Updated: 12/15/2021

Small Bowel Obstruction

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  • Snapshot
    • A 45-year-old woman presents to the emergency room for abdominal pain, nausea, and nonbloody vomiting for the past day. She has not had any flatus during this time. She also endorses decreased appetite. She has a past surgical history of cesarean section. On physical exam, there is diffuse tenderness to palpation of her abdomen but no rebound tenderness or guarding. An abdominal radiograph shows dilated loops of small bowel, which is confirmed with a CT abdomen and pelvis. There are no masses identified. She is admitted to the inpatient floor and a nasogastric tube is placed.
  • 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)
  • 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 (e.g., fever)
            • metabolic acidosis
            • continuous pain
  • Complications
    • Bowel necrosis
    • Peritonitis
    • Bowel perforation
  • Prognosis
    • Partial SBOs often self-resolve
    • Complete SBOs may also self-resolve but often require surgical intervention

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(M2.GI.16.43) A 76-year-old woman is brought to the emergency department after being found unresponsive in her room at her nursing facility. Past medical history is significant for Alzheimer's disease, hypertension, and diabetes. Surgical history is notable for an open cholecystectomy at age 38 and multiple cesarean sections. On arrival, she is non-responsive but breathing by herself, and her vital signs are T 102.9 F, HR 123 bpm, BP 95/64, RR 26/min, and SaO2 97% on 6L nasal cannula. On physical exam the patient has marked abdominal distension and is tympanic to percussion. Laboratory studies are notable for a lactic acidosis. An upright abdominal radiograph and CT abdomen/pelvis with contrast are shown in Figures A and B respectively. She is started on IV fluids and a nasogastric tube is placed to suction which returns green bilious fluid. Repeat vitals 1 hour later are T 101F, HR 140 bpm, BP 75/44, RR 30/min, and SaO2 is 100% on the ventilator after she is intubated for airway concerns. What is the next best step in management?

QID: 104585
FIGURES:

Therapy with levofloxacin and metronidazole

0%

(0/10)

Immediate laparotomy and surgical management

60%

(6/10)

Continue IV fluid hydration, nasogastric suction, NPO

30%

(3/10)

Pneumatic enema

10%

(1/10)

Sigmoidoscopy, attempted derotation and rectal tube placement

0%

(0/10)

M 7 C

Select Answer to see Preferred Response

(M2.GI.16.4685) A 69-year-old female presents to the emergency department with crampy abdominal pain. She has a past medical history of hypertension, dyslipidemia, and cholelithiasis status post cholecystectomy. The patient states she has not passed stool or gas for 48 hrs. On physical exam vitals are T 98.4 F HR 105 bpm BP 155/101 mmHg RR 16 SpO2 96%, abdominal exam is notable for distension, tympany to percussion, and tenderness to palpation without rebound or guarding. Which of the following findings are most likely on radiograph?

QID: 107359

Free air under the diaphragm on upright abdominal radiograph

0%

(0/14)

Apple core defect after lower GI series

0%

(0/14)

Multiple punctate mucosal outpouchings through the serosa on lower GI series

0%

(0/14)

Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph

93%

(13/14)

Loss of haustral markings and "lead pipe" appearance to the descending colon on lower GI series

7%

(1/14)

M 6 B

Select Answer to see Preferred Response

(M2.OMB.4875) A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications. His temperature is 38.5°C (101.3°F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min. His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation. His abdomen is distended and tender in all quadrants, with guarding and rebound present. He also has increased bowel sounds throughout. Laboratory results are as follows:

Hemoglobin: 11 g/dL
Leukocyte count: 16,500/mm^3 with normal differential
Platelets: 250,000/mm^3

Serum:
Creatinine: 1.0 mg/dL
Glucose: 95 mg/dL
Lipase: 45 U/L
Total bilirubin: 0.8 mg/dL
Alkaline phosphatase: 74 U/L
Aspartate aminotransferase (AST, GOT): 32 U/L
Alanine aminotransferase (ALT, GPT): 45 U/L
Lactate: 7.0 mmol/L

Which of the following is the most appropriate next step in management?

QID: 216246

Broad-spectrum antibiotics and serial abdominal radiographs

0%

(0/0)

CT angiography of the abdomen and pelvis

0%

(0/0)

Nasogastric tube placement

0%

(0/0)

Supportive care, NPO, and intravenous fluids

0%

(0/0)

Urgent surgical intervention

0%

(0/0)

M 11 E

Select Answer to see Preferred Response

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