• EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction. Practice management guidelines for small bowel obstruction. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2007. 42 p. [80 references]

This is the current release of the guideline.

Small bowel obstruction

Management
Treatment

Critical Care
Emergency Medicine
Family Practice
Gastroenterology
Internal Medicine
Surgery

Advanced Practice Nurses
Nurses
Physician Assistants

To provide practice management guidelines for small bowel obstruction

Adults and children with small bowel obstruction

Diagnosis

1. Assessment of clinical markers
2. Physical exam
3. Plain film radiographs
4. Computed tomography
5. Magnetic resonance imaging
6. Ultrasound
7. Contrast studies (nonionic low osmolar weight contrast as an alternative to barium)

Management

1. Non-operative management
2. Water soluble contrast
3. Surgery
4. Laparoscopic treatment

• Success rate
• Morbidity and mortality rates

Searches of Electronic Databases

A computerized search of the National Library of Medicine MEDLINE database was undertaken using the PubMed Entrez interface. English language citations during the period of 1991 through 2006 using the primary search strategy: intestinal obstruction[mh] AND intestine, small[mh] AND humans[mh] NOT (case reports[pt] OR letter[pt] OR comment[pt] OR news[pt]) Review articles were also excluded. The PubMed Related Articles algorithm was also employed to identify additional articles similar to the items retrieved by the primary strategy.

Of approximately 550 articles identified, those dealing with either prospective or retrospective studies examining small bowel obstruction were selected, comprising 131 institutional studies evaluating diagnosis and management of adult patients with suspected or proven small bowel obstruction.

Weighting According to a Rating Scheme (Scheme Given)

Class I: Prospective, randomized, controlled trial

Class II: Clinical studies in which the data was collected prospectively, and retrospective analyses which were based on clearly reliable data. Types of studies so classified include: observational studies, cohort studies, prevalence studies, and case control studies.

Class III: Studies based on retrospectively collected data. Evidence used in this class includes clinical series, database or registry reviews, large series of case reviews, and expert opinion.

Systematic Review with Evidence Tables

The articles were reviewed by a group of eleven trauma/critical care surgeons who collaborated to produce this practice management guideline. (See table in the original guideline document).

Expert Consensus

Not stated

Level 1: This recommendation is convincingly justifiable based on the available scientific information alone. It is usually based on Class I data, however, strong Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, weak or contradictory Class I data may not be able to support a level 1 recommendation.

Level 2: This recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert critical care opinion. It is usually supported by Class II data or a preponderance of Class III evidence.

Level 3: This recommendation is supported by available data but adequate scientific evidence is lacking. It is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future studies.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Not stated

Not applicable

The levels of recommendation (1-3) and classes of evidence (I-III) are defined at the end of the "Major Recommendations" field.

Diagnosis

1. All patients being evaluated for small bowel obstruction (SBO) should have plain films due to the fact that plain films are as sensitive as computed tomography (CT) to differentiate obstruction vs. non-obstruction. Level III
2. All patients with inconclusive plain films for complete or high grade SBO should have a CT as CT scan gives incremental information over plain films in regard to differentiating grade of obstruction and etiology of small bowel obstruction leading to changes in planned management. Level I
3. Multiple signs on CT suggesting strangulation should suggest a low threshold for operative intervention. Level II
4. Magnetic resonance imaging (MRI) and ultrasound are an alternative to CT with similar sensitivity and identification of etiology, but have several logistical limitations. Level III
5. There is a variety of literature that contrast studies should be considered in patients who fail to improve after 48 hours of conservative management as a normal contrast study can rule out operative small bowel obstruction. Level II
6. Nonionic low osmolar weight contrast is an alternative to barium for contrast studies to evaluate for SBO for diagnostic purposes. Level I

Management

1. Patients with plain film finding of small bowel obstruction and clinical markers (fever, leukocytosis, tachycardia, metabolic acidosis and continuous pain) or peritonitis on physical exam warrant exploration. Level I
2. Patients without the above mentioned clinical picture, and a partial SBO or a complete SBO can undergo non-operative management safely; although, complete obstruction has a higher level of failure. Level I
3. Patients without resolution of their SBO by day 3-5 of non-operative management should undergo water soluble study or surgery. Level III
4. There is no significant difference with regard to the decompression achieved, the success of nonoperative treatment, or the morbidity rate after surgical intervention comparing long tube decompression with the use of nasogastric tubes. Level I
5. Water soluble contrast (Gastrograffin) given in the setting of partial SBO can improve bowel function (time to bowel movement [BM]), decrease length of stay, and is both therapeutic and diagnostic. Level II
6. In a highly selected group of patients the laparoscopic treatment of small bowel obstruction should be considered and leads to a shorter hospital length of stay. Level II

Definitions:

Classes of Evidence

Class I: Prospective, randomized, controlled trial (there were no Class I articles reviewed)

Class II: Clinical studies in which the data was collected prospectively, and retrospective analyses which were based on clearly reliable data. Types of studies so classified include: observational studies, cohort studies, prevalence studies, and case control studies.

Class III: Studies based on retrospectively collected data. Evidence used in this class includes clinical series, database or registry reviews, large series of case reviews, and expert opinion.

Levels of Recommendation

Level 1: This recommendation is convincingly justifiable based on the available scientific information alone. It is usually based on Class I data, however, strong Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, weak or contradictory Class I data may not be able to support a level 1 recommendation.

Level 2: This recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert critical care opinion. It is usually supported by Class II data or a preponderance of Class III evidence.

Level 3: This recommendation is supported by available data but adequate scientific evidence is lacking. It is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future studies.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Appropriate management and treatment of patients with small bowel obstruction

Complications related to management/treatment

• The Eastern Association for the Surgery of Trauma (EAST) is a multi-disciplinary professional society committed to improving the care of injured patients. The Ad hoc Committee for Practice Management Guideline Development of EAST develops and disseminates evidence-based information to increase the scientific knowledge needed to enhance patient and clinical decision-making, improve health care quality, and promote efficiency in the organization of public and private systems of health care delivery. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors' personal observations and do not imply endorsement by nor official policy of the Eastern Association for the Surgery of Trauma.
• "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in a given guideline. Guidelines are not entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results. While guidelines can be written that take into account variations in clinical settings, resources, or common patient characteristics, they cannot address the unique needs of each patient nor the combination of resources available to a particular community or health care professional or provider. Deviations from clinical practice guidelines may be justified by individual circumstances. Thus, guidelines must be applied based on individual patient needs using professional judgment.

An implementation strategy was not provided.

Getting Better

Effectiveness

• EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction. Practice management guidelines for small bowel obstruction. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2007. 42 p. [80 references]

Not applicable: The guideline was not adapted from another source.

2007

Eastern Association for the Surgery of Trauma - Professional Association

Eastern Association for the Surgery of Trauma (EAST)

EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction

Workgroup Members: Jose J. Diaz, Jr. MD (Co-Chair) Vanderbilt University Medical Center; Faran Bokhari, MD; (Vice-Chair) Stroger Hospital of Cook County; Nathan T. Mowery, MD, Vanderbilt University Medical Center; Jose A. Acosta, MD; Ernest F.J, Block, MD, Orlando Regional Healthcare System; William J. Bromberg, MD, Memorial Health University Medical Center; Bryan R. Collier, DO, Vanderbilt University Medical Center; Daniel C. Cullinane, MD, Mayo Clinic; Kevin M. Dwyer, MD, Inova Fairfax Hospital; Margaret M. Griffen, MD, SHANDS – Jacksonville; John C. Mayberry, MD, Oregon Health & Science University; Rebecca Jerome, Vanderbilt University Medical Center

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on September 12, 2008.

This NGC summary is based on the original guideline, which is copyrighted by the Eastern Association for the Surgery of Trauma (EAST).