Technology Takes a Backseat in Small Bowel Obstruction Diagnosis Improving the Management of Acute Adhesive Small Bowel Obstruction With CT Scan and Water Soluble Contrast Medium: A Prospective Study

Background: Adhesive small bowel obstruction (SBO) is common. Most patients can be managed nonoperatively, although the worry about missing ischemic bowel is always a worry. Signs and symptoms that indicate an urgent trip to the operating room are still lacking even in this day and age of CT assessment of patients with SBO. Objective: To evaluate a treatment algorithm for patients with SBO. Design: Prospective clinical study. Participants: 118 patients with 123 episodes of SBO. Methods: Patients were assessed for SBO based on clinical history and symptoms. Initial evaluation included physical findings, plain radiographs, and CT scanning with IV contrast. Patients were divided into 3 groups based on surgical intervention. Group 1 was taken directly to surgery, Group 2 had a successful nonoperative trial, and Group 3 had a failed nonoperative trial. An attempt was made to define factors that predicted surgical intervention. Interventions: Patients with clinical signs of peritonitis or CT evidence of ischemia were taken immediately to the operating room. All others received a nasogastric tube. After 2 hours of suction and resolution of symptoms, 100 cc of Gastrografin® was instilled in the nasogastric tube which was clamped for 4 hours. A plain abdominal film was taken at 12 hours. If clinical improvement occurred and colon was opacified at 12 hours, patients progressed to oral intake. Return of symptoms prompted operative intervention. Results: 36 patients were taken immediately to the operating room and all had ischemic bowel. CT scan was helpful in making this decision in 5 patients (14%). Of patients, 59 were successfully treated medically and 28 developed recurrent symptoms and required surgery. None of these patients had the contrast reach the colon by 12 hours. Median time to operative intervention was 28 hours. No differences were noted when examining CT findings between groups. Additionally, no parameters were helpful in predicting the need for exploratory laparotomy. Conclusions: Gastrografin might help identify patients who will fail nonoperative management. Reviewer's Comments: We all have had at least one patient with a SBO that received Gastrografin. Sometimes it works and others it does not. This article suggests that Gastrografin may be able to predict which patients need an operation earlier than our clinical assessment. A slow transit of Gastrografin into the colon at 12 hours correlated with the need for operative intervention. CT scans were not all that helpful after an initial one and the authors actually suggest that follow-up CT scans in these patients should not be done. The authors avoid making a claim that Gastrografin can treat SBO. Finally, the authors reaffirm that no test is accurate enough to say it can be used to separate SBO patients into groups that require early or late operative exploration. (Reviewer-John A. Weigelt, MD).