Operative management can be achieved either via open laparotomy or laparoscopy (B). Operative management (C) with laparotomy and lysis of adhesions should be considered in the following conditions: if the patient demonstrates evidence of clinical deterioration as manifest by increasing pain, tenderness, fever, leukocytosis, or acidosis. Most patients with SBO due to adhesions improve with these maneuvers, and do not require surgery. Once the patient has been adequately resuscitated, CT scan (E) with oral contrast is recommended as it is useful in confirming the diagnosis of SBO, determining if the SBO is partial or complete, and ruling out other diagnosis.
Aside from the salutatory effect of NG decompression on the distended bowel, patients with SBO are at risk of aspiration. The initial management of SBO includes placing the patient NPO, aggressive intravenous fluid resuscitation (the patient is tachycardic and likely very dehydrated), and NG tube placement. SBO from adhesions can present many years after surgery.
This patient has evidence (on history, physical, and radiologic imaging) of a small bowel obstruction (SBO) that is most likely secondary to adhesions from prior surgery (scar in RUQ). Amylase, lipase, and liver chemistries are normal.
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Abdominal series demonstrates one loop of markedly distended small bowel in the right upper quadrant with an air fluid level. The rest of the abdominal exam is unremarkable. He has marked right upper quadrant tenderness to palpation with guarding. Bowel sounds are hyperactive with occasional rushes and tinkles. His abdomen has a well-healed midline scar and is distended. On physical exam, his temperature is 100.9 ☏, blood pressure is 110/80 mmHg, and heart rate is 110/min. Past history is significant for prior sigmoid colectomy for diverticulitis 10 years ago. A 65-year-old male presents to the ED with nausea, vomiting, and severe abdominal pain.
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