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Small Bowel Obstruction: the Sun Also Rises?

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Small bowel obstruction (SBO) remains a common reason for emergency/unplanned admissions, and remains a significant burden to SBO patients and the healthcare system alike. The management of SBO has undergone a significant paradigm shift over the years, shifting far from the tenet to “never let the sun rise on a bowel obstruction.” Not only has the timing to surgery changed, but there is also an increased utilization of diagnostic tools to aid clinical decision-making. Furthermore, the surgical management is beginning to favor a less invasive approach. This review will serve to provide an up-to-date review of the evaluation and management of SBO, based on the most recent available evidence and our experience with the methods described.

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Author information

Authors and Affiliations

  1. Department of Surgery, Stanford University, School of Medicine, 300 Pasteur Drive, H-3641, Stanford, CA, 94305, USA

    Kirellos Zamary & David A. Spain

Authors
  1. Kirellos Zamary
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  2. David A. Spain
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Contributions

KZ made substantial contributions to the conception or design of the work. KZ reviewed the background literature and drafted and revised the work and revised it critically. KZ gave his approval of the version to be published. KZ is in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

DS made substantial contributions to the conception or design of the work. DS reviewed the background literature and drafted and revised the work and revised it critically. DS gave his final approval of the version to be published. DS is in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Kirellos Zamary.

Additional information

Disclosure Information

Authors: Kirellos Zamary, MD has nothing to disclose; David A. Spain, MD, FACS has nothing to disclose. Editors-in-Chief: Richard A. Hodin, M.D., Timothy M. Pawlik, M.D., MPH, PhD has nothing to disclose. CME overseers: Arbiter: Timothy M. Pawlik, M.D., MPH, PhD has nothing to disclose; Vice-Arbiter: Melanie Morris, M.D., has nothing to disclose.

Question reviewers: Wasim Dar, MD has nothing to disclose; Sean Dineen, MD has nothing to disclose.

CME questions for this article available to SSAT members at http://ssat.com/jogscme/

Questions

1. A 58 year-old female with a history of gastric bypass presents to the emergency department with abdominal pain, nausea, vomiting, abdominal tenderness, a leukocytosis of 15. No hernias are found on exam. CT scan shows a bowel obstruction with 2 transition points and proximally dilated bowel. What is the next step in management?

a. IVF, NPO, NGT with admission and serial abdominal exams

b. NGT placement with water-soluble contrast challenge

c. Diagnostic laparoscopy

d. Exploratory laparotomy

2. What is the most likely cause of the SBO in the patient from question #1?

. Neoplasm

a. Stricture

b. Internal hernia

c. Inguinal hernia

3. A 35 year-old male with a history of appendectomy 10 years ago presents to the emergency department with abdominal pain, nausea, vomiting and constipation. CT scan demonstrates a transition point in the right lower quadrant. This is his fourth bowel obstruction in the last 5 years, all of which have been managed non-operatively, and his prior CTs demonstrated a transition point in the same location. On exam, he is comfortable and mildly distended, but expresses his frustration with his recurrent obstructions. What is the most effective management for this patient?

. NGT, NPO, IVF and serial abdominal exams

a. Discharge home with return precautions

b. Diagnostic laparoscopy with adhesiolysis

c. Exploratory laparotomy with adhesiolysis

4. The following form of management decreases hospital length of stay in the management of patients with an adhesive SBO that does not have signs of strangulation:

. Laparotomy and lysis of adhesions upon presentation

a. Laparoscopy with lysis of adhesions

b. Implementation of a protocol that involves early water-soluble contrast challenge

c. Using a long intestinal tube (e.g. Cantor or Baker tube) for intestinal decompression

5. Which of the following can decrease both the hospital length of stay and the rate of postoperative complications?

. Non-operative management for at least 5-7 days prior to considering surgery in a patient without signs of bowel compromise

a. The use of laparoscopic adhesiolysis as opposed to open surgery, when feasible, in a patient who has failed non-operative management

b. Early laparotomy (not letting the sun set on a small bowel obstruction)

c. Early removal of the NGT

6. Which is NOT an impediment to the laparoscopic approach in surgical management of SBO?

. Distended bowel causing decreased laparoscopic visibility

a. Risk of enterotomy

b. Risk of missed enterotomy

c. Longer length of stay

7. Which of these is NOT a potential benefit of the laparoscopic approach in the surgical management of SBO?

. Decreased length of stay

a. Decreased hospital charges/costs

b. Reduced odds of major complications and mortality

c. Lower enterotomy rate

8. According the recent practice guidelines, in patients without signs of peritonitis or bowel strangulation, how long should the trial of non-operative management be?

. No more than 2 days

a. No more than 3–5 days

b. No more than 7 days

c. No more than 12 days

9. How long does one wait for passage of contrast into the colon after contrast administration for a water-soluble contrast challenge before deciding that the patient has failed the challenge?

. Up to 8 hours

a. Up to 12 hours

b. Up to 24 hours

c. Up to 48 hours

Graphs/Charts

• Table of the causes of SBO

• Flow diagram of the decision algorithm

• CT showing transition point with proximal dilation and distal decompression

• XR demonstrating successful and failed water-soluble contrast challenge

• Implementation chart for the water-soluble contrast challenge

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Zamary, K., Spain, D.A. Small Bowel Obstruction: the Sun Also Rises?. J Gastrointest Surg 24, 1922–1928 (2020). https://doi.org/10.1007/s11605-019-04351-5

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