Updated: 10/1/2019

Small Bowel Obstruction

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Snapshot
  • A 50-year-old woman presents to the emergency room for nausea, vomiting, loss of appetite, and abdominal pain. She has a history of Crohn disease, on infliximab, but she reports that this did not feel like a flare of her disease. On physical exam, there is tenderness to palpation of her abdomen without any peritoneal signs. An abdominal radiograph shows dilated loops of small bowel. She is started on intravenous fluids, given anti-emetics, and put on bowel rest.
Introduction
  • Overview
    • partial or complete blockage of the small intestines
  • Epidemiology
    • incidence
      • common
    • risk factors
      • prior abdominal surgeries (most common)
        • post-operative adhesions
      • masses/malignancy
      • hernias
      • inflammatory bowel disease
      • intussusception (in children)
  • Prognosis
    • partial SBOs often self-resolve
    • complete SBOs may also self-resolve but often require surgical intervention
Presentation
  • History
    • decreased appetite
    • lack of flatus
    • constipation
  • Symptoms 
    • common symptoms
      • nausea and vomiting
      • abdominal pain
  • Physical exam
    • inspection
      • abdominal distention
    • motion
      • generalized tenderness to palpation
Imaging
  • Abdominal radiographs 
    • indications
      • best initial test
    • findings 
      • dilated loops of small bowel
      • free air may indicate need for immediate surgery
  • Computed tomography (CT) of abdomen and pelvis
    • indications
      • diagnosis of SBO
    • findings
      • dilated loops of small bowel
      • transition point
      • any masses present
Studies
  • Serum labs
    • lactic acid to monitor for bowel necrosis if suspected
  • Invasive studies
    • small bowel follow-through with gastrograffin
      • indication
        • patients who fail to improve clinically after 48 hours of nonoperative treatment
        • may rule out need for surgery
Differential
  • Appendicitis
    • distinguishing factor
      • imaging shows enlarged appendix with signs of inflammation instead of dilated loops of bowel with transition point
Treatment
  • Conservative and lifestyle
    • supportive care
      • modalities
        • intravenous fluids
  • Medical and pharmacologic 
    • treat underlying condition
    • nasogastric decompression and bowel rest
      • indications
        • partial SBO
        • no signs concerning for bowel strangulation
  • Surgical and interventional 
    • surgical intervention with correction of cause of SBO (i.e., lysis of adhesions)
      • indications
        • peritonitis
        • signs concerning for bowel strangulation
          • systemic signs (i.e., fever)
          • metabolic acidosis
          • continuous pain
Complications
  • Bowel necrosis
  • Peritonitis
  • Bowel perforation
 

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