Official reprint from UpToDate

www.uptodate.com 2017 UpToDate

Overview of management of mechanical small bowel obstruction in adults

Authors: Liliana Bordeianou, MD, MPH, Daniel Dante Yeh, MD

Section Editor: Lillian S Kao, MD, MS
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2017. | This topic last updated: May 08, 2017.

INTRODUCTION Small bowel obstruction (SBO) occurs when the normal flow of intestinal contents is
interrupted. The management of bowel obstruction depends upon the etiology, severity, and location of the
obstruction. The goals of initial management are to relieve discomfort and restore normal fluid volume and
electrolytes in preparation for possible surgical intervention. Some patients may be candidates for a trial of
nonoperative management. High-quality data to guide management of SBO are sparse, and clinical practice
is highly variable; however, guidelines based upon the available evidence are available from the Eastern
Association for the Surgery of Trauma (EAST) [1,2], and from the World Society of Emergency Surgery
(Bologna guidelines). The latter focuses on the management of adhesion-related small bowel obstruction
[3,4].

This topic review will focus on the management of mechanical small bowel obstruction. The clinical features
and diagnosis of mechanical small bowel obstruction are discussed separately. (See "Epidemiology, clinical
features, and diagnosis of mechanical small bowel obstruction in adults".)

INITIAL MANAGEMENT Patients with clinical features of small bowel obstruction (SBO) who are
diagnosed with acute mechanical small bowel obstruction generally require admission to the hospital for
initial management that includes intravenous fluid therapy and electrolyte replacement in preparation for
surgery, if indicated, or as an element of nonoperative management. Patients with chronic and/or intermittent
mechanical small bowel obstruction, such as patients with small bowel strictures related to Crohn's disease,
radiation enteritis, or other etiologies that can cause partial bowel obstruction, may be managed expectantly
on an outpatient basis. Such patients should limit their oral intake to fluids, and as long as hydration and
normal electrolyte balance can be maintained, which may require outpatient fluid therapy, hospitalization may
be avoided. In a review of 129 patients, placement of a nasogastric tube to manage nausea and emesis
predicted the need for admission, which occurred in approximately one-half of patients who presented to the
emergency room with varying degrees and etiologies for small bowel obstruction [5].

Surgical consultation For patients with symptoms that are severe enough to require admission for
symptoms of abdominal pain, nausea, and vomiting, we suggest prompt surgical consultation to aid in
determining if immediate surgical intervention is needed. (See 'Indications for surgical exploration' below.)

If surgery is not immediately indicated, we suggest admission to a dedicated surgical service unless such a
service is not available or the patient is not a candidate for, or is unwilling to consider, an operation. (See
'Medical therapies' below.)

Patients with small bowel obstruction admitted to a surgical service have shorter length of stay, fewer hospital
charges, a shorter time to surgery, and lower mortality than patients admitted to medical service [1]. For
patients who are admitted to a medical service for the management of SBO, the use of clear-cut SBO
management protocols reportedly decreases time to surgical consultation, decreases time to operative
intervention, and shortens hospital length of stay [6].

Fluid therapy Patients with bowel obstruction can have severe volume depletion, metabolic acidosis or
alkalosis, and electrolyte abnormalities. This is particularly true for patients with copious emesis from
proximal small bowel obstruction, those with symptoms lasting several days prior to presentation, or
obstruction that causes large-volume intraluminal fluid sequestration. (See "Epidemiology, clinical features,
and diagnosis of mechanical small bowel obstruction in adults", section on 'Pathophysiology'.)

Upon admission, adequate intravenous (IV) access in the form of two large-bore peripheral lines should be
obtained for fluid resuscitation. Lactated ringers or normal saline may be appropriate for intravenous fluid
therapy. Aggressive potassium repletion may be needed, but it is important to be certain the patient does not
have acute kidney injury (acute renal failure) from severe dehydration, in which case potassium
supplementation should be given cautiously until renal function can be improved. (See "Maintenance and
replacement fluid therapy in adults" and "Overview of the management of acute kidney injury (acute renal
failure)".)

Although suspected strangulation warrants operative intervention as soon as possible, fluid resuscitation and
repletion of electrolytes prior to surgery helps minimize complications (eg, hypotension) related to some
anesthesia induction agents. (See "General anesthesia: Induction", section on 'Selection of induction
technique'.)

Diet In general, all patients with mechanical bowel obstruction should be made nil per os (NPO) to limit
bowel distension; however, a small subset of patients with partial bowel obstruction may tolerate a small
amount of liquids.

Gastrointestinal decompression The need for gastrointestinal decompression in the setting of small
bowel obstruction may vary from patient to patient and remains a matter of clinical judgment. For patients
with small bowel mechanical bowel obstruction that is associated with significant distension, nausea, and/or
vomiting, we recommend nasogastric tube decompression [1-3]. In patients with complete or high-grade
small bowel obstruction, decompression of the distended stomach improves patient comfort and also
minimizes the passage of swallowed air, which can worsen distension. The placement and management of
nasogastric tubes is discussed elsewhere. (See "Nasogastric and nasoenteric tubes".)

For patients with recurrent small bowel obstruction who have undergone multiple prior operations, and in
whom another operation is felt to be particularly risky, one can attempt long tube decompression as a
component of conservative management to avoid further surgery. However, there are few data to support this
practice over the use of standard nasogastric decompression, and as such, we do not advocate the routine
use of long tubes in patients with small bowel obstruction. Older trials comparing standard nasogastric tubes
and long tubes weighted with a mercury-filled balloon (eg, Miller-Abbott tube, Anderson tube, Dennis tube
[7,8]), found no significant difference in the percentage of patients ultimately requiring surgical intervention
[3,9]. However, a later randomized trial comparing 90 patients managed with an endoscopically-placed long
hydrophilic silicon tube with 96 patients managed with a nasogastric tube found a significantly decreased
time to relief of clinical symptoms in the group managed with the long tube compared with the nasogastric
tube (4.1 versus 8.5 days) [7]. Overall effectiveness (ie, no need for surgery) was nearly doubled in the long
tube group (90 versus 47 percent). The improved outcomes seen in this one study will need to be replicated
in future studies before routine implementation; concerns remain over the potential risks of long tubes, such
as knot formation.

Pain management In general, pain from mechanical bowel obstruction, which is crampy in nature, is often
not amenable to treatment with analgesics, particularly opioids. If the patient's pain is severe and unrelenting,
there may be a strangulating mechanism that would indicate the need for surgical intervention. However, pain
management with opioids and other pharmacologic agents is reasonable in palliative care patients. (See
'Medical therapies' below.)

INDICATIONS FOR SURGICAL EXPLORATION All patients suspected of having complicated bowel
obstruction (complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, or perforation) based
upon clinical and radiologic examination should be taken to the operating room for abdominal exploration
[1,2]. Although some surgeons may be reluctant to operate on patients with a history of prior surgery for
intraabdominal malignancy because they believe that obstruction due to metastatic cancer is not likely to be
relieved by surgery, this is not necessarily the case as many are due to adhesions. Nonoperative therapy for
malignant obstruction is associated with a high failure rate and high mortality, but on the other hand, palliative
surgery for those in whom the obstruction cannot be relieved is also associated with overall poor outcomes
[10-14]. (See 'Patients with malignancy' below.)

The incidence of complications with adhesive obstruction is overall low [15-25]. Among patients who present
with small bowel obstruction, incarcerated hernias cause the majority of complications [26].

The development of complicated obstruction during a trial of conservative, nonoperative management should
also prompt surgical exploration [2]. Approximately one-fourth of patients admitted with small bowel
obstruction will require surgery. (See 'Trial of nonoperative management' below.)

Clinical features of small bowel obstruction indicative of complicated obstruction are presented separately.
(See "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults", section
on 'Complete obstruction and closed-loop obstruction' and "Epidemiology, clinical features, and diagnosis of
mechanical small bowel obstruction in adults", section on 'Bowel ischemia and perforation'.)

It is difficult to accurately predict bowel ischemia based upon clinical parameters alone [25,27]. In one study,
experienced clinicians were wrong in their preoperative assessment more than half the time in patients
eventually found to have gangrenous bowel [25]. Clinical signs and symptoms that are associated with bowel
ischemia include the following, but each of these clinical signs is nonspecific and cannot be used in isolation
[28-31]: [32]

Fever
Leukocytosis
Tachycardia
Continuous or worsening abdominal pain
Metabolic acidosis
Peritonitis
Systemic inflammatory response syndrome (SIRS) (See "Sepsis syndromes in adults: Epidemiology,
definitions, clinical presentation, diagnosis, and prognosis".)

In addition to laboratory and clinical signs, the following radiologic signs will identify 70 to 96 percent of
patients who will benefit from immediate surgery [25,27,33-37]:

Free air on plain radiographs or abdominal computed tomography (CT) indicating bowel perforation.

Signs of intestinal ischemia. Although advanced ischemia is usually obvious (eg, pneumatosis
intestinalis, portal venous gas), it remains difficult to identify early and intermediate stages of bowel
ischemia. (See "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in
adults", section on 'Bowel ischemia and perforation'.)

Complete or closed loop obstruction (eg, U-shaped, distended, fluid-filled loops; triangular loop; beak
sign; two loops of collapsed bowel adjacent to the obstruction site) [28,38]. (See "Epidemiology, clinical
features, and diagnosis of mechanical small bowel obstruction in adults", section on 'Complete
obstruction and closed-loop obstruction'.)

Other CT scan findings predictive of the need for surgery include findings of an abnormal course of a
mesenteric vessel, a high-grade obstruction, a transition zone, and peritoneal fluid [39,40]. However,
these signs are also nonspecific. In one study that included 145 patients with high-grade obstruction on
CT, 46 percent were successfully managed nonoperatively [31].

In a multivariate analysis, six clinical and radiographic values correlated with the need for bowel resection
[41]. A scoring system was developed that assigned one point to each of these variables, which are listed
below. Among 233 consecutive patients with bowel obstruction, 11 patients with a total score 4 points
required bowel resection. A total score 3 points predicted the need for resection with a specificity of 90.8
percent. The variables include:

History of pain lasting greater than four days

Abdominal guarding on physical exam
Elevated CRP above 75 mg/L
Elevated WBC above 10
Presence of >500 mL of free intraabdominal fluid on CT
Reduced wall contrast enhancement on CT

Another group of investigators identified the presence of free fluid and high-grade obstruction on CT scan as
strong predictors for early surgery [42].

When operative intervention is required for small bowel obstruction, open abdominal surgery is most
commonly performed, although laparoscopic adhesiolysis has been shown to cause less morbidity than open
surgery. In a propensity score-matched study of patients who underwent adhesiolysis for small bowel
obstruction, the use of laparoscopy was associated with significantly lower rates of overall complications
(odds ratio [OR] 0.41, 95% CI 0.28-0.60), surgical site infections (OR 0.15, 95% CI 0.05-0.49) and
intraoperative transfusions (OR 0.22, 95% CI 0.05-0.90), as well as a shorter length of hospital stay (4 versus
10 days) [43]. A systematic review and pooled analysis of 11 nonrandomized studies also showed
laparoscopic adhesiolysis to be associated with lower rates of mortality (pooled OR 0.31, 95% CI 0.16-0.61),
morbidity (pooled OR 0.34, 95 % CI 0.27-0.78), and wound infection (pooled OR 0.29, 95% CI 0.12-0.70), as
well as a shorter length of hospital stay (weighed mean difference -7.11 days, 95% CI -8.47 to -5.75 days)
[44]. However, laparoscopic adhesiolysis is not always feasible, especially in patients who have had prior
abdominal surgery. The benefits of laparoscopic adhesiolysis also need to be validated by controlled,
prospective trials, as in observational studies, healthier patients may have been selected for laparoscopic
surgery.

TRIAL OF NONOPERATIVE MANAGEMENT Many patients without indications for immediate intervention
can safely undergo initial nonoperative management, but clinical evaluation must first exclude complicated
obstruction (eg, strangulation, necrosis) indicating the need for immediate surgery. Considerations for
patients with abdominal malignancies (resected, unresected, metastatic) are discussed below. (See 'Patients
with malignancy' below and 'Indications for surgical exploration' above.)

Conservative nonoperative management resolves symptoms in many patients with partial small bowel
obstruction, but success rates depend upon the etiology [3,45,46]. In the setting of adhesive small bowel
obstruction, nonoperative management is overall successful in 65 to 80 percent of patients [47-50]. Although
the incidence of bowel ischemia during nonoperative management of partial small bowel obstruction is low at
3 to 6 percent [28], the patient still needs to be carefully monitored with serial abdominal examination and
laboratory studies; some will benefit from follow-up imaging.

The management of patients with complete small bowel obstruction due to adhesions is controversial. Some
have demonstrated that nonoperative management is still successful in 41 to 73 percent of patients [47,51];
however, complete adhesive small bowel obstruction is associated with a higher requirement for small-bowel
resection (31 percent) in some series [52]. Nonoperative management of partial and complete adhesive small
bowel obstruction is associated with higher recurrence rates and lower disease-free intervals compared with
operative management [51,53].

A trial of nonoperative management is warranted in patients with the following etiologies for their bowel
obstruction, who do not otherwise have indications for surgical exploration:

Early postoperative bowel obstruction Adhesions associated with early postoperative bowel obstruction
rarely lead to strangulation.
 Inflammatory bowel disease Patients who do not have fulminant disease causing complete bowel
obstruction may respond to medical therapy. However, refractory strictures due to repeated episodes of
inflammation will usually require resection and/or strictureplasty to relieve obstruction. (See "Overview of
the medical management of mild to moderate Crohn disease in adults" and "Management of mild to
moderate ulcerative colitis in adults".)

Gallstone ileus Patients with a gallstone impacted in the duodenum (Bouveret syndrome) may benefit
from a period of nonoperative management that will allow the stone to pass into the small bowel, where
surgical retrieval is less likely to cause complications. Endoscopic fragmentation of stone can also be
attempted in this location, with the goal of sparing the patient a duodenotomy should they need ultimate
surgery [54]. (See "Gallstone ileus".)

Infectious small bowel disease Patients who present with a partial small bowel obstruction due to
tuberculosis may improve with medical management, although, similar to Crohn's disease, delayed
diagnosis is more likely to require surgery [55]. (See "Tuberculous enteritis", section on 'Management'.)

Colonic diverticular disease causing small bowel obstruction Antibiotic therapy reduces peridiverticular
inflammation and may relieve obstructive symptoms. (See "Acute colonic diverticulitis: Medical
management".)

Duration of observation In the past, it has been recommended that patients with small bowel obstruction
(without indications for immediate surgical exploration) should be observed for no longer than 12 to 24 hours,
after which time, if no improvement is seen, the patient should be explored. However, as long as there remain
no findings on serial clinical evaluation to suggest a complicated obstruction, the patient may be observed for
a longer period of time. With nonoperative management, appropriately-selected patients usually improve
within two to five days [28,50]. However, it should be noted that for patients who ultimately require an
operation, a delay of more than one day has been identified as a risk factor for requiring bowel resection [56].
In other studies, nonoperative management for uncomplicated adhesive bowel obstruction exceeding three to
five days was associated with increased morbidity and mortality [57,58]. Earlier rather than later surgery may
be warranted in patients with known malignancy (resected, unresected, metastases), although disease
distribution and location need to be carefully considered and the decision to operate or not individualized
accordingly. (See 'Patients with malignancy' below.)

Serial monitoring Frequent clinical reassessments of the patient are necessary to ensure that
complications are not developing.

Resolution of small bowel obstruction is generally accompanied by a decrease in abdominal distension, the
passage of flatus and/or stool per rectum, and a decrease in the volume of nasogastric tube output. The
volume of output from the nasogastric tube should be carefully documented to help with clinical judgments
regarding the progression or resolution of the obstruction, and the requirement for intravenous fluid therapy.
Nasogastric losses can be replaced with normal saline plus potassium chloride (30 to 40 mEq/L). In cases
where the obstruction is clearly resolved, the nasogastric tube can be removed, and diet initiated and
advanced as tolerated. (See "Maintenance and replacement fluid therapy in adults".)

For patients in whom urine output cannot be adequately assessed, a Foley catheter can be placed, and fluid
therapy administered until the patient makes urine or is clinically euvolemic. Some patients may require more
intensive hemodynamic monitoring. (See "Pulmonary artery catheterization: Indications, contraindications,
and complications in adults".)

Laboratory studies Laboratory tests should be repeated only as indicated by clinical parameters.
Initial laboratory derangements studies such as sodium, creatinine, and hematocrit are not predictive of the
need for operative intervention [56]. In patients with severe electrolyte disturbance, particularly those with
renal dysfunction, blood chemistries should be repeated to ensure that replacement therapy is effective.
Repeat assay of white blood cell counts may be helpful if there is concern for bowel ischemia and/or
strangulation.
Serum procalcitonin (PCT), which is a marker of inflammation, is a promising prognostic biomarker for
predicting failure of nonoperative management of small bowel obstruction [2,59,60]. In the Acute Bowel
Obstruction Diagnostic (ABOD) study, PCT levels were significantly higher in the surgery group compared
with the conservatively managed group (0.53 versus 0.14 ng/mL), and significantly higher in those managed
surgically who had ischemia compared with those who did not (1.16 versus 0.21 ng/mL). A PCT threshold
0.57 ng/mL had an 83 percent positive predictive value and 91 percent negative predictive value for
predicting ischemic bowel at operation; a PCT threshold >0.17 ng/mL had an 85 percent negative predictive
value for failure of nonoperative management, but the positive predictive value was only 39 percent. In this
study, lactate and white blood count were not predictive of ischemia [59]. Patients with early postoperative
obstruction, and obstruction associated with neoplasia or inflammatory bowel disease, and colon obstruction
were excluded from the study.

Follow-up imaging We do not recommend routine serial imaging studies. If the patient does not
improve, we suggest abdominal CT for follow-up imaging, given the insensitivity of plain abdominal imaging
for all but the latest stages of obstruction (eg, perforation). In the Acute Bowel Obstruction Diagnostic (ABOD)
study, the presence of a whirl sign on CT scanning was predictive of failure of conservative management
(odds ratio 3.81, 95% CI 1.23-11.83) [59]. For patients whose clinical condition deteriorates, the potential
information that might be gained on repeat imaging needs to be weighed against any delay it might cause;
surgical exploration may be the more appropriate course of action [32]. (See "Epidemiology, clinical features,
and diagnosis of mechanical small bowel obstruction in adults", section on 'Abdominal CT'.)

Abdominal plain films, however, may be useful for assessing whether or not the patient has clearly resolved
their obstruction by demonstrating that gas has passed from the small bowel into the colon. In patients given
water-soluble contrast as a therapeutic trial, follow-up plain radiographs also determine the progress of the
contrast. (See 'Water-soluble contrast' below.)

Role of antibiotics For uncomplicated small bowel obstruction, antibiotics should not be administered.
Although administering broad-spectrum antibiotics is practiced because of concerns for bacterial
translocation, data are inadequate to support or refute such a practice [61].

In the setting of colonic diverticular disease causing obstruction, antibiotic therapy is warranted. (See "Acute
colonic diverticulitis: Medical management", section on 'Oral antibiotics'.)

Antibiotics are also warranted for patients with complications (eg, perforation) and antibiotic prophylaxis
should be administered to those who will undergo operative exploration (table 1) [62-64]. (See "Overview of
gastrointestinal tract perforation", section on 'Antibiotics'.)

Water-soluble contrast For patients with partial small bowel obstruction, water-soluble gastrointestinal
contrast agents (eg, Gastrografin) may be therapeutic [2,65-71]. Gastrografin draws fluid into the lumen of
the bowel due to its hypertonicity, decreasing intestinal wall edema and stimulating intestinal peristalsis.

The volume of Gastrografin administered generally ranges from 7.5 mL over 30 minutes to 22.5 mL over a
course of two hours and can be repeated if initially ineffective, up to a total dose of 100 mL. Higher doses of
Gastrografin have not been studied [72]. After Gastrografin is administered, abdominal radiographs should be
performed up to but no later than 24 hours afterward. In general, failure of the contrast to reach the colon 24
hours later should influence, but not dictate, the decision to operate. The time allowed for nonoperative
resolution following instillation of Gastrografin is a matter of clinical judgment in these patients. If there is
concern that the patient has increasing pain, distension, and persistent high nasogastric output, surgical
exploration may still be indicated.

Water-soluble contrast has been found in several studies to improve bowel function and decrease length of
hospital stay in those patients who are destined to resolve with nonoperative treatment [65-67,72-75]. In a
2016 systematic review and meta-analysis, water-soluble contrast predicted resolution of obstruction without
surgery with a sensitivity of 92 percent and a specificity of 93 percent. Oral water-soluble contrast also
reduced the need for surgery (odds ratio 0.44), length of stay (weighted mean difference -2.18 days), and
time to resolution (weighted mean difference -28.25 hours). There was no increased morbidity or mortality
associated with water-soluble contrast [76]. Based on these data, a number of algorithms have triaged
patients to surgery versus nonoperative management based on their responses to the water-soluble contrast
challenge [77,78]. In a multicenter prospective observational study comparing patients treated at centers with
and without a Gastrografin protocol, those treated with Gastrografin had a significantly lower rate of operative
exploration (21 versus 44 percent) and a shorter length of stay (4 versus 5 days). The median number of
days between Gastrografin administration and operative exploration (for those who failed nonoperative
treatment) was three days. Multivariable regression confirmed that Gastrografin was independently
associated with successful nonoperative management [79].

However, the benefit of Gastrografin was not shown in all studies. In the Adhesive Small Bowel Obstruction
Study (ASBOS), similar percentages of patients who received 100 mL of Gastrografin versus normal saline
required operative intervention (24 versus 20 percent) or bowel resection (8 versus 4 percent) [80]. Contrary
to other studies, Gastrografin administration did not shorten the length of hospital stay (3.5 days in both
groups). In this study, patients were committed to operative exploration if Gastrografin was not observed in
the cecum by 48 hours after administration, a time threshold that is significantly shorter than those
recommended by others (in the absence of clinical signs mandating exploration). As examples, the World
Society of Emergency Surgery 2013 guidelines recommend waiting 72 hours [81], and the Eastern
Association for the Surgery of Trauma suggests a period of three to five days of nonoperative management
before proceeding with surgery [82]. A large study using the 2009 Nationwide Inpatient Sample (NIS)
reported no increase in complications if surgery is delayed for up to four days [58]. The time necessary for
successful nonoperative treatment of small bowel obstruction varies widely in the literature. In one study
predating the use of therapeutic Gastrografin, an average of 6.9 days was required before nonoperative
resolution. A hypothetical threshold of five days would have subjected 141 of the 220 patients who eventually
resolved nonoperatively to unnecessary surgery [83].

Failure of nonoperative management The decision to proceed with surgical exploration or continue
nonoperative management is based primarily on the clinical status of the patient. Failure to regain bowel
function after five days suggests the need for an operation. A large study reported that delay in operation
intervention greater than five days was associated with higher mortality and longer hospital stay [58].

For patients who do not resolve their small bowel obstruction within 48 hours of admission, data support
performing contrast studies prior to operative intervention to differentiate partial small bowel obstruction,
which might still resolve, from complete obstruction, though this may not be necessary in patients with
malignancy [68,84]. (See 'Patients with malignancy' below.)

PATIENTS WITH MALIGNANCY Primary or secondary tumor involvement can lead to small bowel
obstruction due to intrinsic or extrinsic compression; in addition, bowel obstruction may be due to adhesions,
or postradiation fibrosis. Tumors can also impair bowel motility by infiltrating the mesentery, nerves (eg, celiac
plexus), or bowel wall. Some cancers (eg, colonic, ovarian, pancreatic and gastric) have a particular
propensity for peritoneal dissemination [85].

Most patients with small bowel obstruction in the setting of an advanced intraabdominal or pelvic tumor are
inoperable, and patient survival is generally short. However, approximately one-third of small bowel
obstructions in patients with known tumor recurrence are related to benign adhesions and not directly related
to tumor [12,86]. Computed tomography (CT) or Positron Emission Tomography (PET) scans may clarify
overall disease burden to help in the assessment of long-term prognosis, but they are generally not helpful
(particularly PET) in distinguishing between malignant small bowel obstruction versus adhesions. (See
"Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults", section on
'Tumor'.)

General principles There is no consensus regarding the optimal treatment strategy for management of
malignant bowel obstruction and no strong evidence addressing the relative value of palliative surgery versus
medical management, or for supporting the efficacy of any specific treatment for improving quality of life or
prolonging survival. A decision to proceed to surgical intervention requires careful weighing of risks and
benefits, including an assessment of the estimated life expectancy and goals of care (algorithm 1).

For those without indications for immediate surgery (eg, perforation, bowel infarction), a trial of nonoperative
therapy may be warranted [13]. (See 'Trial of nonoperative management' above.)

For those who fail initial nonoperative management, and if surgical treatment is consistent with the goals of
care, surgery should be pursued in those without clear evidence of multifocal disease involvement and who
are presenting with a long interval from diagnosis of malignancy to development of obstruction [11]. These
patients are more likely to have adhesions rather than recurrent cancer. Obstructions due to recurrent cancer
tend to occur earlier after surgery than obstruction related to adhesions (21 versus 61 months) [11]. For
patients with partial obstruction and either documented recurrent malignancy or short interval to development
of obstruction after surgery for malignancy, as well as those who are in the terminal phases of their
malignancy, prolonged medical management (fluids, control of nausea, gastrointestinal decompression), may
be offered as an alternative to surgery [13]. (See 'Medical therapies' below.)

Palliative surgery Palliative surgery may benefit some patients; however, it is associated with high rates
of mortality and hospitalization during the patient's remaining survival time. In a systematic review that
included 17 observational studies, surgery palliated obstructive symptoms in 32 to 100 percent of patients,
enabled resumption of a diet in 45 to 75 percent of patients, and allowed discharge to home in 34 to 87
percent of patients. Mortality ranged from 6 to 32 percent and serious complications occurred in up to 44
percent of patients. Re-obstruction, reoperation, and rehospitalization were common. Median survival in
these studies ranged from 26 to 273 days, and hospitalization related to surgery consumed 11 to 61 percent
of the patient's remaining life. Factors that have been associated with a poor surgical outcome in other
studies include peritoneal carcinomatosis, multifocal obstruction [87], a large amount of ascites,
hypoalbuminemia, and leukocytosis [88].

If consistent with the goals of care, bowel resection (if feasible) or bowel bypass (enteroenterostomy,
enterocolostomy, colocolostomy) can be used to bypass masses of matted intestines. (See "Locoregional
methods for management and palliation in patients who present with stage IV colorectal cancer", section on
'Methods for surgical palliation' and "Surgical resection of primary colon cancer", section on 'Palliation of
advanced disease'.)

If bowel resection or bypass is not an option, colostomy, ileostomy, and possibly jejunostomy can be used
depending upon the level of obstruction. Jejunostomy can lead to fluid and electrolyte problems.

Gastroenterostomy may relieve symptoms in patients with malignant gastric outlet obstruction; however,
duodenal stenting is preferred in most cases. (See "Local palliation for advanced gastric cancer", section on
'Gastrojejunostomy' and 'Stenting' below.)

Alternatives to surgery Interventions that may be useful for relieving abdominal symptoms in patients
with malignant bowel obstruction who refuse or are not candidates for surgical intervention include stenting
and medical therapies (opioids, glucocorticoids, octreotide) [10,89].

Stenting Duodenal stenting is an alternative to gastroenterostomy for patients with obstructing proximal
small bowel tumors who are not candidates for surgery. (See "Enteral stents for the palliation of malignant
gastroduodenal obstruction".)

Medical therapies For patients with inoperable bowel obstruction and for those who are not candidates
for palliative surgery, initial medical management is focused on providing adequate hydration, controlling
nausea and vomiting, pain control, and lessening abdominal distention. (See 'Initial management' above.)

Initial gastrointestinal decompression using a nasogastric tube removes secretions and can reduce nausea
and vomiting, but should only be used as a temporary measure (five to seven days). For prolonged
gastrointestinal decompression, a gastrostomy tube (open, intervention, endoscopic-assisted) can be placed;
however, gastrostomy tubes may provide incomplete relief of symptoms, may be associated with
complications, and the ongoing presence of these tubes can be uncomfortable and distressing for the patient
and his or her family. (See "Gastrostomy tubes: Placement and routine care" and "Gastrostomy tubes: Uses,
patient selection, and efficacy in adults", section on 'Patients with cancer'.)

In general, nutritional support is not indicated for patients with advanced cancer who are terminally ill, with
few exceptions. (See "The role of parenteral and enteral/oral nutritional support in patients with cancer".)

Medical therapies for control of pain, abdominal distention, and vomiting, and pharmacologic agents that may
reduce symptoms by lessening peritumoral edema (glucocorticoids) and/or diminishing intraluminal
secretions and peristaltic movements (anticholinergic agents and octreotide) may be useful in the
management of malignant bowel obstruction, and are discussed elsewhere. (See "Overview of managing
common non-pain symptoms in palliative care" and "Palliative care: Assessment and management of nausea
and vomiting", section on 'Management'.)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics"
and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Small bowel obstruction (The Basics)")

SUMMARY AND RECOMMENDATIONS

Small bowel obstruction occurs when the normal flow of intestinal contents is interrupted. (See
'Introduction' above.)

The most frequent causes of small bowel obstruction are postoperative adhesions, malignancies, and
hernias. Less frequently, strictures of the small bowel can cause intrinsic blockage. (See "Epidemiology,
clinical features, and diagnosis of mechanical small bowel obstruction in adults".)

The initial management of patients with bowel obstruction includes volume resuscitation, correction of
metabolic abnormalities, and an assessment of the need for surgical exploration. (See 'Initial
management' above.)

Patients with clinical or radiologic signs of complicated bowel obstruction (ischemia, necrosis,
perforation) require prompt surgical exploration. (See 'Indications for surgical exploration' above.)

Nonoperative management with nasogastric suction and intravenous fluids can be successful in patients
with partial small bowel obstruction. This approach requires frequent reassessments of the patient to
ensure that there are no developing complications. (See 'Trial of nonoperative management' above.)

We suggest a period of observation prior to surgery for patients with partial small bowel obstruction,
provided that complications have been ruled out to the extent possible (Grade 2C). (See 'Trial of
nonoperative management' above.)

We suggest giving a hypertonic water-soluble contrast agent (eg, Gastrografin) as part of nonoperative
treatment of partial small bowel obstruction (Grade 2B). Patients who receive Gastrografin may have
more rapid resolution of symptoms, a shorter length of hospital stay, and a lower rate of surgical
 intervention. In order to receive the benefit, Gastrografin should be administered relatively soon after
emergency department admission and the decision to proceed with nonoperative treatment. (See 'Water-
soluble contrast' above.)

For patients with malignant small bowel obstruction, any decision to pursue surgical intervention should
take into account the timing of the obstruction relative to the initial cancer diagnosis, the disease burden,
and goals of care. (See 'Patients with malignancy' above.)

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Topic 89300 Version 10.0

GRAPHICS

Antimicrobial prophylaxis for gastrointestinal surgery in adults

Nature of Common Recommended Usual adult Redose

operation pathogens antimicrobials dose* interval

Gastroduodenal surgery

Procedures Enteric gram- Cefazolin <120 kg: 2 g IV Four hours

involving entry negative bacilli, 120 kg: 3 g IV
into lumen of gram-positive cocci
gastrointestinal
tract

Procedures not Enteric gram- High risk only: <120 kg: 2 g IV Four hours
involving entry negative bacilli, cefazolin 120 kg: 3 g IV
into lumen of gram-positive cocci
gastrointestinal
tract (selective
vagotomy,
antireflux)

Biliary tract surgery (including pancreatic procedures)

Open procedure or Enteric gram- Cefazolin <120 kg: 2 g IV Four hours

laparoscopic negative bacilli, 120 kg: 3 g IV
procedure (high enterococci,
risk) clostridia OR cefotetan 2 g IV Six hours

OR cefoxitin 2 g IV Two hours

OR ampicillin- 3 g IV Two hours

sulbactam

Laparoscopic N/A None None None

procedure (low
risk)

Appendectomy

Enteric gram- Cefoxitin 2 g IV Two hours

negative bacilli,
OR cefotetan 2 g IV Six hours
anaerobes,

enterococci OR cefazolin <120 kg: 2 g IV Four hours
120 kg: 3 g IV

PLUS metronidazole 500 mg IV N/A

Small intestine surgery

Nonobstructed Enteric gram- Cefazolin <120 kg: 2 g IV Four hours

negative bacilli, 120 kg: 3 g IV
gram-positive cocci

Obstructed Enteric gram- Cefoxitin 2 g IV Two hours

negative bacilli,
OR cefotetan 2 g IV Six hours
anaerobes,
enterococci OR cefazolin <120 kg: 2 g IV Four hours
120 kg: 3 g IV

PLUS metronidazole 500 mg IV N/A

Hernia repair

Aerobic gram- Cefazolin <120 kg: 2 g IV Four hours

positive organisms 120 kg: 3 g IV

Colorectal surgery

Enteric gram- Parenteral:

negative bacilli,
Cefoxitin 2 g IV Two hours

 anaerobes, OR cefotetan 2 g IV Six hours
enterococci
OR cefazolin <120 kg: 2 g IV Four hours
120 kg: 3 g IV

PLUS 500 mg IV N/A

metronidazole

OR ampicillin- 3 g IV (based on Two hours

sulbactam ,** combination)

Oral (used in conjunction with mechanical bowel preparation):

Neomycin PLUS
erythromycin base
or metronidazole

IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If
vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to 120 minutes before the initial incision
to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the
time of induction of anesthesia.
For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional
intraoperative doses should be given at intervals one to two times the half-life of the drug.
For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg IV; not to exceed
2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or aztreonam (2 g IV) is a
reasonable alternative. Metronidazole (500 mg IV) plus an aminoglycoside or fluoroquinolone are also acceptable
alternative regimens, although metronidazole plus aztreonam should not be used, since this regimen does not have
aerobic gram-positive activity.
Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy
or perforation, or immunosuppression.
Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis, nonfunctioning gall bladder,
obstructive jaundice, common bile duct stones, immunosuppression.
Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.
For a ruptured viscus, therapy is often continued for approximately five days.
Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles
should be reviewed prior to use.
In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered. 1 g of neomycin plus
1 g of erythromycin base at 1 PM, 2 PM, and 11 PM, or 2 g of neomycin plus 2 g of metronidazole at 7 PM and 11 PM the
day before an 8 AM operation. Issues related to mechanical bowel preparation are discussed further separately. Refer to
UpToDate topic on overview of colon resection.

Data from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg
Infec (Larchmt) 2013; 14:73.

Graphic 65369 Version 31.0

An algorithmic approach to clinical management of malignant bowel obstruction in
palliative care patients

SBO: small bowel obstruction; LBO: large bowel obstruction.

* If evidence of perforation or ischemia is present on plain radiography, cross-sectional imaging may not be necessary.
Symptomatic care may include one or more of the following: glucocorticoids, antiemetics (typically haloperidol, not
metoclopramide or constipating 5HT3 receptor antagonists), octreotide, anticholinergics, analgesics, +/ gastrointestinal
decompression.
Stenting is not an option when perforation or ischemia is present.
Depending upon the location and suspected etiology of the obstruction, immediate surgery or stenting should be
considered. Some etiologies, such as closed loop SBO, and most LBO leading to complete obstruction are not likely to
resolve with conservative management.
Gastrograffin may be more useful for partial SBO related to adhesions. Colorectal obstruction is less likely to respond.
Conservative care can continue, as long as there is no clinical deterioration. The duration of conservative management is
generally shorter for complete versus partial obstruction, but is highly variable.
Sites amenable to stenting include large bowel, distal ileum, proximal jejunum.

Graphic 95084 Version 1.0

Contributor Disclosures
Liliana Bordeianou, MD, MPH Nothing to disclose Daniel Dante Yeh, MD Grant/Research/Clinical Trial
Support: Nestle [Nutrition in the ICU (Peptamen Bariatric)];KCI [Wound care (Prevena VAC)].
Consultant/Advisory Boards: Covidien [Feeding tubes (Kangaroo feeding tube)]. Lillian S Kao, MD,
MS Nothing to disclose Wenliang Chen, MD, PhD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

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