Wednesday, July 11, 2012

Management of small bowel obstruction

Pascal Frey (@alpascal) asks, While reading your posts on Twitter I stumbled upon "Ask SkepticalScalpel," and I really like your idea. As a medically and technically interested resident I always like to ask many questions and have only little time (and experience) to find (or get) good answers. So here's my first question for you: is there any good data on the outcome comparing conservative vs. surgical treatment of small intestine ileus (of any form or origin, e.g. due to adhesions)?

Good question. It's a topic that I've always been interested in and it's about the third most common illness I see. The short answer is "No." I am not aware of any quality study comparing the results of surgery vs. observation for small bowel obstruction.

Management depends on the cause of the small bowel obstruction. Obstruction due to hernia or tumor almost always requires surgery. Obstruction secondary to adhesions responds to observation, bowel rest, NG suction and IV hydration in about 75% of cases. Early postop bowel obstruction or ileus is a big problem and nearly always gets better without re-operation.

The hardest decisions are who needs an operation and when to operate. If one waits for fever, tachycardia, localized pain, elevated WBC or metabolic acidosis to operate, it’s often too late and a resection of part of the intestine will be necessary. There are numerous papers on this subject, but it always comes down to each case being handled by almost instinct.

Outcomes are hard to compare because a randomized trial would be difficult to do because of the diverse nature of the patients and the types of obstruction.

I’m sorry I couldn’t be more definitive. Thanks for your interest.