PHILADELPHIA – Closely monitoring patients admitted for small bowel obstruction every 4 hours and starting them on intravenous fluids, bowel rest, and nasogastric tube decompression may aid in quickly differentiating partial and complete SBO and direct them into targeted treatment earlier, according to investigators at the University of Florida Health, Gainesville.
“Despite the prevalence of small bowel obstruction and the fact that we’ve been dealing with it for more than a century, we still do not have a general consensus on how to differentiate between partial bowel obstruction and complete obstruction,” Dr. Janeen Jordan said at the annual meeting of the American Association for the Surgery of Trauma. Dr. Jordan reported on a study involving 91 patients admitted for SBO over 1 year at the University of Florida Health.
Early differentiation of partial vs. complete bowel obstruction and early intervention were goals of the protocol, Dr. Jordan said. “We really wanted to get them to surgery within 3 days with hopes of decreasing our bowel resection rate, hospital length of stay and, of course, mortality,” she said.
She outlined the protocol her institution used in symptomatic patients with x-ray findings positive for SBO: admission for intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and exams every 4 hours. Once stabilized, patients received a CT scan with only intravenous contrast to confirm the diagnosis. “If there was any suggestion of bowel compromise such as pneumatosis, mesenteric edema, or suggestion of a closed-loop obstruction, they were evaluated immediately for operation,” Dr. Jordan said. “If patients had none of those findings or had fecalization, which suggests a chronic problem instead of an acute issue, those patients were admitted for bowel decompression and IV fluid resuscitation.”
After resuscitation, patients with peritonitis or CT imaging positive for bowel compromise had exploratory surgery. All other patients received an osmotically active, water-soluble contrast agent and diagnostic imaging at 4, 8, 12 and 24 hours. If contrast did not reach the colon in 24 hours, the patient underwent exploratory surgery.
Twenty-six patients went directly to the OR without entering the protocol, 58% of whom required bowel resection, Dr. Jordan said. Among the 75 patients in the protocol, 43% required surgery. The average time to surgery was within 1 day for those not on the protocol and 2 days for those managed with contrast. Demographics between the two groups were similar, although the nonprotocol patients were more likely to have bowel wall thickening on CT scan.
The analysis also compared patients who received contrast and those who did not, and further broke that down into patients who had surgery vs. nonoperative management in each group. “Giving them contrast didn’t increase hospital length of stay,” Dr. Jordan said. “And the patients who didn’t get surgery had an overall hospital length of stay of 3-4 days; if they had surgery, regardless whether or not they received contrast, their hospital length of stay was approximately 10 days.” Additionally, the length of time for the contrast to reach the colon was predictive of who would fail at eating or drinking by mouth or have recurrent symptoms before discharge.
Discussant Dr. Clay Cothren Burlew of Denver Health said she found the concept of a protocol for patients with symptoms of SBO “incredibly appealing.” However, she added, “Patients without overt clinical signs of peritonitis mandating operative intervention are often fraught with challenges. Questions of the timing of intervention to bring about resolution have never really been met. It’s a gray zone in surgery.”
Dr. Martin Schreiber of Oregon Health & Science University, Portland, questioned the cost involved in imaging without contrast. “Instead of doing a CT scan without enteral contrast and then doing an upper GI, why not do the CT with enteral contrast and then do your follow-up x-rays to see if contrast reaches the colon? Skip a step and save lots of money.”
Dr. Ronald Maier of the University of Washington, Seattle, pointed out the protocol seeks to rule out surgery for a patient population that’s unlikely to have surgery anyway. “We know, as many studies have presented, 85% of these people – if you never operate on them – go home without an operation and they do fine,” he said. “So you’re hunting for the 15%, and yet in your protocol you operate on nearly half of them.”
Previously published studies that linked interventions after 3 days in the hospital with higher bowel resection and mortality determined the timing of surgery in the protocol, Dr. Jordan said. However, she admitted that the rate of surgery was lower at the end of the study period than at the beginning.