PENATALAKSANAAN

Emergency Department Care

Initial emergency department (ED) treatment of small-bowel obstruction (SBO)

consists of aggressive fluid resuscitation, bowel decompression, administration of

analgesia and antiemetic as indicated clinically, early surgical consultation, and

administration of antibiotics. (Antibiotics are used to cover against gram-negative

and anaerobic organisms.)

Initial decompression can be performed by placement of a nasogastric (NG) tube for

suctioning GI contents and preventing aspiration. Monitor airway, breathing, and

circulation (ABCs).

Blood pressure monitoring, as well as cardiac monitoring in selected patients

(especially elderly patients or those with comorbid conditions), is important.

Nonoperative inpatient care

Continued NG suction provides symptomatic relief, decreases the need for

intraoperative decompression, and benefits all patients. No clinical advantage to

using a long tube (nasointestinal) instead of a short tube (NG) has been observed.

A nonoperative trial of as many as 3 days is warranted for partial or simple

obstruction. Provide adequate fluid resuscitation and NG suctioning. Resolution of

obstruction occurs in virtually all patients with these lesions within 72 hours. Good

data regarding nonoperative management suggest it to be successful in 65-81% of

partial SBO cases without peritonitis. [10, 13] Nonoperative treatment for several

types of SBO are as follows:

Malignant tumor: Obstruction by tumor is usually caused by metastasis; initial

treatment should be nonoperative (surgical resection is recommended when feasible)

Inflammatory bowel disease: To reduce the inflammatory process, treatment

generally is nonoperative in combination with high-dose steroids; consider parenteral

treatment for prolonged periods of bowel rest, and undertake surgical treatment,

bowel resection, and/or stricturoplasty if nonoperative treatment fails.

Intra-abdominal abscess: CT scan ̶ guided drainage is usually sufficient to relieve

obstruction

Radiation enteritis: If obstruction follows radiation therapy acutely, nonoperative

treatment accompanied by steroids is usually sufficient; if the obstruction is a

chronic sequela of radiation therapy, surgical treatment is indicated

Incarcerated hernia: Initially use manual reduction and observation; advise elective

hernia repair as soon as possible after reduction

Acute postoperative obstruction: This is difficult to diagnose, because symptoms

often are attributed to incisional pain and postoperative ileus; treatment should be

nonoperative

Adhesions: Decreasing intraoperative trauma to the peritoneal surfaces can prevent

adhesion formation

Water-soluble oral contrast medium

Studies have evaluated the use of WSCM as a tool in the management of SBO and

as a predictive tool for nonoperative resolution of adhesive SBO. Although it does

not cause resolution of the SBO, WSCM may reduce the hospital stay in patients not

requiring surgery.

However, a more recent systematic review that analyzed retrospective data (2006-

2009) from 242 patients in 10 studies with uncomplicated acute adhesive SBO

indicated no benefit of administering gastrografin compared with saline solution in

reducing the need for surgical intervention (24% vs 20%, respectively) or bowel

resection (8% and 4%). Results were similar for both groups with respect to the time

interval between the initial CT scan and surgery, as well as the time interval between
oral refeeding and discharge. [28] The sole potential risk factor for failure of

nonoperative management was age.

Surgical Care

A strangulated obstruction is a surgical emergency. In patients with a complete

small-bowel obstruction (SBO), the risk of strangulation is high and early surgical

intervention is warranted. Patients with simple complete obstructions in whom

nonoperative trials fail also need surgical treatment but experience no apparent

disadvantage to delayed surgery.

Laparoscopy has been shown to be safe and effective in selected cases of SBO. [6, 7]

A review of retrospective clinical trials showed that laparoscopy showed better

results in terms of hospital stay and mortality reduction versus open surgery, but

prospective, randomized, controlled trials to assess all outcomes are still needed. [29]

Surgical outcomes for SBO, particularly malignant bowel obstruction, have

relatively high risk for mobidity and mortality. [30] In a retrospective study (2012-

2015) of 2233 patients who underwent surgery for bowel obstruction, those with

malignant bowel obstruction had a 14.5% adjusted mortality rate and a 32.2%

adjusted complication rate. Independent prognostic factors for mortality included

bowel resection, disseminated disease, advanced age, higher American Society of

Anesthesiologists score (IV/V), as well as the presence of sepsis, albumin level

below 3.5 g/dL, hematocrit below 30%, cirrhosis, ascites, and urinary tract infection.

[30] https://emedicine.medscape.com/article/774140-treatment#showall

In all cases, it is important to note that SBO is a medical emergency. Diagnosis

requires immediate resuscitation and occasionally urgent surgery depending on

whether SBO is partial (some flatus) or complete (no flatus/no air in rectum on

imaging), and whether it is simple (no peritonitis) or complicated (peritonitis

present).
In general:

Patients with complete SBO with or without peritonitis require surgery.

Patients with partial SBO may benefit from nasogastric decompression and close

observation.

Patients should initially be treated in the emergency department with fluid

resuscitation, bowel decompression, and administration of analgesia and antibiotics.

Early surgical consultation with a general surgeon should take place. Operative

treatment is indicated in patients with complete SBO, peritonitis, evidence of

strangulation, and those who do not respond to non-operative treatment.

Correction of the underlying cause will be required for treatment of the concomitant

intestinal obstruction.

All patients

Non-operative treatment

Fluid resuscitation: placement of intravenous lines and administration of large

volumes of intravenous fluids is indicated in all patients. A Foley catheter should be

placed to monitor urine output.

Bowel decompression: in cases of partial or complete SBO, the placement of a

nasogastric tube is indicated to decompress air/fluid in the upper GI tract. Surgical

consultation (general surgeon) is indicated at this stage.

Antiemesis: although patients with complete SBO often have severe nausea, anti-

emetics are generally not administered as they do not provide significant relief. The

most effective anti-emetic strategy is nasogastric decompression. For partial SBO an

anti-emetic may be beneficial, but only if nasogastric aspirates are minimal. [13]

Analgesia: it is essential to provide adequate analgesia in patients with partial or

complete SBO. This can be readily accomplished with morphine.

Antibiotics: there is insufficient evidence that broad-spectrum antibiotics are

beneficial in these patients.By contrast, antibiotic prophylaxis is indicated if surgery

is needed.

The administration of intravenous fluids and passage of a nasogastric tube result in

the correction of partial SBO in approximately one-third to one-half of cases. Rarely

will a complete SBO respond to non-operative therapy, and for this reason, surgery

is generally indicated, except in cases of Crohn's disease or radiation enteritis where

nasogastric decompression alone may be beneficial. Typically, conservative therapy

may be adopted for 48 to 72 hours in cases of partial SBO before surgery is

performed, except in patients with evidence of bowel strangulation where prompt

surgical intervention is crucial. [11]

In cases where surgery is deemed not to be in the patient’s best interests, such as

where the SBO is due to advanced malignancy, the focus of treatment should be on

palliation of symptoms. This is achieved by best conservative treatment to

decompress the bowel if possible, combined with anti-emetics, antispasmodics, and

adequate analgesia.
Correction of the underlying cause will be required for treatment of the concomitant

intestinal obstruction. Specific treatment, such as appendectomy for appendicitis,

Ladd procedure for malrotation, tumour resection for obstructing tumour, and hernia

repair for inguinal hernia should be performed when diagnosed. The most frequent

causes include adhesions, inguinal hernia, or tumour in adults in whom no previous

surgery is present.

Patients with complete SBO, peritonitis, strangulation, or failed non-operative

treatment

Operative treatment

The nature of the obstruction determines the type and extent of surgery. Exploratory

laparotomy should be performed in patients with complete SBO, in all cases in

which there is documented peritonitis, or evidence of strangulation, and in patients

who do not respond to non-operative treatment as manifest by persistent abdominal

pain, leukocytosis, worsening air-fluid levels on abdominal x-ray (or demonstration

of a gas-less abdomen), or in an inconsolable infant with documented malrotation. In

complicated SBO, peritonitis is present (rebound, guarding), which mandates

immediate resuscitation and prompt surgical intervention. [11]

In patients with complete SBO, peritonitis will develop in time if not already present.

For this reason, early surgical intervention is crucial whenever complete SBO is

suspected or diagnosed, in order to prevent this complication from occurring.

Antibiotic prophylaxis
Patients undergoing surgery for SBO will require broad-spectrum antibiotics (e.g.,

cefoxitin, or ampicillin plus gentamicin) as prophylaxis for wound infection.

Acute

Patient group

Treatment line

Treatmenthide all

complete or complicated or strangulated SBO: surgical candidate

1st

emergency laparotomy plus fluid resuscitation

In patients with complete SBO, peritonitis is usually present, which mandates

immediate resuscitation and prompt surgical intervention by exploratory laparotomy.

Peritonitis will develop in time if not already present; for this reason early surgical

intervention is crucial to prevent this complication from occurring. An exception

would be cases of advanced malignancy where life expectancy is limited.

Placement of intravenous lines and administration of large volumes of intravenous

fluid (either lactated Ringer's or normal saline) is indicated.

A Foley catheter should be placed to monitor urine output.

plus

preoperative antibiotic prophylaxis

Broad-spectrum antibiotics are indicated preoperatively as prophylaxis for wound

infection.

Usually antibiotics are administered for up to 24 hours after surgery.

Primary options

ampicillin: children: 50 mg/kg intravenously 30 minutes before surgery, followed by

25 mg/kg 6 hours later; adults: 2 g intravenously 30 minutes before surgery,

followed by 1 g 6 hours later

and

gentamicin: children: 2 mg/kg intravenously 30 minutes before surgery, followed by

1 mg/kg 8 hours later; adults: 1.5 mg/kg intravenously 30 minutes before surgery,

followed by 1.5 mg/kg 8 hours later

OR

cefoxitin: children >3 months of age: 30–40 mg/kg intravenously 30-60 minutes

before surgery, followed by 30-40 mg/kg every 6 hours for 24 hours; adults: 1-2 g

intravenously 30-60 minutes before surgery, followed by 1-2 g every 6-8 hours for

24 hours
plus

supportive care plus close observation

In cases of complete SBO, the placement of a nasogastric tube is indicated to

decompress air/fluid in the upper GI tract. It is also a very effective anti-emetic

strategy.

It is essential to provide adequate analgesia in these patients. This can be readily

accomplished with intravenous administration of morphine.

Primary options

morphine sulfate: children: 0.1 mg/kg intravenously every 3-4 hours when required;

adults: 2.5 to 5 mg intravenously every 3-4 hours when required

plus

correction of the underlying cause

Correction of the underlying cause will be required for treatment of the concomitant

intestinal obstruction.

Specific treatment such as appendectomy for appendicitis, Ladd procedure for

malrotation (infants), tumour resection for obstructing tumour, and hernia repair for

inguinal hernia should be performed when diagnosed.

The most frequent causes include adhesions, inguinal hernia, or tumour in adults in

whom there is no history of previous surgery.

complete or complicated or strangulated SBO: surgery contraindicated

1st

nasogastric decompression plus fluid resuscitation

In cases where surgery is deemed not to be in the patient's best interests (e.g., SBO is

due to advanced malignancy) the focus of treatment should be on palliation of

symptoms. Placement of a nasogastric tube is indicated to decompress air/fluid in the

upper GI tract.

Placement of intravenous lines and administration of sufficient volume of

intravenous fluid (either lactated Ringer or normal saline) to resuscitate and maintain

hydration is indicated. A Foley catheter should be placed to monitor urine output.

plus

analgesics

Adequate analgesia should be provided to all patients. This can be readily

accomplished with intravenous administration of morphine.

Primary options

morphine sulfate: children: 0.1 mg/kg intravenously every 3-4 hours when required;

adults: 2.5 to 5 mg intravenously every 3-4 hours when required

adjunct

anti-emetics

Anti-emetics can be a useful adjunct to nasogastric decompression for patients with

emesis and/or nausea in cases where surgery is contraindicated.

Metoclopramide is contraindicated in patients with bowel obstruction.

Primary options

ondansetron: 4 mg intravenously every 8 hours when required

adjunct

antispasmodics

Antispasmodics can benefit patients in terms of abdominal pain or discomfort.

partial SBO

1st
fluid resuscitation plus nasogastric decompression

Placement of intravenous lines and administration of large volumes of intravenous

fluid (either lactated Ringer's or normal saline) is indicated in all patients.

A Foley catheter should be placed to monitor urine output.

The placement of a nasogastric tube is indicated to decompress air/fluid in the upper

GI tract.

Fluid replacement and passage of a nasogastric tube result in the correction of partial

SBO in approximately one-third to one-half of cases.

Typically, conservative therapy may be adopted for 48 to 72 hours in cases of partial

SBO before surgery is performed, if needed.

plus

correction of the underlying cause

Correction of the underlying cause will be required for treatment of the concomitant

intestinal obstruction. Specific treatment such as appendectomy for appendicitis,

Ladd procedure for malrotation (infants), tumour resection for obstructing tumour,

and hernia repair for inguinal hernia should be performed when diagnosed.
The most frequent causes include adhesions, inguinal hernia, or tumour in adults in

whom there is no history of previous surgery.

plus

supportive care plus close observation

Surgical consultation (general surgeon) is indicated at this stage.

Typically, conservative therapy may be adopted for 48 to 72 hours in cases of partial

SBO before surgery is performed if needed.

Adequate analgesia should be provided to all patients. This can be readily

accomplished with intravenous administration of morphine.

Primary options

morphine sulfate: children: 0.1 mg/kg intravenously every 3-4 hours when required;

adults: 2.5 to 5 mg intravenously every 3-4 hours when required

poor clinical response after 48 to 72 hours

plus
laparotomy

Exploratory laparotomy should be performed in patients who do not respond after 48

to 72 hours of non-operative treatment, as manifest by persistent abdominal pain,

leukocytosis, worsening air-fluid levels on abdominal x-ray (or demonstration of a

gas-less abdomen), or an inconsolable infant with documented malrotation.

plus

preoperative antibiotic prophylaxis

Broad-spectrum antibiotics are indicated preoperatively as prophylaxis for wound

infection.

Usually antibiotics are administered for up to 24 hours after surgery.

Primary options

ampicillin: children: 50 mg/kg intravenously 30 minutes before surgery, followed by

25 mg/kg 6 hours later; adults: 2 g intravenously 30 minutes before surgery,

followed by 1 g 6 hours later

and
gentamicin: children: 2 mg/kg intravenously 30 minutes before surgery, followed by

1 mg/kg 8 hours later; adults: 1.5 mg/kg intravenously 30 minutes before surgery,

followed by 1.5 mg/kg 8 hours later

OR

cefoxitin: children >3 months of age: 30-40 mg/kg intravenously 30-60 minutes

before surgery, followed by 30-40 mg/kg every 6 hours for 24 hours; adults: 1-2 g

intravenously 30-60 minutes before surgery, followed by 1-2 g every 6-8 hours for

24 hours

plus

correction of an underlying cause

Correction of the underlying cause will be required for treatment of the concomitant

intestinal obstruction. Specific treatment such as appendectomy for appendicitis,

Ladd procedure for malrotation (infants), tumour resection for obstructing tumour,

and hernia repair for inguinal hernia should be performed when diagnosed. The most

frequent causes include adhesions, inguinal hernia, or tumour in adults in whom

there is no history of previous surgery. http://bestpractice.bmj.com/best-

practice/monograph/993/treatment/details.html

KOMPLIKASI 1,2

Komplikasi obstruksi ileus tergantung pada beratnya kondisi, usia pasien, adanya

penyakit yang menyertai dan seringkali juga dipengaruhi durasi gejala yang muncul,

yaitu:

1. Nekrosis intestinum
Pada pasien yang tidak terobati secara komprehensif, kemungkinan terjadi

nekrosis intestinum sangat tinggi. Ketika obstruksi berlangsung, perfusi

intestinum menurun yang mengakibatkan perubahan iskemik dan nekrosis. Hal ini

diperparah dengan onset peritonitis, leukositosis, dehidrasi, dan gagal ginjal pre-

renal.

2. Sepsis

Pasien yang menderita nekrosis intestinum yang diobati atau tidak diobati maupun

penanganan yang terlambat memiliki risiko perforasi intestinum dengan sepsis

dan kegagalan organ multisistem. Kegagalan organ multisistem inilah yang

menyebabkan kematian.

3. Abses intra-abdominal

Jika terjadi obstruksi intestinum yang disertai perforasi, pasien dapat mengalami

infeksi intra-abdominal dengan abses. Abses ini memerlukan penatalaksanaan

baik dengan operasi terbuka maupun drainase.

4. Short bowel syndrome

Jika penatalaksanaan small bowel obstruction memerlukan tindakan reseksi pada

intestinum atau akibat dari multiple surgery, pasien dapat mengalami short bowel

syndrome. Hal ini diketahui dengan kehilangan fungsi maupun anatomi pada

segmen intestinum yang menyebabkan absorpsi inadekuat nutrisi enteral.

PENCEGAHAN3,4

Pencegahan dilakukan untuk menghindari atau meminimalisasi morbiditas dan

obstruksi yang dapat terjadi di kemudian hari, yaitu

a. Sepsis intra abdominal seperti apendisitis, peritonitis, tuberkulosis, dan

sebagainya harus segera diidentifikasi dan diterapi.

b. Meminimalisasi terjadinya infeksi jaringan

c. Multiple surgeries tidak direkomendasikan

d. Meminimalisasi tindakan invasif jika memungkinkan

Selain itu, menurut Alberta Health Service, pencegahan small bowel obstruction

dapat dilakukan dengan mengubah kebiasaan makan sebagai berikut:

a. Mengunyah makanan dengan baik

b. Makan dengan tidak terburu-buru

c. Makan dalam jumlah porsi yang kecil tetapi teratur

d. Membatasi konsumsi minuman berkafein

e. Minum suplemen vitamin bila perlu

1. Ramnarine, M (2017). Small Bowel Obstruction.

https://emedicine.medscape.com/article/774140-overview#a7 – Diakses pada 20

Oktober 2017.

2. Jetkins, JT and Malietzis G (2016). Small Bowel Obstruction.

http://bestpractice.bmj.com/best-practice/monograph/993/follow-

up/complications.html – Diakses pada Oktober 2017.

3. PA Ramani, Rao KJ, Chinth JR, Prakash GR, Krishna KS (2016). Evaluation of

etiopathological factors of intestinal obstruction and methods of prevention in a

tertiary care hospital. IAIM. 3(8): 164-169.

4. Alberta Health Services. Eating to Lower the Risk of a Bowel Obstruction.

http://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-eating-well-to-

lower-the-risk-bowel-obstruction.pdf – Diakses pada Oktober 2017.

Although there is no reliable strategy to prevent the occurrence of intestinal

obstruction after abdominal surgery, best surgical practice may minimise their

formation. [6] There are a variety of agents designed to limit the extent of

adhesion formation, [7] although their efficacy remains controversial. The

diagnosis and correction of malrotation can significantly prevent the development

of SBO due to intestinal volvulus. [8] Treatment of Crohn's disease and surgical

correction of hernias can also limit its development. One of the potential

advantages of laparoscopic compared with open colorectal surgery is a reduction

in postoperative bowel obstruction events. A meta-analysis showed that

laparoscopic surgery for colorectal disease reduces overall early postoperative

bowel obstruction, including ileus, as well as early bowel obstruction in

subgroups of patients having surgery for cancer and diverticular disease. [9]

1. Ramnarine, M (2017). Small Bowel Obstruction.

https://emedicine.medscape.com/article/774140-overview#a7 – Diakses pada 20

Oktober 2017.

2. Jetkins, JT and Malietzis G (2016). Small Bowel Obstruction.

http://bestpractice.bmj.com/best-practice/monograph/993/follow-

up/complications.html – Diakses pada Oktober 2017.

PENCEGAHAN

Although there is no reliable strategy to prevent the occurrence of intestinal

obstruction after abdominal surgery, best surgical practice may minimise their

formation. [6] There are a variety of agents designed to limit the extent of

adhesion formation, [7] although their efficacy remains controversial. The

diagnosis and correction of malrotation can significantly prevent the development

of SBO due to intestinal volvulus. [8] Treatment of Crohn's disease and surgical

correction of hernias can also limit its development. One of the potential
advantages of laparoscopic compared with open colorectal surgery is a reduction

in postoperative bowel obstruction events. A meta-analysis showed that

laparoscopic surgery for colorectal disease reduces overall early postoperative

bowel obstruction, including ileus, as well as early bowel obstruction in

subgroups of patients having surgery for cancer and diverticular disease. [9]

PENATALAKSANAAN

Tujuan utama penatalaksanaan adalah dekompresi bagian yang mengalami

obstruksiuntuk mencegah perforasi. Tindakan operasi biasanya selalu diperlukan.

Menghilangkan penyebab obstruksi adalah tujuan kedua. Kadang-kadang suatu

penyumbatan sembuh dengansendirinya tanpa pengobatan, terutama jika

disebabkan oleh perlengketan. Penderita penyumbatan usus harus di rawat di

rumah sakit. 7,8

1. Persiapan

Pipa lambung harus dipasang untuk mengurangi muntah, mencegah aspirasi dan

mengurangi distensi abdomen (dekompresi). Pasien dipuasakan, kemudian

dilakukan juga resusitasi cairan dan elektrolit untuk perbaikan keadaan umum.

Setelah keadaanoptimum tercapai barulah dilakukan laparatomi. Pada obstruksi

parsial atau karsinomatosis abdomen dengan pemantauan dan konservatif. 6,7,8

2. Operasi

Operasi dapat dilakukan bila sudah tercapai rehidrasi dan organ-organ vital

berfungsi secara memuaskan. Tetapi yang paling sering dilakukan adalah

pembedahan sesegera mungkin. Tindakan bedah dilakukan bila :-Strangulasi-

Obstruksi lengkap-Hernia inkarserata-Tidak ada perbaikan dengan pengobatan

konservatif (dengan pemasangan NGT, infus,oksigen dan kateter). 6,7,8

18
3. Pasca Bedah

Pengobatan pasca bedah sangat penting terutama dalam hal cairan dan elektrolit.Kita harus

mencegah terjadinya gagal ginjal dan harus memberikan kalori yang cukup.Perlu diingat bahwa

pasca bedah usus pasien masih dalam keadaan paralitik. 7,8