation.
Signsofintestinalischemia.Althoughadvancedischemiaisusuallyobvious(eg,pneumatosisintestinalis,portal
venousgas),itremainsdifficulttoidentifyearlyandintermediatestagesofbowelischemia.(See"Epidemiology,
clinicalfeatures,anddiagnosisofmechanicalsmallbowelobstructioninadults",sectionon'Bowelischemiaand
perforation'.)
Completeorclosedloopobstruction(eg,Ushaped,distended,fluidfilledloopstriangularloopbeaksigntwo
loopsofcollapsedboweladjacenttotheobstructionsite)[29,39].(See"Epidemiology,clinicalfeatures,and
diagnosisofmechanicalsmallbowelobstructioninadults",sectionon'Completeobstructionandclosedloop
obstruction'.)
OtherCTscanfindingspredictiveoftheneedforsurgeryincludefindingsofanabnormalcourseofamesenteric
vessel,ahighgradeobstruction,atransitionzone,andperitonealfluid[40,41].However,thesesignsarealso
nonspecific.Inonestudythatincluded145patientswithhighgradeobstructiononCT,46percentwere
successfullymanagednonoperatively[32].
Inamultivariateanalysis,sixclinicalandradiographicvaluescorrelatedwiththeneedforbowelresection[42].A
scoringsystemwasdevelopedthatassignedonepointtoeachofthesevariables,whicharelistedbelow.Among233
consecutivepatientswithbowelobstruction,11patientswithatotalscore4pointsrequiredbowelresection.Atotal
score3pointspredictedtheneedforresectionwithaspecificityof90.8percent.Thevariablesinclude:

Historyofpainlastinggreaterthanfourdays
Abdominalguardingonphysicalexam
ElevatedCRPabove75mg/L
ElevatedWBCabove10
Presenceof>500mLoffreeintraabdominalfluidonCT
ReducedwallcontrastenhancementonCT

AnothergroupofinvestigatorsidentifiedthepresenceoffreefluidandhighgradeobstructiononCTscanasstrong
predictorsforearlysurgery[43].
Whenoperativeinterventionisrequiredforsmallbowelobstruction,openabdominalsurgeryismostcommonly
performed,althoughlaparoscopicadhesiolysishasbeenshowntocauselessmorbiditythanopensurgery.Ina
propensityscorematchedstudyofpatientswhounderwentadhesiolysisforsmallbowelobstruction,theuseof
laparoscopywasassociatedwithsignificantlylowerratesofoverallcomplications(oddsratio[OR]0.41,95%CI0.28
0.60),surgicalsiteinfections(OR0.15,95%CI0.050.49)andintraoperativetransfusions(OR0.22,95%CI0.05
0.90),aswellasashorterlengthofhospitalstay(4versus10days)[44].Asystematicreviewandpooledanalysisof
11nonrandomizedstudiesalsoshowedlaparoscopicadhesiolysistobeassociatedwithlowerratesofmortality
(pooledOR0.31,95%CI0.160.61),morbidity(pooledOR0.34,95%CI0.270.78),andwoundinfection(pooledOR
0.29,95%CI0.120.70),aswellasashorterlengthofhospitalstay(weighedmeandifference7.11days,95%CI
8.47to5.75days)[45].However,laparoscopicadhesiolysisisnotalwaysfeasible,especiallyinpatientswhohave
hadpriorabdominalsurgery.Thebenefitsoflaparoscopicadhesiolysisalsoneedtobevalidatedbycontrolled,
prospectivetrials,asinobservationalstudies,healthierpatientsmayhavebeenselectedforlaparoscopicsurgery.
TRIALOFNONOPERATIVEMANAGEMENTManypatientswithoutindicationsforimmediateinterventioncan
safelyundergoinitialnonoperativemanagement,butclinicalevaluationmustfirstexcludecomplicatedobstruction(eg,
strangulation,necrosis)indicatingtheneedforimmediatesurgery.Considerationsforpatientswithabdominal
malignancies(resected,unresected,metastatic)arediscussedbelow.(See'Patientswithmalignancy'belowand
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'Indicationsforsurgicalexploration'above.)
Conservativenonoperativemanagementresolvessymptomsinmanypatientswithpartialsmallbowelobstruction,but
successratesdependupontheetiology[3,46,47].Inthesettingofadhesivesmallbowelobstruction,nonoperative
managementisoverallsuccessfulin65to80percentofpatients[4851].Althoughtheincidenceofbowelischemia
duringnonoperativemanagementofpartialsmallbowelobstructionislowat3to6percent[29],thepatientstillneeds
tobecarefullymonitoredwithserialabdominalexaminationandlaboratorystudiessomewillbenefitfromfollowup
imaging.
Themanagementofpatientswithcompletesmallbowelobstructionduetoadhesionsiscontroversial.Somehave
demonstratedthatnonoperativemanagementisstillsuccessfulin41to73percentofpatients[48,52]however,
completeadhesivesmallbowelobstructionisassociatedwithahigherrequirementforsmallbowelresection(31
percent)insomeseries[53].Nonoperativemanagementofpartialandcompleteadhesivesmallbowelobstructionis
associatedwithhigherrecurrenceratesandlowerdiseasefreeintervalscomparedwithoperativemanagement[52,54].
Atrialofnonoperativemanagementiswarrantedinpatientswiththefollowingetiologiesfortheirbowelobstruction,
whodonototherwisehaveindicationsforsurgicalexploration:
EarlypostoperativebowelobstructionAdhesionsassociatedwithearlypostoperativebowelobstructionrarely
leadtostrangulation.
InflammatoryboweldiseasePatientswhodonothavefulminantdiseasecausingcompletebowelobstruction
mayrespondtomedicaltherapy.However,refractorystricturesduetorepeatedepisodesofinflammationwill
usuallyrequireresectionand/orstrictureplastytorelieveobstruction.(See"Overviewofthemedicalmanagement
ofmildtomoderateCrohndiseaseinadults"and"Managementofmildtomoderateulcerativecolitisinadults".)
GallstoneileusPatientswithagallstoneimpactedintheduodenum(Bouveretsyndrome)maybenefitfroma
periodofnonoperativemanagementthatwillallowthestonetopassintothesmallbowel,wheresurgicalretrieval
islesslikelytocausecomplications.Endoscopicfragmentationofstonecanalsobeattemptedinthislocation,
withthegoalofsparingthepatientaduodenotomyshouldtheyneedultimatesurgery[55].(See"Gallstone
ileus".)
InfectioussmallboweldiseasePatientswhopresentwithapartialsmallbowelobstructionduetotuberculosis
mayimprovewithmedicalmanagement,although,similartoCrohnsdisease,delayeddiagnosisismorelikelyto
requiresurgery[56].(See"Tuberculousenteritis",sectionon'Management'.)
ColonicdiverticulardiseasecausingsmallbowelobstructionAntibiotictherapyreducesperidiverticular
inflammationandmayrelieveobstructivesymptoms.(See"Acutecolonicdiverticulitis:Medicalmanagement".)
DurationofobservationInthepast,ithasbeenrecommendedthatpatientswithsmallbowelobstruction(without
indicationsforimmediatesurgicalexploration)shouldbeobservedfornolongerthan12to24hours,afterwhichtime,if
noimprovementisseen,thepatientshouldbeexplored.However,aslongasthereremainnofindingsonserialclinical
evaluationtosuggestacomplicatedobstruction,thepatientmaybeobservedforalongerperiodoftime.With
nonoperativemanagement,appropriatelyselectedpatientsusuallyimprovewithintwotofivedays[29,51].However,it
shouldbenotedthatforpatientswhoultimatelyrequireanoperation,adelayofmorethanonedayhasbeenidentified
asariskfactorforrequiringbowelresection[57].Inotherstudies,nonoperativemanagementforuncomplicated
adhesivebowelobstructionexceedingthreetofivedayswasassociatedwithincreasedmorbidityandmortality
[58,59].Earlierratherthanlatersurgerymaybewarrantedinpatientswithknownmalignancy(resected,unresected,
metastases),althoughdiseasedistributionandlocationneedtobecarefullyconsideredandthedecisiontooperateor
notindividualizedaccordingly.(See'Patientswithmalignancy'below.)
SerialmonitoringFrequentclinicalreassessmentsofthepatientarenecessarytoensurethatcomplicationsare
notdeveloping.
Resolutionofsmallbowelobstructionisgenerallyaccompaniedbyadecreaseinabdominaldistension,thepassageof
flatusand/orstoolperrectum,andadecreaseinthevolumeofnasogastrictubeoutput.Thevolumeofoutputfromthe
nasogastrictubeshouldbecarefullydocumentedtohelpwithclinicaljudgmentsregardingtheprogressionorresolution
oftheobstruction,andtherequirementforintravenousfluidtherapy.Nasogastriclossescanbereplacedwithnormal
salinepluspotassiumchloride(30to40mEq/L).Incaseswheretheobstructionisclearlyresolved,thenasogastric
tubecanberemoved,anddietinitiatedandadvancedastolerated.(See"Maintenanceandreplacementfluidtherapyin
adults".)
Forpatientsinwhomurineoutputcannotbeadequatelyassessed,aFoleycathetercanbeplaced,andfluidtherapy
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administereduntilthepatientmakesurineorisclinicallyeuvolemic.Somepatientsmayrequiremoreintensive
hemodynamicmonitoring.(See"Pulmonaryarterycatheterization:Indications,contraindications,andcomplicationsin
adults".)
LaboratorystudiesLaboratorytestsshouldberepeatedonlyasindicatedbyclinicalparameters.Initial
laboratoryderangementsstudiessuchassodium,creatinine,andhematocritarenotpredictiveoftheneedfor
operativeintervention[57].Inpatientswithsevereelectrolytedisturbance,particularlythosewithrenaldysfunction,
bloodchemistriesshouldberepeatedtoensurethatreplacementtherapyiseffective.Repeatassayofwhitebloodcell
countsmaybehelpfulifthereisconcernforbowelischemiaand/orstrangulation.
Serumprocalcitonin(PCT),whichisamarkerofinflammation,isapromisingprognosticbiomarkerforpredictingfailure
ofnonoperativemanagementofsmallbowelobstruction[2,60,61].IntheAcuteBowelObstructionDiagnostic(ABOD)
study,PCTlevelsweresignificantlyhigherinthesurgerygroupcomparedwiththeconservativelymanagedgroup
(0.53versus0.14ng/mL),andsignificantlyhigherinthosemanagedsurgicallywhohadischemiacomparedwiththose
whodidnot(1.16versus0.21ng/mL).APCTthreshold0.57ng/mLhadan83percentpositivepredictivevalueand
91percentnegativepredictivevalueforpredictingischemicbowelatoperationaPCTthreshold>0.17ng/mLhadan
85percentnegativepredictivevalueforfailureofnonoperativemanagement,butthepositivepredictivevaluewasonly
39percent.Inthisstudy,lactateandwhitebloodcountwerenotpredictiveofischemia[60].Patientswithearly
postoperativeobstruction,andobstructionassociatedwithneoplasiaorinflammatoryboweldisease,andcolon
obstructionwereexcludedfromthestudy.
FollowupimagingWedonotrecommendroutineserialimagingstudies.Ifthepatientdoesnotimprove,we
suggestabdominalCTforfollowupimaging,giventheinsensitivityofplainabdominalimagingforallbutthelatest
stagesofobstruction(eg,perforation).IntheAcuteBowelObstructionDiagnostic(ABOD)study,thepresenceofa
whirlsignonCTscanningwaspredictiveoffailureofconservativemanagement(oddsratio3.81,95%CI1.2311.83)
[60].Forpatientswhoseclinicalconditiondeteriorates,thepotentialinformationthatmightbegainedonrepeatimaging
needstobeweighedagainstanydelayitmightcausesurgicalexplorationmaybethemoreappropriatecourseof
action[33].(See"Epidemiology,clinicalfeatures,anddiagnosisofmechanicalsmallbowelobstructioninadults",
sectionon'AbdominalCT'.)
Abdominalplainfilms,however,maybeusefulforassessingwhetherornotthepatienthasclearlyresolvedtheir
obstructionbydemonstratingthatgashaspassedfromthesmallbowelintothecolon.Inpatientsgivenwatersoluble
contrastasatherapeutictrial,followupplainradiographsalsodeterminetheprogressofthecontrast.(See'Water
solublecontrast'below.)
RoleofantibioticsForuncomplicatedsmallbowelobstruction,antibioticsshouldnotbeadministered.Although
administeringbroadspectrumantibioticsispracticedbecauseofconcernsforbacterialtranslocation,dataare
inadequatetosupportorrefutesuchapractice[62].
Inthesettingofcolonicdiverticulardiseasecausingobstruction,antibiotictherapyiswarranted.(See"Acutecolonic
diverticulitis:Medicalmanagement",sectionon'Oralantibiotics'.)
Antibioticsarealsowarrantedforpatientswithcomplications(eg,perforation)andantibioticprophylaxisshouldbe
administeredtothosewhowillundergooperativeexploration(table1)[6365].(See"Overviewofgastrointestinaltract
perforation",sectionon'Antibiotics'.)
WatersolublecontrastForpatientswithpartialsmallbowelobstruction,watersolublegastrointestinalcontrast
agents(eg,Gastrografin)maybetherapeutic[2,6672].Gastrografindrawsfluidintothelumenofthebowelduetoits
hypertonicity,decreasingintestinalwalledemaandstimulatingintestinalperistalsis.Gastrografinhasbeenfoundin
severalstudiestoimprovebowelfunctionanddecreaselengthofhospitalstay[6668,73,74].
ThevolumeofGastrografinadministeredgenerallyrangesfrom7.5mLover30minutesto22.5mLoveracourseof
twohoursandcanberepeatedifinitiallyineffective,toatotaldoseof100mL.HigherdosesofGastrografinhavenot
beenstudied[73].
Inametaanalysisof14studiesevaluatingtheeffectsofwatersolublecontrastagents(diagnosticandtherapeutic
administration),theappearanceofcontrastinthecolon4to24hoursafteradministrationpredictedresolutionofthe
adhesivesmallbowelobstructionwithasensitivityandspecificityof96and98percent[75].Ineighttrials,therewasa
significantreductionintheneedforanoperativeinterventioninpatientsrandomlyassignedtoreceivewatersoluble
contrastasacomponentofconservativemanagement(bowelrest,nasogastricdecompression,intravenousfluid
therapy)comparedwiththosewhodidnotreceivewatersolublecontrast(21versus30percent).Thosewhoreceived
watersolublecontrastfortherapeuticreasonsalsohadasignificantlyshorterhospitalstaybyalmosttwodays.
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Abdominalradiographsshouldbeperformednolaterthan24hoursafteradministrationoftheGastrografin.Ingeneral,
failureofthecontrasttoreachthecolon24hourslatershouldinfluence,butnotdictate,thedecisiontooperate.The
timeallowedfornonoperativeresolutionfollowinginstillationofGastrografinisamatterofclinicaljudgmentinthese
patients.Ifthereisconcernthatthepatienthasincreasingpain,distension,andpersistenthighnasogastricoutput,
surgicalexplorationshouldbeconsidered.
FailureofnonoperativemanagementThedecisiontoproceedwithsurgicalexplorationorcontinuenonoperative
managementisbasedprimarilyontheclinicalstatusofthepatient.Failuretoregainbowelfunctionafterfivedays
suggeststheneedforanoperation.Alargestudyreportedthatdelayinoperationinterventiongreaterthanfivedays
wasassociatedwithhighermortalityandlongerhospitalstay[59].
Forpatientswhodonotresolvetheirsmallbowelobstructionwithin48hoursofadmission,datasupportperforming
contraststudiespriortooperativeinterventiontodifferentiatepartialsmallbowelobstruction,whichmightstillresolve,
fromcompleteobstruction,thoughthismaynotbenecessaryinpatientswithmalignancy[69,76].(See'Patientswith
malignancy'below.)
PATIENTSWITHMALIGNANCYPrimaryorsecondarytumorinvolvementcanleadtosmallbowelobstructiondue
tointrinsicorextrinsiccompressioninaddition,bowelobstructionmaybeduetoadhesions,orpostradiationfibrosis.
Tumorscanalsoimpairbowelmotilitybyinfiltratingthemesentery,nerves(eg,celiacplexus),orbowelwall.Some
cancers(eg,colonic,ovarian,pancreaticandgastric)haveaparticularpropensityforperitonealdissemination[77].
Mostpatientswithsmallbowelobstructioninthesettingofanadvancedintraabdominalorpelvictumorareinoperable,
andpatientsurvivalisgenerallyshort.However,aboutonethirdofsmallbowelobstructionsinpatientswithknown
tumorrecurrencearerelatedtobenignadhesionsandnotdirectlyrelatedtotumor[12,78].Computedtomography(CT)
orPositronEmissionTomography(PET)scansmayclarifyoveralldiseaseburdentohelpintheassessmentoflong
termprognosis,buttheyaregenerallynothelpful(particularlyPET)indistinguishingbetweenmalignantsmallbowel
obstructionversusadhesions.(See"Epidemiology,clinicalfeatures,anddiagnosisofmechanicalsmallbowel
obstructioninadults",sectionon'Tumor'.)
GeneralprinciplesThereisnoconsensusregardingtheoptimaltreatmentstrategyformanagementofmalignant
bowelobstructionandnostrongevidenceaddressingtherelativevalueofpalliativesurgeryversusmedical
management,orforsupportingtheefficacyofanyspecifictreatmentforimprovingqualityoflifeorprolongingsurvival.
Adecisiontoproceedtosurgicalinterventionrequirescarefulweighingofrisksandbenefits,includinganassessment
oftheestimatedlifeexpectancyandgoalsofcare(algorithm1).
Forthosewithoutindicationsforimmediatesurgery(eg,perforation,bowelinfarction),atrialofnonoperativetherapy
maybewarranted[13].(See'Trialofnonoperativemanagement'above.)
Forthosewhofailinitialnonoperativemanagement,andifsurgicaltreatmentisconsistentwiththegoalsofcare,
surgeryshouldbepursuedinthosewithoutclearevidenceofmultifocaldiseaseinvolvementandwhoarepresenting
withalongintervalfromdiagnosisofmalignancytodevelopmentofobstruction[11].Thesepatientsaremorelikelyto
haveadhesionsratherthanrecurrentcancer.Obstructionsduetorecurrentcancertendtooccurearlieraftersurgery
thanobstructionrelatedtoadhesions(21versus61months)[11].Forpatientswithpartialobstructionandeither
documentedrecurrentmalignancyorshortintervaltodevelopmentofobstructionaftersurgeryformalignancy,aswell
asthosewhoareintheterminalphasesoftheirmalignancy,prolongedmedicalmanagement(fluids,controlofnausea,
gastrointestinaldecompression),maybeofferedasanalternativetosurgery[13].(See'Medicaltherapies'below.)
PalliativesurgeryPalliativesurgerymaybenefitsomepatientshowever,itisassociatedwithhighratesof
mortalityandhospitalizationduringthepatientsremainingsurvivaltime.Inasystematicreviewthatincluded17
observationalstudies,surgerypalliatedobstructivesymptomsin32to100percentofpatients,enabledresumptionofa
dietin45to75percentofpatients,andalloweddischargetohomein34to87percentofpatients.Mortalityranged
from6to32percentandseriouscomplicationsoccurredinupto44percentofpatients.Reobstruction,reoperation,
andrehospitalizationwerecommon.Mediansurvivalinthesestudiesrangedfrom26to273days,andhospitalization
relatedtosurgeryconsumed11to61percentofthepatientsremaininglife.Factorsthathavebeenassociatedwitha
poorsurgicaloutcomeinotherstudiesincludeperitonealcarcinomatosis,multifocalobstruction[79],alargeamountof
ascites,hypoalbuminemia,andleukocytosis[80].
Ifconsistentwiththegoalsofcare,bowelresection(iffeasible)orbowelbypass(enteroenterostomy,enterocolostomy,
colocolostomy)canbeusedtobypassmassesofmattedintestines.(See"Surgeryforrecurrentepithelialovarian
cancer"and"LocoregionalmethodsformanagementandpalliationinpatientswhopresentwithstageIVcolorectal
cancer",sectionon'Methodsforsurgicalpalliation'and"Surgicalresectionofprimarycoloncancer",sectionon
'Palliationofadvanceddisease'.)
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Ifbowelresectionorbypassisnotanoption,colostomy,ileostomy,andpossiblyjejunostomycanbeuseddepending
uponthelevelofobstruction.Jejunostomycanleadtofluidandelectrolyteproblems.
Gastroenterostomymayrelievesymptomsinpatientswithmalignantgastricoutletobstructionhowever,duodenal
stentingispreferredinmostcases.(See"Localpalliationforadvancedgastriccancer",sectionon'Gastrojejunostomy'
and'Stenting'below.)
AlternativestosurgeryInterventionsthatmaybeusefulforrelievingabdominalsymptomsinpatientswith
malignantbowelobstructionwhorefuseorarenotcandidatesforsurgicalinterventionincludestentingandmedical
therapies(opioids,glucocorticoids,octreotide)[10,81].
StentingDuodenalstentingisanalternativetogastroenterostomyforpatientswithobstructingproximalsmall
boweltumorswhoarenotcandidatesforsurgery.(See"Enteralstentsforthepalliationofmalignantgastroduodenal
obstruction".)
MedicaltherapiesForpatientswithinoperablebowelobstructionandforthosewhoarenotcandidatesfor
palliativesurgery,initialmedicalmanagementisfocusedonprovidingadequatehydration,controllingnauseaand
vomiting,paincontrol,andlesseningabdominaldistention.(See'Initialmanagement'above.)
Initialgastrointestinaldecompressionusinganasogastrictuberemovessecretionsandcanreducenauseaand
vomiting,butshouldonlybeusedasatemporarymeasure(fivetosevendays).Forprolongedgastrointestinal
decompression,agastrostomytube(open,intervention,endoscopicassisted)canbeplacedhowever,gastrostomy
tubesmayprovideincompletereliefofsymptoms,maybeassociatedwithcomplications,andtheongoingpresenceof
thesetubescanbeuncomfortableanddistressingforthepatientandhisorherfamily.(See"Gastrostomytubes:
Placementandroutinecare"and"Gastrostomytubes:Uses,patientselection,andefficacyinadults",sectionon
'Patientswithcancer'.)
Ingeneral,nutritionalsupportisnotindicatedforpatientswithadvancedcancerwhoareterminallyill,withfew
exceptions.(See"Theroleofparenteralandenteral/oralnutritionalsupportinpatientswithcancer".)
Medicaltherapiesforcontrolofpain,abdominaldistention,andvomiting,andpharmacologicagentsthatmayreduce
symptomsbylesseningperitumoraledema(glucocorticoids)and/ordiminishingintraluminalsecretionsandperistaltic
movements(anticholinergicagentsandoctreotide)maybeusefulinthemanagementofmalignantbowelobstruction,
andarediscussedelsewhere.(See"Overviewofmanagingcommonnonpainsymptomsinpalliativecare"and
"Palliativecare:Assessmentandmanagementofnauseaandvomiting",sectionon'Management'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingonpatientinfo
andthekeyword(s)ofinterest.)
Basicstopic(see"Patientinformation:Smallbowelobstruction(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Smallbowelobstructionoccurswhenthenormalflowofintestinalcontentsisinterrupted.(See'Introduction'
above.)
Themostfrequentcausesofsmallbowelobstructionarepostoperativeadhesions,malignancies,andhernias.
Lessfrequently,stricturesofthesmallbowelcancauseintrinsicblockage.(See"Epidemiology,clinicalfeatures,
anddiagnosisofmechanicalsmallbowelobstructioninadults".)
Theinitialmanagementofpatientswithbowelobstructionincludesvolumeresuscitation,correctionofmetabolic
abnormalities,andanassessmentoftheneedforsurgicalexploration.(See'Initialmanagement'above.)
Patientswithclinicalorradiologicsignsofcomplicatedbowelobstruction(ischemia,necrosis,perforation)require
promptsurgicalexploration.(See'Indicationsforsurgicalexploration'above.)
Nonoperativemanagementwithnasogastricsuctionandintravenousfluidscanbesuccessfulinpatientswith
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partialsmallbowelobstruction.Thisapproachrequiresfrequentreassessmentsofthepatienttoensurethatthere
arenodevelopingcomplications.(See'Trialofnonoperativemanagement'above.)
Wesuggestaperiodofobservationpriortosurgeryforpatientswithpartialsmallbowelobstruction,providedthat
complicationshavebeenruledouttotheextentpossible(Grade2C).(See'Trialofnonoperativemanagement'
above.)
Wesuggestgivingahypertonicwatersolublecontrastagent(eg,Gastrografin)aspartofnonoperativetreatment
ofpartialsmallbowelobstruction(Grade2B).Patientswhoreceivegastrografinhavemorerapidresolutionof
symptoms,ashorterlengthofhospitalstay,andpossiblylessneedforsurgicalintervention.(See'Watersoluble
contrast'above.)
Forpatientswithmalignantsmallbowelobstruction,anydecisiontopursuesurgicalinterventionshouldtakeinto
accountthetimingoftheobstructionrelativetotheinitialcancerdiagnosis,thediseaseburden,andgoalsof
care.(See'Patientswithmalignancy'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Oncol20142:13.
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obstruction.Surgery2012152:747.
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willbenefitfromsurgicalintervention.EurJSurgOncol201440:899.
Topic89300Version7.0

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GRAPHICS
Antimicrobialprophylaxisforgastrointestinalsurgeryinadults
Natureof
operation

Common
pathogens

Recommended
antimicrobials

Usualadult
dose*

Redose
interval

Gastroduodenalsurgery
Procedures
involvingentry

Entericgram
negativebacilli,

intolumenof

grampositive

gastrointestinal
tract

cocci

Proceduresnot

Entericgram

involvingentry
intolumenof

negativebacilli,
grampositive

gastrointestinal

cocci

Cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV

Highrisk only:
cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV

tract(selective
vagotomy,
antireflux)
Biliarytractsurgery(includingpancreaticprocedures)
Open

Entericgram

procedureor

negativebacilli,

laparoscopic
procedure

enterococci,
clostridia

(highrisk)

Cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV
ORcefotetan

2gIV

Sixhours

ORcefoxitin

2gIV

Twohours

ORampicillin

3gIV

Twohours

sulbactam
Laparoscopic
procedure(low

N/A

None

None

None

Entericgram

Cefoxitin

2gIV

Twohours

negativebacilli,
anaerobes,

ORcefotetan

2gIV

Sixhours

ORcefazolin

<120kg:2gIV

Fourhours

risk)
Appendectomy

enterococci

120kg:3gIV
PLUSmetronidazole

500mgIV

N/A

Cefazolin

<120kg:2gIV

Fourhours

Smallintestinesurgery
Nonobstructed

Entericgram
negativebacilli,
grampositive

120kg:3gIV

cocci
Obstructed

Entericgram
negativebacilli,
anaerobes,
enterococci

Cefoxitin

2gIV

Twohours

ORcefotetan

2gIV

Sixhours

ORcefazolin

<120kg:2gIV

Fourhours

120kg:3gIV
PLUSmetronidazole

500mgIV

N/A

Herniarepair

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Aerobicgram
positive

Cefazolin

<120kg:2gIV

Fourhours

120kg:3gIV

organisms
Colorectalsurgery

Entericgram
negativebacilli,
anaerobes,
enterococci

Parenteral:
Cefoxitin

2gIV

Twohours

ORcefotetan

2gIV

Sixhours

ORcefazolin

<120kg:2gIV

Fourhours

120kg:3gIV
PLUS
metronidazole

500mgIV

N/A

ORampicillin

3gIV(basedon

Twohours

sulbactam ,**

combination)

Oral(usedinconjunctionwithmechanicalbowel
preparation):
NeomycinPLUS

erythromycin
baseor
metronidazole
IV:intravenous.
*ParenteralprophylacticantimicrobialscanbegivenasasingleIVdosebegunwithin60minutesbeforethe
procedure.Ifvancomycinorafluoroquinoloneisused,theinfusionshouldbestartedwithin60to120
minutesbeforetheinitialincisiontohaveadequatetissuelevelsatthetimeofincisionandtominimizethe
possibilityofaninfusionreactionclosetothetimeofinductionofanesthesia.
Forprolongedprocedures(>3hours)orthosewithmajorbloodlossorinpatientswithextensiveburns,
additionalintraoperativedosesshouldbegivenatintervalsonetotwotimesthehalflifeofthedrug.
Forpatientsallergictopenicillinsandcephalosporins,clindamycin(900mg)orvancomycin(15mg/kgIV
nottoexceed2g)witheithergentamicin(5mg/kgIV),ciprofloxacin(400mgIV),levofloxacin(500mgIV),
oraztreonam(2gIV)isareasonablealternative.Metronidazole(500mgIV)plusanaminoglycosideor
fluoroquinolonearealsoacceptablealternativeregimens,althoughmetronidazoleplusaztreonamshouldnot
beusedsincethisregimendoesnothaveaerobicgrampositiveactivity.
Morbidobesity,gastrointestinal(GI)obstruction,decreasedgastricacidityorGImotility,gastricbleeding,
malignancyorperforation,orimmunosuppression.
Factorsthatindicatehighriskmayinclude:Age>70years,pregnancy,acutecholecystitis,nonfunctioning
gallbladder,obstructivejaundice,commonbileductstones,immunosuppression.
Cefotetan,cefoxitin,andampicillinsulbactamarereasonablealternatives.
Forarupturedviscus,therapyisoftencontinuedforapproximatelyfivedays.
Useofertapenemorothercarbapenemsnotrecommendedduetoconcernsofresistance.
**DuetoincreasingresistanceofEscherichiacolitofluoroquinolonesandampicillinsulbactam,local
sensitivityprofilesshouldbereviewedpriortouse.
Inadditiontomechanicalbowelpreparation,thefollowingoralantibioticregimenisadministered.1gof
neomycinplus1goferythromycinbaseat1PM,2PM,and11PM,or2gofneomycinplus2gof
metronidazoleat7PMand11PMthedaybeforean8AMoperation.Issuesrelatedtomechanicalbowel
preparationarediscussedfurtherseparately.RefertoUpToDatetopiconoverviewofcolonresection.
Datafrom:
1.Antimicrobialprophylaxisforsurgery.TreatGuidelMedLett201210:73.
2.BratzlerDW,DellingerEP,OlsenKM,etal.Clinicalpracticeguidelinesforantimicrobialprophylaxisin
surgery.SurgInfec(Larchmt)201314:73.
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Analgorithmicapproachtoclinicalmanagementofmalignantbowel
obstructioninpalliativecarepatients

SBO:smallbowelobstructionLBO:largebowelobstruction.
*Ifevidenceofperforationorischemiaispresentonplainradiography,crosssectionalimagingmaynotbe
necessary.
Symptomaticcaremayincludeoneormoreofthefollowing:glucocorticoids,antiemetics(typicallyhaloperidol,
notmetoclopramideorconstipating5HT3receptorantagonists),octreotide,anticholinergics,analgesics,+/
gastrointestinaldecompression.
Stentingisnotanoptionwhenperforationorischemiaispresent.
Dependinguponthelocationandsuspectedetiologyoftheobstruction,immediatesurgeryorstentingshouldbe
considered.Someetiologies,suchasclosedloopSBO,andmostLBOleadingtocompleteobstructionarenotlikely
toresolvewithconservativemanagement.
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GastrograffinmaybemoreusefulforpartialSBOrelatedtoadhesions.Colorectalobstructionislesslikelyto
respond.
Conservativecarecancontinue,aslongasthereisnoclinicaldeterioration.Thedurationofconservative
managementisgenerallyshorterforcompleteversuspartialobstruction,butishighlyvariable.
Sitesamenabletostentingincludelargebowel,distalileum,proximaljejunum.
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ContributorDisclosures
LilianaBordeianou,MD,MPHNothingtodisclose.DanielDanteYeh,MDGrant/Research/ClinicalTrialSupport:
Nestle[NutritionintheICU(PeptamenBariatric)]KCI[Woundcare(PrevenaVAC)]Smith&Nephew[Woundcare
(OASIS)].Consultant/AdvisoryBoards:Covidien[Feedingtubes(Kangaroofeedingtube)].DavidISoybel,MD
Nothingtodisclose.WenliangChen,MD,PhDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy

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