Intestinal Obstruction: Evaluation and Management

 

Acute intestinal obstruction occurs when the forward flow of intestinal contents is interrupted or impaired by a mechanical cause. It is most commonly induced by intra-abdominal adhesions, malignancy, and herniation. The clinical presentation generally includes nausea, emesis, colicky abdominal pain, and cessation of passage of flatus and stool, although the severity of these clinical symptoms varies based on the acuity and anatomic level of obstruction. Abdominal distension, tympany to percussion, and high-pitched bowel sounds are classic findings. Laboratory evaluation should include a complete blood count, metabolic panel, and serum lactate level. Imaging with abdominal radiography or computed tomography can confirm the diagnosis and assist in decision making for therapeutic planning. Management of uncomplicated obstructions includes intravenous fluid resuscitation with correction of metabolic derangements, nasogastric decompression, and bowel rest. Patients with fever and leukocytosis should receive antibiotic coverage against gram-negative organisms and anaerobes. Evidence of vascular compromise or perforation, or failure to resolve with adequate nonoperative management is an indication for surgical intervention.

Acute intestinal obstruction occurs when the forward flow of intestinal contents is interrupted or impaired by a mechanical cause. Its incidence in patients who present to the emergency department is estimated at 2% to 8%.14 Although morbidity and mortality associated with acute intestinal obstruction have declined, clinical management remains challenging.5 The decision to pursue nonoperative management or surgical intervention must be carefully determined by experienced clinicians (Figure 1).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

A closed-loop obstruction should be treated as a surgical emergency.

C

5, 11, 12

A closed-loop obstruction may quickly lead to compromised arterial flow, ischemia, necrosis, and ultimately perforation.

Abdominal radiography is an appropriate initial examination in patients with suspected intestinal obstruction.

C

1517

Although CT has greater sensitivity and specificity, plain radiography may be considered as an initial diagnostic option, particularly in patients who are hemodynamically unstable or unable to undergo cross-sectional imaging, or who have equivocal clinical findings.

CT with intravenous or enteric contrast media is recommended in patients with suspected intestinal obstruction.

C

17, 19

CT can reliably determine the cause of obstruction and associated complications.

Admission to or consultation with a surgical service should occur upon diagnosis of intestinal obstruction.

B

11, 23, 24

Surgical involvement is associated with improved patient satisfaction, shorter time to operation when required, and shorter hospital stay.

Clinically stable patients should be treated with bowel rest, tube decompression, and intravenous fluid resuscitation.

B

3, 6, 25

Several clinical trials have shown that nonoperative management resolves most uncomplicated small bowel obstructions.

Surgical exploration is recommended for most patients in whom three to five days of nonoperative management is ineffective, or who clinically deteriorate at any point during hospitalization.

B

2732

Conservative management beyond 48 hours does not diminish the need for surgery, but increases surgical morbidity.


CT = computed tomography.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

A closed-loop obstruction should be treated as a surgical emergency.

C

5, 11, 12

A closed-loop obstruction may quickly lead to compromised arterial flow, ischemia, necrosis, and ultimately perforation.

Abdominal radiography is an appropriate initial examination in patients with suspected intestinal obstruction.

C

1517

Although CT has greater sensitivity and specificity, plain radiography may be considered as an initial diagnostic option, particularly in patients who are hemodynamically unstable or unable to undergo cross-sectional imaging, or who have equivocal clinical findings.

CT with intravenous or enteric contrast media is recommended in patients with suspected intestinal obstruction.

C

17, 19

CT can reliably determine the cause of obstruction and associated complications.

Admission to or consultation with a surgical service should occur upon diagnosis of intestinal obstruction.

B

11, 23, 24

Surgical involvement is associated with improved patient satisfaction, shorter time to operation when required, and shorter hospital stay.

Clinically stable

The Authors

show all author info

PATRICK JACKSON, MD, is chief of general surgery at Med-star Georgetown University Hospital, Washington, D.C....

MARIANA VIGIOLA CRUZ, MD, is a fifth-year surgical resident at Medstar Georgetown University Hospital.

Address correspondence to Patrick Jackson, MD, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Washington, DC 20007 (e-mail: pgj5@gunet.georgetown.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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