Adhesive small bowel obstruction: predictive value of oral contrast administration on the need for surgery

Prognostic factors to identify resolution of small bowel obstruction without need for operative management: systematic review

OBJECTIVES

To identify imaging, clinical, and laboratory variables potentially prognostic for surgical management of small bowel obstruction.

METHODS

Two researchers systematically reviewed indexed literature 2001-2021 inclusive for imaging, clinical, and laboratory variables potentially predictive of surgical management of small bowl obstruction and/or ischaemia at surgery, where performed. Risk of bias was assessed. Contingency tables for variables reported in at least 5 studies were extracted and meta-analysed to identify strong evidence of association with clinical outcomes, across studies.

RESULTS

Thirty-one studies were ultimately included, reporting 4638 patients (44 to 313 per study). 11 (35%) studies raised no risk of bias concerns. CT was the modality reported most (29 studies, 94%). Meta-analysis of 21 predictors identified 5 strongly associated with surgical intervention, 3 derived from CT (peritoneal free fluid, odds ratio [OR] 3.24, 95%CI 2.45 to 4.29; high grade obstruction, OR 3.58, 95%CI 2.46 to 5.20; mesenteric inflammation, OR 2.61, 95%CI 1.94 to 3.50; abdominal distension, OR 2.43, 95%CI 1.34 to 4.42; peritonism, OR 3.97, 95%CI 2.67 to 5.90) and one with conservative management (previous abdominopelvic surgery, OR 0.58, 95%CI 0.40 to 0.85). Meta-analysis of 10 predictors identified 3 strongly associated with ischaemia at surgery, 2 derived from CT (peritoneal free fluid, OR 3.49, 95%CI 2.28 to 5.35; bowel thickening, OR 3.26 95%CI 1.91 to 5.55; white cell count, OR 4.76, 95%CI 2.71 to 8.36).

CONCLUSIONS

Systematic review of patients with small bowel obstruction identified four imaging, three clinical, and one laboratory predictors associated strongly with surgical intervention and/or ischaemia at surgery.

CLINICAL RELEVANCE STATEMENT

Via systematic review and meta-analysis, we identified imaging, clinical, and laboratory predictors strongly associated with surgical management of small bowel obstruction and/or ischaemia. Multivariable model development to guide management should incorporate these since they display strong evidence of potential utility.

KEY POINTS

• While multivariable models incorporating clinical, laboratory, and imaging factors could predict surgical management of small bowel obstruction, none are used widely. • Via systematic review and meta-analysis we identified imaging, clinical, and laboratory variables strongly associated with surgical management and/or ischaemia at surgery. • Development of multivariable models to guide management should incorporate these predictors, notably CT scanning, since they display strong evidence of potential utility.

Computed Tomography in Emergency Diagnosis and Management Considerations of Small Bowel Obstruction for Surgical vs. Non-surgical Approach

BACKGROUND

Small bowel obstruction (SBO) accounts for 15% of abdominal pain complaints referred to emergency departments and imposes significant financial burdens on the healthcare system. The absence of passage of flatus or stool and abdominal distention are reported as the most common symptom and a sign of SBO, respectively. Patients who do not demonstrate severe clinical or imaging findings are typically treated with conservative approaches. Patients with clinical signs of sepsis or physical findings of peritonitis are often instantly transferred to the operating room without supplementary imaging assessment. However, in cases where symptoms are non-specific, or the physical examination is challenging, such as in cases with loss of consciousness, the diagnosis can be complicated. This paper discusses the key findings detectable on Computed tomography (CT), which are vital for the emergent triage, proper treatment, and decision making in patients with speculated SBO.

METHOD

Narrative review of the literature.

RESULTS AND CONCLUSION

CT plays a key role in emergent triage, proper treatment, and decision making. It provides high sensitivity, specificity, and accuracy in the detection of early-stage obstruction and acute intestinal vascular compromise. It can also differentiate between various etiologies of this entity which is considered an important criterion in the triage of patients into surgical vs. non-surgical treatment. There are multiple CT findings, such as mesenteric edema, lack of the small-bowel feces, bowel wall thickening, fat stranding in the mesentery, and intraperitoneal fluid, which are predictive of urgent surgical exploration.

Chronic intentional chicken bone ingestion mimicking inflammatory bowel disease

Ingestion of food by-products, such as peach pits, chicken bones and fish bones, may lead to intestinal complications. The ingestion of the foreign body is often acute and non-intentional. Acute and life-threatening complications include intestinal perforation or obstruction. Sharp-pointed objects are associated with an estimated 35% rate of complications within the gastrointestinal tract prior to passage and require prompt removal. Endoscopic retrieval is often recommended if foreign objects have not transited beyond the proximal duodenum. We present a unique case of a previously healthy 23-year-old male suffering months of abdominal pain. While the initial presentation and imaging were suspicious for Crohn's disease, the endoscopic findings were unexpected. Numerous chicken bone fragments were clustered in the caecum and in the terminal ileum. The distal terminal ileum was edematous and ulcerated. Subsequent patient history revealed years of chronic and intentional foreign body consumption with recent onset of abdominal pain.

Adhesive small bowel obstruction - an update

Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.

Surgical indicators for the operative treatment of acute mechanical intestinal obstruction due to adhesions

Purpose

Our aim was to investigate the predictive factors indicating strangulation, and the requirement for surgery in patients with acute mechanical intestinal obstruction due to adhesions.

Methods

This study retrospectively evaluated the records of patients with adhesive acute mechanical intestinal obstruction. The surgical treatment (group S), conservative treatment (group C), intraoperative bowel ischemia (group I), and intraoperative adhesion only (group A) groups were statistically evaluated according to the diagnostic and surgical parameters.

Results

The study group of 252 patients consisted of 113 women (44.8%), and 139 men (55.2%). The mean age was 62.79 ± 18.08 years (range, 20-98 years). Group S consisted of 50 patients (19.8%), and 202 (80.2%) were in group C. Group I consisted of 19 patients (38%), where as 31 (62%) were in group A. In group S, the prehospital symptomatic period was longer, incidence of fever was increased, and elevated CRP levels were significant (P < 0.05). Plain abdominal radiography, and abdominal computerized tomography were significantly sensitive for strangulation (P < 0.05). The elderly were more prone to strangulation (P < 0.05). Fever, rebound tendernes, and urea & creatinine levels were significantly higher in the presence of strangulation (P < 0.05, P < 0.05, and P < 0.05, consecutively).

Conclusion

Fever, rebound tenderness, urea & creatinine levels, plain abdominal radiography, and abdominal computerized tomography images were important indicators of bowel ischemia. Longer prehospital symptomatic period was related with a tendency for surgical treatment, and the elderly were more prone to strangulation. CRP detection was considered to be useful for the decision of surgery, but not significantly predictive for strangulation.

Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO.

METHODS

A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011.

RESULTS

The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting.

CONCLUSION

Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

Pattern of acute intestinal obstruction: is there a change in the underlying etiology?

BACKGROUND/AIM

To study the changing pattern of acute intestinal obstruction at a teaching institute.

PATIENTS AND METHODS

It is a prospective descriptive study conducted at a teaching hospital during the period from June 2004 to June 2009. All patients with clinical or radiological evidence of acute intestinal obstruction were included in this study regardless of the gender of the patient. Patients below the age of 10 years were excluded from the study. The treatment strategy was planned ranging from conservative treatment to emergency laparotomy after resuscitation and rehydration of the patient. Details of individual patients were recorded on a pro forma sheet and data analyzed statistically on SPSS version 14.

RESULTS

A total of 229 patients with acute intestinal obstruction were admitted and treated. The mean age of the study population was 43.08 ± 13.07 years. Postoperative adhesions accounted for 41% (n = 95) of the total cases, followed by abdominal tuberculosis (25%, n = 58), obstructed/ strangulated hernias of different types (18%, n = 42). There was an obvious change in the pattern of etiology of acute intestinal obstruction as the common causes were postoperative adhesions and abdominal tuberculosis instead of obstructed inguinal hernias.

CONCLUSION

An increase in the adhesive obstruction and a concomitant decrease in the incidence of obstructed hernias indicate a changing trend towards early operation before it gets complicated. Abdominal tuberculosis is emerging as another common cause of acute bowel obstruction.

Acute mechanical bowel obstruction: Clinical presentation, etiology, management and outcome

AIM: To identify and analyze the clinical presentation, management and outcome of patients with acute mechanical bowel obstruction along with the etiology of obstruction and the incidence and causes of bowel ischemia, necrosis, and perforation.

METHODS: This is a prospective observational study of all adult patients admitted with acute mechanical bowel obstruction between 2001 and 2002.

RESULTS: Of the 150 consecutive patients included in the study, 114 (76%) presented with small bowel and 36 (24%) with large bowel obstruction. Absence of passage of flatus (90%) and/or feces (80.6%) and abdominal distension (65.3%) were the most common symptoms and physical finding, respectively. Adhesions (64.8%), incarcerated hernias (14.8%), and large bowel cancer (13.4%) were the most frequent causes of obstruction. Eighty-eight patients (58.7%) were treated conservatively and 62 (41.3%) were operated (29 on the first day). Bowel ischemia was found in 21 cases (14%), necrosis in 14 (9.3%), and perforation in 8 (5.3%). Hernias, large bowel cancer, and adhesions were the most frequent causes of bowel ischemia (57.2%, 19.1%, 14.3%), necrosis (42.8%, 21.4%, 21.4%), and perforation (50%, 25%, 25%). A significantly higher risk of strangulation was noticed in incarcerated hernias than all the other obstruction causes.

CONCLUSION: Absence of passage of flatus and/or feces and abdominal distension are the most common symptoms and physical finding of patients with acute mechanical bowel obstruction, respectively. Adhesions, hernias, and large bowel cancer are the most common causes of obstruction, as well as of bowel ischemia, necrosis, and perforation. Although an important proportion of these patients can be nonoperatively treated, a substantial portion requires immediate operation. Great caution should be taken for the treatment of these patients since the incidence of bowel ischemia, necrosis, and perforation is significantly high.