Principles of management

The history and examination are valuable in suspected gastrointestinal obstruction to identify the approximate level of blockage.

The underlying management can be summarised as 'drip and suck'. The patient is kept nil by mouth and given intravenous fluids - the volume and type of which depend on the state of hydration and electrolyte balance. A nasogastric tube is placed in small bowel obstruction or if the patient is vomiting. This minimises the risk of aspiration of gastric contents, especially during the induction of general anaesthesia if surgery is required. Pain relief is given. Antibiotic prophylaxis against sepsis should be considered.

Indications for immediate surgery include:

• crescendo pain
• localised peritonism, implying perforation or ischaemia
• complete colonic obstruction with competent ileocaecal valve and caecum dilated to greater than 8cm
• "closed loop" seen radiologically
• obstruction occurring as a result of hernial incarceration

If peritonism is absent, then treatment is conservative for two or three days; i.e. nil by mouth, with nasogastric tube. If the features of obstruction do not resolve, or if there is general deterioration of the patient's condition with onset of abdominal tenderness and a tachycardia, then surgery is indicated.

Large bowel obstruction caused by faecal impaction may be treated with enemas or manual removal of faeces.

Non-mechanical bowel obstruction will usually resolve with conservative treatment and removal of any precipitating cause.

Reference

1. Association of Surgeons of Great Britain and Ireland; Royal College of Surgeons of England. Commissioning guide: emergency general surgery (acute abdominal pain). April 2014 [internet publication].