Thissiteisintendedforhealthcareprofessionals

SmallBowelObstruction
Updated:Jan20,2015
Author:BrianANobie,MDChiefEditor:StevenCDronen,MD,FAAEMmore...

OVERVIEW

PracticeEssentials
Asmallbowelobstruction(SBO)iscausedbyavarietyofpathologicprocesses.Theleadingcauseof
SBOinindustrializedcountriesispostoperativeadhesions(60%),followedbymalignancy,Crohn
disease,andhernias.Seetheimagebelow.

Smallbowelobstruction.ImagecourtesyofAdemolaAdewale,MD.

ViewMediaGallery
SeeCan'tMissGastrointestinalDiagnoses,aCriticalImagesslideshow,tohelpdiagnosethe
potentiallylifethreateningconditionsthatpresentwithgastrointestinalsymptoms.

Signsandsymptoms
Obstructioncanbecharacterizedaseitherpartialorcompleteversussimpleorstrangulated.
Abdominalpain,oftendescribedascrampyandintermittent,ismoreprevalentinsimpleobstruction.
Usually,painthatoccursforashorterdurationoftimeandiscolickyandaccompaniedbybilious
vomitingmaybemoreproximal.Painthatlastsaslongasseveraldays,isprogressiveinnature,and
isaccompaniedbyabdominaldistentionmaybetypicalofamoredistalobstruction.
SomesignsandsymptomsassociatedwithSBOincludethefollowing:
Nausea
VomitingAssociatedmorewithproximalobstructions
DiarrheaAnearlyfinding

ConstipationAlatefinding,asevidencedbytheabsenceofflatusorbowelmovements
FeverandtachycardiaOccurlateandmaybeassociatedwithstrangulation
Previousabdominalorpelvicsurgery,previousradiationtherapy,orbothMaybepartofthe
patient'smedicalhistory
HistoryofmalignancyParticularlyovarianandcolonicmalignancy
SeeClinicalPresentationformoredetail.

Diagnosis
Labtests
ThefollowingareadjunctivelabtestsusedintheevaluationofSBO:
Serumchemistries
Bloodureanitrogen(BUN)level
Creatinine
Completebloodcount(CBC)
Lactatedehydrogenasetests
Urinalysis
Typeandcrossmatch
Laboratoryteststoexcludebiliaryorhepaticdiseasearealsoneededtheyincludethefollowing:
Phosphatelevel
Creatinekinaselevel
Liverpanels
Imagingtests
ObtainplainradiographsfirstforpatientsinwhomSBOissuspected.Atleast2views,supineorflat
andupright,arerequired.Plainradiographsarediagnosticallymoreaccurateincasesofsimple
obstruction.
Enteroclysisisvaluableindetectingthepresenceofobstructionandindifferentiatingpartialfrom
completeblockages.Thisstudyisusefulwhenplainradiographicfindingsarenormalinthepresence
ofclinicalsignsofSBOorwhenplainradiographicfindingsarenonspecific.
Computedtomography(CT)scanningisthestudyofchoiceifthepatienthasfever,tachycardia,
localizedabdominalpain,and/orleukocytosis.
UltrasonographyislesscostlyandinvasivethanCTscanningandmayreliablyexcludeSBOinas
manyas89%ofpatientsspecificityisreportedly100%.
SeeWorkupformoredetail.

Management
Nonoperativetreatment
NonoperativetreatmentforseveraltypesofSBOareasfollows:
MalignanttumorObstructionbytumorisusuallycausedbymetastasisinitialtreatmentshould
benonoperative(surgicalresectionisrecommendedwhenfeasible)

InflammatoryboweldiseaseToreducetheinflammatoryprocess,treatmentgenerallyis
nonoperativeincombinationwithhighdosesteroidsconsiderparenteraltreatmentfor
prolongedperiodsofbowelrest,andundertakesurgicaltreatment,bowelresection,and/or
stricturoplastyifnonoperativetreatmentfails.
IntraabdominalabscessCTscanguideddrainageisusuallysufficienttorelieveobstruction
RadiationenteritisIfobstructionfollowsradiationtherapyacutely,nonoperativetreatment
accompaniedbysteroidsisusuallysufficientiftheobstructionisachronicsequelaofradiation
therapy,surgicaltreatmentisindicated
IncarceratedherniaInitiallyusemanualreductionandobservationadviseelectivehernia
repairassoonaspossibleafterreduction
AcutepostoperativeobstructionThisisdifficulttodiagnose,becausesymptomsoftenare
attributedtoincisionalpainandpostoperativeileustreatmentshouldbenonoperative
AdhesionsDecreasingintraoperativetraumatotheperitonealsurfacescanpreventadhesion
formation
Surgicalcare
Astrangulatedobstructionisasurgicalemergency.Inpatientswithacompletesmallbowel
obstruction(SBO),theriskofstrangulationishighandearlysurgicalinterventioniswarranted.
LaparoscopyhasbeenshowntobesafeandeffectiveinselectedcasesofSBO.[1,2]
SeeTreatmentandMedicationformoredetail.

Background
Asmallbowelobstruction(SBO)iscausedbyavarietyofpathologicprocesses.Theleadingcauseof
SBOinindustrializedcountriesispostoperativeadhesions(60%),followedbymalignancy,Crohn
disease,andhernias,althoughsomestudieshavereportedCrohndiseaseasagreateretiologic
factorthanneoplasia.SurgeriesmostcloselyassociatedwithSBOareappendectomy,colorectal
surgery,andgynecologicanduppergastrointestinal(GI)procedures(seetheimagebelow).(See
Etiology.)

Smallbowelobstruction.ImagecourtesyofAdemolaAdewale,MD.

ViewMediaGallery
OnestudyfromCanadareportedahigherfrequencyofSBOaftercolorectalsurgery,followedby
gynecologicsurgery,herniarepair,andappendectomy.Lowerabdominalandpelvicsurgeriesleadto
obstructionmoreoftenthanupperGIsurgeries.(SeeEtiology.)

SBOscanbepartialorcomplete,simple(ie,nonstrangulated)orstrangulated.Strangulated
obstructionsaresurgicalemergencies.Ifnotdiagnosedandproperlytreated,vascularcompromise
leadstobowelischemiaandfurthermorbidityandmortality.Becauseasmanyas40%ofpatients
havestrangulatedobstructions,differentiatingthecharacteristicsandetiologiesofobstructionis
criticaltoproperpatienttreatment.SBOaccountsfor20%ofallacutesurgicaladmissions.(See
Clinical,Workup,andTreatment.)

Pathophysiology
Smallbowelobstruction(SBO)leadstoproximaldilatationoftheintestineduetoaccumulationofGI
secretionsandswallowedair.Thisboweldilatationstimulatescellsecretoryactivity,resultinginmore
fluidaccumulation.Thisleadstoincreasedperistalsisaboveandbelowtheobstruction,withfrequent
loosestoolsandflatusearlyinitscourse.
Vomitingoccursifthelevelofobstructionisproximal.Increasingsmallboweldistentionleadsto
increasedintraluminalpressures.Thiscancausecompressionofmucosallymphatics,leadingto
bowelwalllymphedema.Withevenhigherintraluminalhydrostaticpressures,increasedhydrostatic
pressureinthecapillarybedsresultsinmassivethirdspacingoffluid,electrolytes,andproteinsinto
theintestinallumen.Thefluidlossanddehydrationthatensuemaybesevereandcontributeto
increasedmorbidityandmortality.
StrangulatedSBOsaremostcommonlyassociatedwithadhesionsandoccurwhenaloopof
distendedboweltwistsonitsmesentericpedicle.Thearterialocclusionleadstobowelischemiaand
necrosis.Ifleftuntreated,thisprogressestoperforation,peritonitis,anddeath.
Bacteriainthegutproliferateproximaltotheobstruction.Microvascularchangesinthebowelwall
allowtranslocationtothemesentericlymphnodes.Thisisassociatedwithanincreaseinthe
incidenceofbacteremiaduetoEscherichiacoli,buttheclinicalsignificanceisunclear.

Etiology
Themostcommoncauseofsmallbowelobstruction(SBO)ispostsurgicaladhesions.Postoperative
adhesionscanbethecauseofacuteobstructionwithin4weeksofsurgeryorofchronicobstruction
decadeslater.TheincidenceofSBOparallelstheincreasingnumberoflaparotomiesperformedin
developingcountries.
PreventionofSBOmaybeessentiallylimitedtodecreasingtheriskofadhesionformationby
decreasingthenumberofintraabdominalprocedures(ie,laparotomies)andresultantscarformation.
InastudybyVanDerWaletal,theincidenceofchronicabdominalsymptomswassignificantly
reducedaftertheuseofahyaluronicacidcarboxymethylcellulosemembrane(Seprafilm).However,
SeprafilmplacementdidnotprovideprotectionagainstSBO.[3]
AnothercommonlyidentifiedcauseofSBOisanincarceratedgroinhernia.Otheretiologiesinclude
malignanttumor(20%),hernia(10%),inflammatoryboweldisease(5%),volvulus(3%),and
miscellaneouscauses(2%).ThecausesofSBOinpediatricpatientsincludecongenitalatresia,
pyloricstenosis,andintussusception.

Prognosis
Withproperdiagnosisandtreatmentoftheobstruction,prognosisinsmallbowelobstruction(SBO)is
good.Completeobstructionstreatedsuccessfullynonoperativelyhaveahigherincidenceof
recurrencethandothosetreatedsurgically.

ComplicationsofSBOincludethefollowing:
Sepsis
Intraabdominalabscess
Wounddehiscence
Aspiration
Shortbowelsyndrome(asaresultofmultiplesurgeries)
Death(secondarytodelayedtreatment)
Mortalityandmorbidityaredependentontheearlyrecognitionandcorrectdiagnosisofobstruction.If
untreated,strangulatedobstructionscausedeathin100%ofpatients.Ifsurgeryisperformedwithin
36hours,themortalityratedecreasesto8%.Themortalityrateis25%ifthesurgeryispostponed
beyond36hoursinthesepatients.
Somefactorsassociatedwithdeathandpostoperativecomplicationsincludeage,comorbidity,and
treatmentdelay.AccordingtooneNorwegiangroup,morbidityandmortalitydecreasedfrom1961to
1995.
ClinicalPresentation
WhattoReadNextonMedscape
RelatedConditionsandDiseases

PituitaryTumorsPathology
AcquiredNystagmus
IntestinalEnterokinaseDeficiency
BeckwithWiedemannSyndrome
Alpha1AntitrypsinDeficiency
PelizaeusMerzbacherDisease
News&Perspective

PopularHeartburnMedicationLinkedtoIncreasedStroke

AlternateDayFastingPosesNoThreattoBoneHealth

TRUEAHFShakesUpBeliefsAboutTreatingAcuteDecompensatedHeartFailure
Tools

DrugInteractionChecker
PillIdentifier
Calculators
Formulary
MostPopularArticles

AccordingtoGastroenterologists
1.TreatingGastrointestinalDisordersThroughImprovedSleep
2.TenPearlsofWisdomFromAcutePancreatitisExperts
3.ExpertOpinionsandScientificEvidenceforColonoscopyKeyPerformanceIndicators
4.ProtonPumpInhibitorsandDementia:CauseforConcern?
5.PromisingTreatmentsontheHorizonforNAFLDandNASH
ViewMore