Intestinal Obstruction Management

- Executive Summary

This guideline offers evidence-based recommendations on the targeted levels of Clinical practice guidelines and provide healthcare professionals with practical guidance on the diagnosis and treatment of acute intestinal obstruction.

·       We recommend depending on initial evaluation which include a focused history, physical examination, and basic laboratory assessment, (Strong Recommendation).

·       Initial evaluation should be complemented with assessment of the laboratory tests evaluating at least blood count, lactate, and electrolytes, CRP and BUN/Creatinine, (Good Practical Statement).

·       Plain X-rays may be recommended in the work-up of patients with small bowel obstruction, (Conditional Recommendation).

·       Optimal diagnostic work-up should include CT scan with water soluble oral contrast in the assessment, (Strong Recommendation).

·       Ultrasound may be recommended in children in special situations, (Conditional Recommendation).

·        MRI may be recommended in recurrent intestinal obstruction, (Conditional Recommendation).

·       In the absence of the need to perform immediate surgery, we recommend a follow-up abdominal X-ray after 24 h. (If the contrast has reached the colon, this is indicative for resolution of the bowel obstruction), (Strong Recommendation).

·       Colonoscopy may be recommended in LBO to identify tumors, strictures or volvulus, (Conditional Recommendation).

·       A trial of non-operative management can be recommended safely for 72 hours, (Conditional Recommendation).

·       In the absence of signs that require emergent surgical exploration (i.e., peritonitis, strangulation, or bowel ischemia), non-operative management is recommended, (Conditional Recommendation).

·       We recommend the use of naso-gastric tubes or long trilumen naso-intestinal tubes in non-operative management, (Strong Recommendation).

·       We recommend conservative treatment for postoperative (paralytic) ileus after abdominal surgery, by implementation of enhanced recovery measures that include early oral feeding, minimizing opioid analgesics and early mobilization, (Good Practical Statement).

·       We recommend exploration for patients with plain film or CT finding of SBO and clinical markers, (fever, leukocytosis, tachycardia, metabolic acidosis and continuous pain) or peritonitis on physical examination, (Strong Recommendation).

·       We recommend Laparoscopic or open adhesiolysis for treatment of adhesive SBO, (Strong Recommendation).

·       We recommend hernia repair with bowel resection for strangulated hernia, (Strong Recommendation).

·       We recommend lower endoscopy for patients with sigmoid volvulus and without hemodynamic instability, peritonitis, or evidence of perforation to assess sigmoid colon viability, detorse the anatomy, and decompress the colon, (Conditional Recommendation).

·       We recommend urgent sigmoid resection when endoscopic detorsion of the sigmoid colon fails and in cases of nonviable or perforated colon, (Strong Recommendation).

·       Patients who undergo successful endoscopic detorsion should be considered for sigmoid colectomy during the same hospital admission to prevent recurrent volvulus, (Strong Recommendation).

·       Endoscopic or operative fixation of the sigmoid colon may be recommended in selected patients in whom operative intervention presents a prohibitive risk, (Conditional Recommendation).

·       Segmental resection is the recommended treatment for patients with cecal volvulus, (Strong Recommendation).

·       We recommend emergency resection with anastomosis or diverting colostomy for patients with acute on top of chronic intestinal obstruction due to colonic cancer, (Strong Recommendation).

·       Initial evaluation of ACPO should include a focused history and physical examination, baseline laboratory tests, and diagnostic imaging, (Strong Recommendation).

·       We recommend supportive treatment for ACPO which includes eliminating or correcting conditions that predispose patients to ACPO or prolong its course (e.g. immobility, neurological disorders, etc.), (Strong Recommendation).

·       Pharmacologic treatment with neostigmine is recommended when ACPO does not resolve with supportive therapy, (Strong Recommendation).

·       Endoscopic colonic decompression is recommended in patients with ACPO in whom neostigmine therapy is contraindicated or ineffective, (Strong Recommendation).

·       Operative treatment is recommended for ACPO complicated by colon ischemia or perforation or ACPO refractory to pharmacologic and endoscopic therapies, (Conditional Recommendation).