Treatment Of Intestinal Obstruction

Treatment involves placing a tube through the nose into the stomach or intestine to help relieve abdominal distention and vomiting.

Surgery may be needed to relieve the obstruction if the tube does not relieve the symptoms, or if there are signs of tissue death.

Treatment

• Nasogastric suction
• IV fluids
• IV antibiotics if bowel ischemia suspected

Patients with possible intestinal obstruction should be hospitalized. Treatment of acute intestinal obstruction must proceed simultaneously with diagnosis. A surgeon should always be involved.

Supportive care is similar for small and large bowel obstruction
nasogastric suction, IV fluids (0.9% saline or lactated Ringer's solution for intravascular volume repletion), and a urinary catheter to monitor fluid output. Electrolyte replacement should be guided by test results, although in cases of repeated vomiting serum Na and K are likely to be depleted. If bowel ischemia or infarction is suspected, antibiotics should be given [eg, a 3rd-generation cephalosporin, such as cefotetan 2 g IV]before laparotomy.

Complete obstruction of the small bowel is preferentially treated with early laparotomy, although surgery can be delayed 2 or 3 h to improve fluid status and urine output in a very ill, dehydrated patient. The offending lesion is removed whenever possible. If a gallstone is the cause of obstruction, it is removed through an enterotomy, and cholecystectomy need not be done. Procedures to prevent recurrence should be done, including repair of hernias, removal of foreign bodies, and lysis of the offending adhesions. In some patients with early postoperative obstruction or repeated obstruction caused by adhesions, simple intubation with a long intestinal tube (many consider a standard NGT to be equally effective), rather than surgery, may be attempted in the absence of peritoneal signs.

Disseminated intraperitoneal cancer obstructing the small bowel is a major cause of death in adult patients with GI tract cancer. Bypassing the obstruction, either surgically or with endoscopically placed stents, may palliate symptoms briefly.

When diverticulitis causes obstruction, perforation is often present. Removal of the involved area may be very difficult but is indicated if perforation and general peritonitis are present. Resection and colostomy are done, and anastomosis is postponed.

Obstructing colon cancers can often be treated by a single-stage resection and anastomosis. Other options include a diverting ileostomy and distal anastomosis. Occasionally, a diverting colostomy with delayed resection is required.

Fecal impaction usually occurs in the rectum and can be removed digitally and with enemas. However, a fecal concretion alone or in a mixture (ie, with barium or antacids) that causes complete obstruction (usually in the sigmoid) requires laparotomy.

Treatment of cecal volvulus consists of resection and anastomosis of the involved segment or fixation of the cecum in its normal position by cecostomy in the frail patient. In sigmoidal volvulus, an endoscope or a long rectal tube can often decompress the loop, and resection and anastomosis may be deferred for a few days. Without a resection, recurrence is almost inevitable.