Conservative management of adhesive obstruction is a trial, not a default. Reassess at fixed intervals and know beforehand what ends it.
Fever, tachycardia, continuous rather than colicky pain, peritonism, rising lactate or white cell count, or CT features of ischaemia (reduced wall enhancement, mesenteric fluid, closed loop) should take the patient to theatre. Contrast failing to reach the colon by 24 hours predicts that non-operative management will fail.
- Set review times at the start of a conservative trial.
- Treat continuous pain, peritonism or tachycardia as signs to operate.
- Look for closed-loop and ischaemic signs on CT.
- Use water-soluble contrast to predict which patients will settle.
Why it matters
Most harm in adhesive obstruction comes from operating late on bowel that was already ischaemic.
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