Most adhesive small bowel obstructions settle with drip and suck, but a few strangulate, and the cost of missing them is high. Non-operative management should be a time-limited trial with explicit stop points, reviewed by a senior at each ward round.
Signs of ischaemia override the trial at any point.
- Operate without delay for peritonitis, fever with tachycardia, rising lactate or CT signs of ischaemia or closed loop.
- Give water-soluble contrast early; contrast in the colon by about 24 hours predicts resolution.
- Reassess clinically at least twice a day while managing non-operatively.
- If the obstruction has not resolved after about 72 hours, discuss operation.
- In a patient with no previous abdominal surgery, look for another cause before calling it adhesional.
Why it matters
Late recognition of strangulation, not the decision to wait, is where these patients come to harm.
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