START: Suspected Small Bowel Obstruction
Abdominal pain, distension, vomiting, obstipation
All Pathways
Emergency MedicineEmergency
Small Bowel Obstruction Management (WSES 2017)
Small Bowel Obstruction Management (WSES 2017): START: Suspected Small Bowel Obstruction → Confirm Diagnosis → Signs of Strangulation or Peritonitis? → ...
Pathway Overview
11 steps
Algorithm Steps
11 total
01Start 02Action Confirm Diagnosis
Clinical + imaging
- History: Prior surgery (adhesions), hernias, malignancy
- Exam: Distension, bowel sounds, tenderness, hernias
- Labs: CBC, BMP, lactate
- CT abdomen/pelvis with IV contrast (gold standard)
03Decision Signs of Strangulation or Peritonitis?
Identify surgical emergency
- STRANGULATION SIGNS: Constant severe pain, fever, tachycardia, peritoneal signs, elevated lactate, CT signs (mesenteric edema, reduced enhancement, closed loop)
04Warning EMERGENCY SURGERY
Do not delay for strangulation
- Immediate surgical exploration
- Resuscitation while preparing OR
- Broad-spectrum antibiotics
- Risk of bowel necrosis/perforation
05Outcome Discharge
Resolution of SBO
- Tolerating regular diet
- Passing flatus/stool
- Pain controlled
- Discuss recurrence risk (up to 30%)
- Return if symptoms recur
06Action Initial Non-Operative Management
Trial of conservative therapy
- NPO
- NG tube decompression
- IV fluids and electrolyte correction
- Foley catheter for monitoring
- Serial abdominal exams
07Action Water-Soluble Contrast Challenge
Gastrografin via NG tube
- 50-100 mL Gastrografin via NG tube
- Clamp NG for 2 hours
- Abdominal X-ray at 4-8 hours and 24 hours
- Therapeutic: Osmotic effect may resolve partial SBO
- Diagnostic: Predicts need for surgery
08Decision Contrast in Colon at 24 Hours?
Predicts resolution
- CONTRAST IN COLON: 99% sensitivity for resolution
- NO CONTRAST: Unlikely to resolve, surgery indicated
09Action SBO Resolving
Continue conservative management
- Advance diet slowly
- Remove NG when tolerating PO
- Bowel function returns
- Typically resolves in 24-48 hours
- Path rejoins step 05Shared downstream outcome
10Action No Resolution
Failed conservative management
- No contrast in colon at 24-48h
- Worsening clinical status
- Complete obstruction on imaging
11Action Surgical Intervention
Laparoscopy or laparotomy
- Laparoscopic approach if feasible
- Adhesiolysis
- Bowel resection if necrosis
- Open if complex or failed laparoscopy
- Path rejoins step 05Shared downstream outcome
Guideline Source
WSES Bologna Guidelines for Diagnosis and Management of Adhesive SBO
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Focused on adhesive SBO - other etiologies may differ
- Water-soluble contrast timing may vary
- Surgical decision requires clinical judgment
- Does not address malignant obstruction in detail
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
Global: WSES guidelines widely adopted
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Small Bowel Obstruction Management (WSES 2017)?
The Small Bowel Obstruction Management (WSES 2017) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on WSES Bologna Guidelines for Diagnosis and Management of Adhesive SBO.
What guideline is the Small Bowel Obstruction Management (WSES 2017) based on?
This algorithm is based on WSES Bologna Guidelines for Diagnosis and Management of Adhesive SBO (DOI: 10.1186/s13017-017-0141-3).
What are the limitations of the Small Bowel Obstruction Management (WSES 2017)?
Known limitations include: Focused on adhesive SBO - other etiologies may differ; Water-soluble contrast timing may vary; Surgical decision requires clinical judgment; Does not address malignant obstruction in detail. Individual patient factors may require deviation from these recommendations.
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