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small intestinal obstruction

Etiology: 1) postoperative adhesion (most common cause) 2) hernia: inguinal, femoral, umbilical, ventral or incisional 3) neoplasm, most likely extension from an intra-abdominal primary: colon, pancreas, stomach, gynecologic cancer 4) intussusception 5) volvulus 6) gallstones 7) foreign body 8) trichobezoar 9) inflammatory bowel disease 10) intestinal helminths 11) trauma 12) radiation injury 13) meconium in newborns 14) congenital intrinsic lesions Clinical manifestations: see intestinal obstruction Laboratory: see intestinal obstruction Radiology: - CT of abdomen - > 1 beak sign (tapering of bowel at the obstruction site) suggests surgical intervention - multiple beak signs implies twisting or closed-loop obstruction [3] Management: 1) medical management of partial obstruction a) NG tube decompression may be of no benefit [4] b) IV fluids c) two strategies 1] nothing by mouth (76% managed without surgery) [2] 2] magnesium oxide to stimulate bowel movement, simethicone to accelerate gas passage, Lactobacillus acidophilus to promote digestion of undigested food in the bowel lumen (91% managed without surgery) [2] 2) surgery may lower risk for recurrence with adhesive small bowel obstruction [5] 3) early surgery benefits some patients with malignant small bowel obstruction [6]

General

intestinal obstruction

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 337-38
  2. Chen SC, Yen ZS, Lee CC, Liu YP, Chen WJ, Lai HS, Lin FY, Chen WJ. Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial. CMAJ. 2005 Nov 8;173(10):1165-9. PMID: 16275967
  3. Millet I et al. Adhesive small-bowel obstruction: Value of CT in identifying findings associated with the effectiveness of nonsurgical treatment. Radiology 2014 Nov; 273:425 PMID: 24991990
  4. Berman DJ, Ijaz H, Alkhunai M et al. Nasogastric decompression not associated with a reduction in surgery or bowel ischemia for acute small bowel obstruction. Am J Emerg Med 2017 Aug 15 PMID: 28912083 http://www.ajemjournal.com/article/S0735-6757(17)30676-9/fulltext
  5. Behman R, Nathens AB, Mason S et al. Association of surgical intervention for adhesive small bowel obstruction with the risk of recurrence. JAMA Surg 2019 May; 154:413. PMID: 30698610 https://jamanetwork.com/journals/jamasurgery/fullarticle/2722649
  6. Krouse RS et al. Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): A pragmatic comparative effectiveness trial. Lancet Gastroenterol Hepatol 2023 Oct; 8:908. PMID: 37541263 PMCID: PMC10530384 (available on 2024-10-01) https://www.thelancet.com/journals/langas/article/PIIS2468-1253(23)00191-7/fulltext