Current Management of Small-Bowel Obstruction

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PATHOGENESIS

Small-bowel obstruction may be caused by a variety of intrinsic or extrinsic lesions (Table 1). In technologically advanced countries, the predominant cause is adhesions from a prior laparotomy, which account for up to 50% to 80% of the cases in many centers.2, 3 In less developed nations, advanced hernias, volvuli, and intussusception are the predominant causes.4, 5

Adhesions are responsible for approximately 60% of all cases of intestinal obstruction in the United States. In a retrospective

PATHOPHYSIOLOGY

Mechanical small-bowel obstruction is accompanied first by the development of mild, proximal intestinal distension that results from the accumulation of normal gastrointestinal secretions and gas above the obstructed segment. Initially, this distension physiologically stimulates peristalsis above and below the point of the obstruction. This distal peristalsis accounts for the frequent loose bowel movements that may accompany partial or even complete small-bowel obstruction in the early hours

CLINICAL PRESENTATION

The diagnostic and therapeutic approach to small-bowel obstruction should be systematic and lends itself to classification into 4 phases: (1) recognizing mechanical obstruction, (2) distinguishing partial from complete obstruction, (3) distinguishing simple from strangulating obstruction, and (4) identifying the underlying cause. This illustrates that the initial approach to bowel obstruction is generic, and attention to the underlying cause is usually a secondary consideration.

SYSTEMATIC RESUSCITATION

Patients with small-bowel obstructions are usually intravascularly depleted, often massively, because of a decreased oral intake, vomiting, and the sequestration of fluid from the intravascular space within the bowel wall and lumen. This requires aggressive replacement with an IV saline solution such as Ringer's lactate. Routine laboratory measurements of serum sodium, potassium, chloride, bicarbonate, and creatinine levels should be obtained. Serial measurements of the hematocrit level, white

Summary

The most significant advances in the management of small-bowel obstruction are developments in imaging modalities available to assist in the diagnosis itself, as well as to possibly assist in the early identification of those cases requiring urgent operative decompression. The most marked of these have been in the use and interpretation of contrast-enhanced CT. This has decreased the use of barium studies and has largely supplanted ultrasound and magnetic resonance imaging in the management of

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