Small Bowel Obstruction Initial Triage and Management Guideline

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Small Bowel Obstruction Initial Triage and Management Guideline

EVALUATION:

Patients with symptoms consistent with possible small bowel obstruction should have the following:

• Complete physical examination including a digital rectal exam and gynecologic exam if appropriate
• Acute abdominal series
• CBC, comprehensive panel, lactate, and urinalysis

CT scan is not required for all patients, but if the history, physical examination, and initial imaging are supportive of a possible bowel obstruction and there is no absolute indication for an emergent surgical consultation (free air, peritonitis, non-reducible symptomatic hernia, abdominal surgery in the last 30 days), then an abdominal CT with IV and PO contrast should be performed unless there is a contraindication to the study. The study can be done without IV contrast for those with contrast allergy or high creatinine. Relative contraindications to CT imaging may include multiple recent studies or recent surgery and reimaging should then be left to the discretion of the care providers.

INITIAL TREATMENT

Initial therapy for all patients diagnosed with complete or high-grade partial bowel obstructions should be:

• Placement of a 18F nasogastric tube on continuous suction
• IV fluid with NPO status
• Careful monitoring of urine output
• Serial abdominal examinations
• Early general surgery consultation to determine need for operative management

Initial therapy for partial small bowel obstructions patients should include:

• Placement of a nasogastric tube on continuous suction if ongoing vomiting
• IV fluid with NPO status
• Careful monitoring of urine output
• Serial abdominal examinations
• General surgery consultation if no improvement in 48 hours or with change or worsening of the patient’s condition or abdominal examination.

ADMISSION

If a transition point is identified on CT or the patient is deemed an emergent operative candidate or the patient has had an abdominal surgery within the last 30 days, the patient will be admitted to a surgical service. Exceptions which may warrant a medical service admission could be:

• Patients with intra-abdominal metastases.
• Patients with active inflammatory bowel disease who are to have a trial of systemic therapy
• Acute, severe medical conditions requiring stabilization (ie-acute MI, severe COPD exacerbation…).

 

Patients with known dilated bowel secondary to dysmotility problems or other medical conditions can be admitted to medicine. Examples of this include:

• Chronic narcotic-induced obstipation
• Dysmotility or constipation from chronic psychotropic use or mental/developmental disorders
• Cystic fibrosis patients
• Collagen vascular diseases with bowel involvement