GUIDELINES

Evaluation and management of small-bowel obstruction:

An Eastern Association for the Surgery of Trauma
practice management guideline
Adrian A. Maung, MD, Dirk C. Johnson, MD, Greta L. Piper, MD, Ronald R. Barbosa, MD,
Susan E. Rowell, MD, Faran Bokhari, MD, Jay N. Collins, MD, Joseph R. Gordon, MD, Jin H. Ra, MD,
and Andrew J. Kerwin, MD

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 in-
formation 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 man-
agement 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 dem-
onstrated to be a viable alternative to laparotomy in selected cases. (J Trauma Acute Care Surg. 2012;73: S362YS369. Copyright *
2012 by Lippincott Williams & Wilkins)
KEY WORDS: Small-bowel obstruction; practice management guidelines; laparoscopy; surgery; diagnosis.

STATEMENT OF THE PROBLEM SBO did not become commonly accepted until the advent of
anesthesia, antisepsis, and safer surgical techniques in the late
Although small-bowel obstruction (SBO) has been rec- 1800s.1 At the same time, the increased prevalence of ab-
ognized since the time of Hippocrates, surgical therapy for dominal and pelvic surgery created a new source of SBOV
postoperative adhesions. Adhesions are currently the leading
Submitted: March 14, 2012, Revised: June 22, 2012, Accepted: July 16, 2012. cause of SBO in industrialized countries (È70%), followed by
From the Department of Surgery (A.A.M., D.C.J., G.L.P.), Section of Trauma, malignancy, inflammatory bowel disease, and hernias. SBO
Surgical Critical Care, and Surgical Emergencies, Yale University School of accounts for as many as 12% to 16% of surgical admissions
Medicine, New Haven, Connecticut; Trauma Services (R.R.B.), Legacy Emanuel
Hospital and Health Center, Portland, Oregon; Department of Surgery (S.E.R.), and more than 300,000 operations annually in the United
Oregon Health & Science University, Portland, Oregon; Department of Trauma States. This represents more than 2.3 billion dollars in health
and Burns (F.B.), Stroger Hospital of Cook County, Chicago, Illinois; Department care expenditures.2Y4
of Surgery (J.N.C.), Eastern Virginia Medical School, Norfolk, Virginia; Depart-
ment of Surgery (J.R.G.), Danbury Hospital, Danbury, Connecticut; Department
Over the centuries, the management of SBO has evolved.
of Surgery (J.R.G.), University of Vermont College of Medicine, Burlington, Early treatments included bloodletting and ingestion of heavy
Vermont; and Department of Surgery (J.H.R., A.J.K.), University of Florida metals. Advancements brought intestinal tube decompression
College of Medicine, Jacksonville, Florida. and operative interventions. In 2007, the Eastern Association
This work was presented at the 25th Annual Scientific Assembly of the Eastern
Association for the Surgery of Trauma, January 10-14-2012, in Lake Buena for the Surgery of Trauma (EAST) developed modern guide-
Vista, Florida. lines for the management of SBO that were subsequently pub-
Supplemental digital content is available for this article. Direct URL citations appear in lished in the Journal of Trauma in 2008.1 The guidelines
the printed text, and links to the digital files are provided in the HTML text of this
article on the journal’s Web site (www.jtrauma.com).
offered 12 evidence-based recommendations for the diag-
Address for reprints: Adrian Anthony Maung, MD, Department of Surgery, nosis and management of SBO based on a systematic review
Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale of the English literature published between 1991 and 2006.
University School of Medicine, 330 Cedar Street (BB-310), New Haven, CT
06520; email: adrian.maung@yale.edu.
However, optimal strategies are in constant flux secondary to
advances in imaging techniques, critical care, and surgical tech-
DOI: 10.1097/TA.0b013e31827019de niques. For example, in the 5-year interim period, multiple
J Trauma Acute Care Surg
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J Trauma Acute Care Surg
Volume 73, Number 5, Supplement 4 Maung et al.

studies have further evaluated the role of computed tomographic RECOMMENDATIONS

(CT) scans in the diagnosis and management of SBO, as well
as the increasing use and role of laparoscopy in the treatment Diagnosis
of SBO. This update to the practice management guidelines 1. CT scan of abdomen and pelvis should be considered in all
was therefore developed, presented, and discussed at the 2012 patients with SBO because it can provide incremental in-
EAST Annual Meeting. formation over plain films in differentiating grade, severity,
and etiology of SBOs that may lead to changes in man-
PROCESS agement. Level 1.
2. Water-soluble contrast study should be considered in
A computerized search of the National Library of Medi-
patients who fail to improve after 48 hours of nonoperative
cine MEDLINE database was undertaken using the PubMed
management because a normal contrast study can rule out
Entrez interface for English language citations during the pe-
operative SBO. Level 2.
riod of 2007 through 2011 using the primary search strategy:
3. If available, multidetector CT scanner and multiplanar re-
intestinal obstruction[mh] AND intestine, small[mh] AND
construction should be used because they aid in the diag-
humans[mh] NOT
nosis and localization of SBOs. Level 3.
(case reports[pt] OR letter[pt] OR comment[pt] OR news[pt])
4. Magnetic resonance imaging (MRI) and ultrasound are po-
tential alternatives to computed tomography but may have
The primary search identified 259 articles that met our
several logistical limitations. Level 3.
criteria. After the exclusion of review and pediatric and inflam-
5. CT scan should be considered to aid in the diagnosis of
matory bowel disease articles, 53 new articles were identified.
small-bowel volvulus. Findings include multiple transition
These articles detailed both prospective and retrospective stud-
points, posterior location, and the ‘‘whirl’’ sign. Level 3.
ies examining adult patients with suspected or proven SBO.
These articles were added to the 131 previous studies reviewed
in the 2007 practice management guidelines (Appendix, Sup- Management
plemental Digital Content 1, http://links.lww.com/TA/A200). 1. Patients with SBO and generalized peritonitis on physical
77Y91,93Y160
A group of 10 acute care surgeons collaborated to examination or with other evidence of clinical deteriora-
produce this practice management guidelines update. Each tion such as fever, leukocytosis, tachycardia, metabolic
article was reviewed and graded according to the level of evi- acidosis, and continuous pain should undergo timely sur-
dence (Table 1) by at least two surgeons. The correlation be- gical exploration. Level 1.
tween the evidence and the level of recommendations as 2. Patients without the previously mentioned clinical picture
defined by EAST is as follows: can safely undergo initial nonoperative management for
both partial and complete SBO, although complete ob-
Level 1: This recommendation is convincingly justifiable based struction has a higher level of failure. Level 1.
on the available scientific information alone. It is usually 3. CT findings consistent with bowel ischemia should suggest
based on Class I data; however, strong Class II evidence a low threshold for operative intervention. Level 2.
may form the basis for a Level 1 recommendation espe- 4. Laparoscopic treatment of SBO is a viable alternative to
cially if the issue does not lend itself to testing in a ran- laparotomy in selected cases. When successful, it may be
domized format. Conversely, weak or contradictory Class I associated with decreased morbidity and a shorter length
data may not be able to support a Level 1 recommendation. of stay. Level 2.
Level 2: This recommendation is reasonably justifiable by 5. Water-soluble contrast should be considered in the setting
available scientific evidence and strongly supported by of partial SBO that has not resolved in 48 hours because it
expert critical care opinion. It is usually supported by Class can improve bowel function (time to bowel movement),
II data or a preponderance of Class III evidence. decrease length of stay, and is both therapeutic and diag-
Level 3: This recommendation is supported by available data, nostic. Level 2.
but adequate scientific evidence is lacking. It is generally 6. Patients without resolution of the SBO by days 3 to 5 of
supported by Class III data. This type of recommenda- nonoperative management should undergo water-soluble
tion is useful for educational purposes and in guiding fu- contrast study or surgery. Level 3.
ture studies. 7. Patients with SBO should generally be admitted to a sur-
gical service because this has been shown to be associated
TABLE 1. Grading of Scientific Evidence Based on the with a shorter length of stay, less hospital charges, and lower
EAST Criteria mortality compared with admission to a medical service.
Level 3.
Class I Prospective, randomized, controlled trials
Class II Clinical studies in which the data were collected prospectively
and retrospective analyses that were based on clearly reliable SCIENTIFIC FOUNDATION
data. Types of studies so classified include observational
studies, cohort studies, prevalence studies, and The evaluation of patients with suspected SBO endea-
case-control studies. vors not only to confirm the diagnosis but also to determine
Class III Studies based on retrospectively collected data. Evidence the need for and timing of surgery. The workup should dis-
used in this class includes clinical series, database or registry tinguish mechanical obstruction from ileus, determine the
review, large series of case reviews, and expert opinion.
cause of the obstruction, and differentiate partial (low-grade)

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 J Trauma Acute Care Surg
Maung et al. Volume 73, Number 5, Supplement 4

from complete (high-grade) obstructions. In addition, the patient CT scans can also be used for the detection of small-
should be assessed for signs of bowel ischemia. bowel volvulus; predictors include multiple transition points,
An appropriate history and physical examination should posterior location of transition point, and the presence of the
be performed. Specific historical elements that should be dis- whirl sign.14 ‘‘Whirl sign’’ refers to a ‘‘characteristic swirl of
cerned include previous abdominal operations, radiation, and the mesenteric fat and soft tissue attenuations with adjacent
other abdominal disorders (inflammatory bowel disease, neo- loops of small bowel surrounding rotated intestinal vessels.’’92
plasm, etc.) that may cause SBO. The physical examination Multidetector helical CT and multiplanar reformats may aid
should include an evaluation for signs of systemic toxicity, a in the diagnosis of SBO by allowing visualization of the loops
thorough abdominal examination, and an evaluation for poten- of bowel in multiple planes.15,16
tial external hernias. Laboratory studies should be performed
to evaluate for the presence of metabolic derangements, acido- Ultrasound and MRI
sis, or leukocytosis. These may suggest that bowel ischemia is Class II and III data have demonstrated that ultrasound
present, although the specificity is low. findings can diagnose SBO with accuracy comparable to plain
films.6,17Y20 In addition, it can detect free fluid that may sug-
Plain Radiography gest the presence of ischemia.21 Although experience with
Radiologic evaluation has traditionally started with a using ultrasound findings for diagnosing SBO is currently not
three-view abdominal radiograph series (upright chest radio- widespread, the technique can be easily learned.20
graph, upright and supine abdominal radiographs) to confirm Half-Fourier Acquisition Single-shot Turbo-spin Echo
the diagnosis of SBO. Although there is Class III evidence to (HASTE) MRI has been shown in Class II and III studies to
suggest that plain films and CT scans have similar sensitivity diagnose SBO with a high reported sensitivity (95%), speci-
for detection of high-grade obstruction (86 vs. 82%), there is ficity (100%), and accuracy at determining the level of ob-
also data to suggest that plain films are less sensitive in the struction (73%).22Y26 However, MRI may not be available at
setting of partial bowel obstruction.5 The overall sensitivity of all centers (especially at night), has a longer scan time, and may
abdominal radiographs for the detection of SBO ranges from not be as reliable in identifying the cause of obstruction.
59% to 93% but is dependent on the radiologist’s experi-
ence.5Y7 Small-bowel ileus and large-bowel obstruction may
Contrast Studies and Enteroclysis
also mimic SBO findings in traditional planar radiographs. In
addition, plain radiographs are nondiagnostic or nonspecific Contrast examination of the small bowel can be helpful
in many cases.8 Plain films, however, currently remain part of particularly in identifying cases of low-grade or partial SBO
the initial diagnostic evaluation because of their widespread that can be difficult to detect on CT scan.27,28 Fluoroscopic,
availability, low cost, and ability to follow disease progression CT, and MRI enteroclysis techniques have all been used but
serially. have not been compared directly with themselves to determine
which is superior in SBO patients. Both nonionic low-osmolar-
Computed Tomography weight contrast and barium can be used.29 Contrast studies
can be used in conjunction with CT for equivocal cases of
CT scans have been shown in Class II and III studies to
SBO with an increased combined sensitivity and specificity.30
be superior to plain film radiography in the overall diagnosis
Water-soluble contrast studies can accurately predict the need
of SBO. They can also provide additional information that
for surgery and reduce the need for operation and shorten
alters patient management. CT scans have been shown to be
hospital stay.31Y34 Although more labor intensive than CT
83% to 94% accurate at diagnosing obstruction.6,9 Findings
scanning, contrast studies may offer greater sensitivity in the
consistent with SBO on CT scan include
detection of intraluminal or mural etiologies of obstruction.
1. a transition point with dilation of bowel proximally and
decompression distally; Initial Management: Operative
2. a decompressed colon; and Versus Nonoperative
3. failure of intraluminal contrast to pass beyond the transi- Early operative management should be pursued in patients
tion point. with suspected bowel strangulation because this is associated
with an increased morbidity and mortality. Clinical indica-
CT scans can determine not only the level of obstruc- tors, which include fever, leukocytosis, tachycardia, contin-
tion (93%) but also the cause (80Y91%) in most patients.6,9,10 uous pain, metabolic acidosis, peritonitis, and the systemic
There are also Class II data to suggest that CT is 85% to 100% inflammatory response syndrome (SIRS), correctly identify
sensitive in detection of bowel ischemia.9Y13 CT findings sug- bowel ischemia in approximately 40% to 50% of cases.35Y37
gestive of ischemia include The addition of imaging studies will identify most patients
who need early operative intervention (70Y96%).38Y40
1. reduced bowel wall enhancement; The initial management of patients with complete SBO
2. wall thickening; remains controversial. Although complete SBO is associated
3. mesenteric venous congestion; with a higher requirement for small-bowel resection (31%)
4. mesenteric fluid; in some series,41 others have demonstrated that nonoperative
5. unusual course of the mesenteric vasculature; and management is still successful in 41% to 73% of patients with
6. ascites. complete obstruction.42Y44

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J Trauma Acute Care Surg
Volume 73, Number 5, Supplement 4 Maung et al.

Operative management of both partial and complete difference in SBO with the use of Seprafilm, although in the
SBO is associated with lower reoccurrence rates and lon- intestinal resection study, the Seprafilm group had a lower rate
ger disease-free interval when compared with nonoperative of SBO that required reoperation.69,70 Other retrospective trials
management.45Y48 have reported a decreased incidence of SBO with the use of
Patients without clinical or radiologic signs and symp- Seprafilm.71Y74 Placing Seprafilm near an anastomosis should
toms of bowel ischemia can safely undergo initial nonopera- be done with trepidation because it has been associated with
tive management. Progression to bowel ischemia in the setting higher rates of anastomotic leak.75
of partial SBO is unlikely to occur with nonoperative man-
agement (3Y6%),35 but patients need to be monitored with Admitting Service
serial abdominal examinations and laboratory studies. Non- There are Class III data to suggest that patients with
operative management is overall successful in 65% to 80% SBO admitted to a surgical service have shorter length of stay,
of patients, especially in the setting of partial SBO and early less hospital charges, shorter time to surgery, and lower mor-
postoperative period SBO.42,43,49,50 Most patients improve tality than patients admitted to medical service.76 This may be
within 2 to 5 days after initiation of therapy.35,50 Failure to confounded by a number of factors. Patients who are unable
regain bowel function after 5 days suggests the need for an to tolerate or are unwilling to undergo an operation can be
operation. considered for admission to a medical service.

Hypertonic Contrast in Partial SBO SUMMARY

In patients who do not have resolution of SBO within
48 hours of admission, Class I and II data support performing Evaluation and management of SBO continue to evolve
contrast studies before operative intervention to differentiate with advances in medical technology and techniques. Since
complete from partial SBO.51Y53 For patients with a partial the publication of the EAST practice management guideline
SBO, the water-soluble contrast study may itself be therapeu- on SBO in 2008, there has been increased support for the use
tic because it causes a shift of fluid into the intestinal lumen, of CT scans to confirm the diagnosis of SBO and assist in de-
thus increasing the pressure gradient across the site of obstruc- termining the initial clinical management. Minimally inva-
tion. This may speed the return of bowel function and decrease sive surgery is being used with increasing frequency and in
the overall length of stay.51,52,54Y58 more complex cases. In the current era of cost containment
and regulatory agencies analysis of outcomes, further studies
Operative Approach: Open Versus Laparoscopic are needed to better delineate the expected short- and long-
A preponderance of Class III studies has demonstrated term outcomes after both nonoperative and operative man-
that laparoscopic surgery for SBO is a safe and acceptable agement of SBO.
alternative to open surgery. Although previously reserved only
for simple SBO, current literature supports the use of laparos- AUTHORSHIP
copy in complex SBO with dilated bowel and multiple pre- A.A.M. and D.C.J. performed the literature search. All authors partici-
vious abdominal operations.59,60 The appropriate setting not pated in review of the available literature, data analysis and develop-
ment of the recommendations. A.A.M., D.C.J., and G.L.P. wrote the
only depends on the patient but also on the surgeon’s experi- manuscript. All authors participated in critical revisions.
ence. A meta-analysis of 29 studies and 2005 patients reported
a conversion rate of 29% and an enterotomy rate of 7%.61
Patients with a single-band adhesive obstruction have a higher DISCLOSURE
success rate.59,62Y64 Successful laparoscopic surgery is asso- The authors declare no conflicts of interest.
ciated with an earlier recovery of bowel function and a shorter
length of stay.62,65Y67
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