Intestinal Obstruction Management

Section I. Clinical Diagnosis of Intestinal Obstruction:

·   We recommend depending on initial evaluation which include a focused history, physical examination, and basic laboratory assessment, (Strong recommendation, low certainty evidence, ⁽³⁾).

Section II. Laboratory Work-Up for Intestinal Obstruction:

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

Section III. Diagnostic imaging for Intestinal Obstruction:

·  Plain X-rays may be recommended in the work-up of patients with small bowel obstruction, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).

·  Optimal diagnostic work-up should include CT scan with water soluble oral contrast in the assessment, (Strong recommendation, moderate certainty evidence, ⁽⁷⁾).

·  Ultrasound may be recommended in children in special situations, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).

· MRI may be recommended in recurrent intestinal obstruction, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).

·  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, moderate certainty evidence, ⁽⁷⁾).

·   Colonoscopy may be recommended in LBO to identify tumors, strictures or volvulus, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).

Section IV. Conservative (Non-Operative) Management, (Figure 1)⁽⁸⁾:

·  A trial of non-operative management can be recommended safely for 72 hours, (Conditional recommendation, moderate certainty evidence, ⁽⁷⁾).

·  In the absence of signs that require emergent surgical exploration (i.e., peritonitis, strangulation, or bowel ischemia), non-operative management is recommended, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).

·  We recommend the use of naso-gastric tubes or long trilumen naso-intestinal tubes in non-operative management, (Strong recommendation, high certainty evidence, ⁽⁷⁾).

·  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).

Section V. Surgical management:

·  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, high certainty evidence, ⁽⁷⁾).

·  We recommend Laparoscopic or open adhesiolysis for treatment of adhesive SBO, (Strong recommendation, high certainty evidence, ⁽⁷⁾).

Section VI. Special considerations:

·  We recommend hernia repair with bowel resection for strangulated hernia, (Strong recommendation, high certainty evidence, ⁽⁷⁾).

·   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, low certainty evidence, ⁽³⁾).

· We recommend urgent sigmoid resection when endoscopic detorsion of the sigmoid colon fails and in cases of nonviable or perforated colon, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

· Patients who undergo successful endoscopic detorsion should be considered for sigmoid colectomy during the same hospital admission to prevent recurrent volvulus, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·  Endoscopic or operative fixation of the sigmoid colon may be recommended in selected patients in whom operative intervention presents a prohibitive risk, (Conditional recommendation, low certainty evidence, ⁽³⁾).

·  Segmental resection is the recommended treatment for patients with cecal volvulus, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·   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, moderate certainty evidence, ⁽⁷⁾).

Section VII. Acute colonic pseudo-obstruction:

·  Initial evaluation of ACPO should include a focused history and physical examination, baseline laboratory tests, and diagnostic imaging, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·  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, moderate certainty evidence, ⁽⁷⁾).

·  Pharmacologic treatment with neostigmine is recommended when ACPO does not resolve with supportive therapy, (Strong recommendation, moderate certainty evidence, ⁽⁷⁾).

·   Endoscopic colonic decompression is recommended in patients with ACPO in whom neostigmine therapy is contraindicated or ineffective, (Strong recommendation, moderate certainty evidence, ⁽⁷⁾).

·   Operative treatment is recommended for ACPO complicated by colon ischemia or perforation or ACPO refractory to pharmacologic and endoscopic therapies, (Conditional recommendation, low certainty evidence, ⁽⁷⁾).