List of Abbreviations
CI – confidence interval
IO – intestinal obstruction
CT – computed tomography
MRI – magnetic resonance imaging
RCT – randomized controlled trial
Level of Evidence (LoE) – level of certainty of evidence
Ultrasound – ultrasound examination
LoE – level of evidence / recommendation strength
ENID – endoscopic nasoenteric decompression
NOM – non-operative management
CA – contrast agent (according to the ATC classification, contrast media)
LA – laparoscopic adhesiolysis
SIRS – systemic inflammatory response syndrome
Terms and Definitions
Intestinal obstruction (IO) is functional or mechanical obstruction (from Lat. obstructio – block, barrier, hindrance) of the small or large intestine.
Intestinal (mesenteric) ischemia – impairment of arterial or venous mesenteric blood flow or microcirculation in a segment of the intestine.
Strangulating IO (from English *strangulation*) is the most frequent cause of intestinal ischemia due to compression of the mesenteric vessels and a segment of the intestine within a constricting ring formed by adhesions or a hernia ring. Other causes of intestinal ischemia include intussusception, volvulus, and pressure sores (decubitus) of the intestinal wall caused by an intraluminal mass (gallstone, bezoar) or a dense adhesion.
Early surgery for small bowel obstruction – surgery performed within the first 24 hours of inpatient treatment.
Late surgery for small bowel obstruction – surgery performed later than 24 hours after admission.
Emergency surgery is performed within 2 hours of hospitalization. Emergency, early, and late surgeries are used in the management of IO.
Non-operative management of IO – a system of measures including infusion therapy, nasogastric decompression, complication prevention, and monitoring of parameters to resolve IO without surgery.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Intestinal obstruction – functional or mechanical obstruction (from Lat. *obstructio* – blockage, barrier, hindrance) of the small or large intestine.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Among the causes of mechanical small bowel obstruction, adhesive IO accounts for 49–73%, incarcerated hernia for 2–15%, primary or metastatic tumors for 5–13%, and Crohn's disease for 4–7%. Intussusception, volvulus, obstruction by a bezoar, gallstone or foreign body, sclerosing enteritis, etc., collectively account for 4 to 12% [1–3]. Small bowel obstruction is 4–5 times more frequent than large bowel obstruction. Non-tumor diseases account for 20 to 40% of large bowel obstructions, the most frequent causes being volvulus (11–15%) and diverticulitis (4–10%). Other nosologies account for no more than 5%, including intussusception, hernia, inflammatory bowel diseases, foreign bodies, acute colonic pseudo-obstruction, etc. Functional (dynamic) obstruction often develops against the background of opioid and anticholinergic drug use. Intestinal motility disorders are aggravated by fluid-electrolyte and neurological disturbances, as well as recent abdominal surgeries [4].
To understand the local (abdominal cavity, intestinal wall, and mesentery) and systemic (organ) manifestations of IO, which are similar regardless of etiology, it is essential to understand the basic mechanisms of IO pathophysiology. Disruption of normal intestinal transit is accompanied by bowel dilation, abdominal distension, delayed passage of stool and gas, nausea, and vomiting. A positive feedback loop has been established between intestinal wall distension and the secretion of fluid and electrolytes into its lumen, which sometimes manifests as post-obstructive diarrhea [5,6]. Colicky abdominal pain is a consequence of increased peristalsis proximal and distal to the obstruction. Tachycardia or decreased blood pressure is observed in patients due to fluid and electrolyte loss from vomiting, inability to take oral food and fluids, as well as abdominal pain, intestinal ischemia, and sepsis [7].
Ischemic injury. When intraluminal pressure increases to 30 mm Hg, the terminal lacteals become occluded, leading to lymphedema of the intestinal wall [8]. At pressures exceeding 50 mm Hg, postcapillary venules are obstructed, increasing filtration through the capillary bed into the intestinal lumen, which leads to hypovolemia, hypotension, tachycardia, and metabolic acidosis. Increasing venous hypertension is accompanied by arterial compression and intestinal wall necrosis [2]. Even before irreversible ischemic changes develop due to disruption of the intestinal-mucosal barrier, bacterial translocation occurs as one of the potential sources of sepsis. In strangulated IO, microorganism translocation into the systemic circulation occurs within a few hours, whereas in non-strangulated IO, translocation into the portal venous system is observed later than 24–48 hours of experiment, and even later into the systemic circulation [9]. It should be emphasized that reaching critical intraluminal pressure levels required for ischemic injury to the intestinal wall in patients without strangulation is considered unlikely due to the natural decompression of the upper gastrointestinal tract via vomiting [10]. Non-strangulated IO in experiments was accompanied by very low intraluminal pressure, only 5–10 mm Hg, which did not pose a serious threat to intestinal viability [11]. Conditions for increased intraluminal pressure arise when an isolated (closed) intestinal loop is formed ("closed loop obstruction") [12, 13]. The timeframe for irreversible intestinal damage in strangulated IO ranges from several hours to several days and depends on the degree of impaired intestinal blood supply. With 25% preservation of arterial blood flow for 12 hours, significant ischemic intestinal injury was not established [14]. With complete cessation of mesenteric blood flow, irreversible changes in the intestinal wall develop by 6 hours [15]. Data on the timelines of ischemic intestinal damage in non-strangulated IO are limited—in experimental IO after 3 days, changes corresponding to hypertrophy were found in the afferent intestine [16]. By 5 days in another experimental study, only reversible changes were established [17]. It is noted that the safe duration of non-operative treatment for IO can reach up to 10 days [15]. At the same time, localized intestinal necrosis may form at the site of intestinal compression by a coarse adhesion. Pressure sores of the intestinal wall caused by an intraluminal formation—a gallstone or bezoar—are noted as rare causes of intestinal ischemia [18].
1.3 Epidemiology of the Disease or Condition
In 2010, in the Russian Federation, 47,430 patients were treated for non-tumor IO, of whom 2,427 (5.1%) patients died [19]. In 2020, in the Russian Federation, out of 64,834 patients, 6,333 (9.8%) patients died, among whom non-tumor IO accounted for 43 thousand patients, and adhesive IO for 28,645 patients. Of the patients with adhesive IO, 1,408 patients died [20]. For comparison, in the USA, 300–350 thousand patients with IO are hospitalized annually, of whom about 30,000 patients die [13].
1.4 Features of Coding the Disease or Condition
K31.5 – Duodenal obstruction
K56.0 – Paralytic ileus
K56.1 – Intussusception
K56.2 – Volvulus
K56.3 – Gallstone ileus
K56.4 – Other impaction of intestine
K56.5 – Intestinal adhesions [adhesions] with obstruction
K56.6 – Other and unspecified intestinal obstruction
K56.7 – Ileus, unspecified
1.5 Classification of the disease or condition
A classification of IO forms has been proposed based on the etiological principle (adhesive, gallstone obturation, etc.) and the presence of intestinal ischemia (including strangulating IO), in which it is recommended to distinguish the degree of intestinal wall damage: no ischemic injury, reversible ischemic injury, and irreversible ischemic injury [22]. Adhesive IO occurring less than 6 weeks after the latest abdominal surgery is classified as early adhesive IO [4]. Furthermore, depending on the degree of obturation and the presence of contents in the distal parts of the intestine, complete and partial IO are distinguished. According to available data, patients with complete adhesive IO more often require surgical treatment, whereas the majority of patients with partial IO will respond effectively to non-operative management (NOM) [21].
Based on the aforementioned principles, the American Association for the Surgery of Trauma (AAST) has proposed a classification for adhesive IO [22]:
partial obstruction;
complete obstruction. The bowel is viable and undamaged;
complete obstruction. The bowel is damaged but viable;
complete obstruction. The bowel is non-viable or perforated.
In patients with any form of IO, targeted screening for intestinal ischemia, including strangulating IO and peritonitis, is recommended; their presence is an indication for emergency surgery [23–25].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis of the disease/condition. The diagnosis of IO is established based on:
clinical signs: colicky abdominal pain, cessation of stool and gas passage, nausea, vomiting, systemic inflammatory response syndrome (SIRS);
laboratory data: SIRS, fluid and electrolyte disturbances;
instrumental data: intestinal dilation with the formation of arches and fluid levels on abdominal radiography and CT, "pendulum-like" movement of intestinal contents with luminal widening on abdominal ultrasound.
Complete IO is diagnosed when the passage of contrast medium through the intestine ceases on plain abdominal radiography with radiopaque contrast agents.
The etiology of IO is established based on abdominal CT, which allows determining the dynamic or mechanical nature of IO and, most importantly, the presence of intestinal ischemia [26–29].
2.1 Complaints and Anamnesis
When IO is suspected, an examination by a surgeon is recommended [30].
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
When taking a medical history in patients with suspected IO, it is recommended to ascertain the presence and nature of previous abdominal surgeries to determine whether an abdominal adhesion process is present [30,31].
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
History data obtained by the surgeon are useful for diagnosing forms of IO. IO following previous abdominal surgeries indicates adhesive IO with a sensitivity and specificity of 85% and 78%, respectively [7]. The absence of prior surgeries in the history does not rule out adhesive IO, as adhesions may be congenital (embryonic) or result from previous abdominal infections. There is evidence that in patients with a "virgin (unoperated) abdomen," the incidence of strangulating IO is higher than in patients who have undergone prior surgeries [3,32], although this pattern is non-obvious and does not align with the position of the World Society of Emergency Surgery (WSES) [33]. Previous episodes of diverticulitis or chronic constipation in the presence of dolichosigmoid may indicate stenosis or volvulus of the sigmoid colon. In patients with altered mental status or those taking psychotropic drugs, there is a risk of colonic pseudo-obstruction (Ogilvie syndrome) [7].
In a patient with suspected IO, it is recommended to ascertain the duration of the disease, the presence, nature, and intensity of the pain syndrome, the presence, volume, and character of vomiting, and the passage of stool and gas [30,31].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
The duration of the disease must be established during the initial examination, as there is evidence of the danger of non-operative management when the disease duration exceeds 3 days [34].
Complaints of pain, abdominal distension, nausea, vomiting, and delayed stool and gas passage are non-specific signs of IO.
Pain. Intestinal wall stretching and increased peristalsis aimed at moving contents past the obstruction are accompanied by pain, which is most often colicky in nature. Intense, constant abdominal pain not relieved by analgesics, accompanied by restless behavior and a forced patient position, is indicated as a symptom of intestinal ischemia and perforation [24]. However, patients with strangulated intestinal obstruction (IO) often have such mild pain syndrome that the presence of any disease is questioned at all [35]. The Consensus Conference did not recognize pain as a constant symptom of IO [36].
Abdominal distension. The degree of abdominal distension increases with distal obstruction and may be minimal with proximal small bowel obstruction, which can be the cause of delayed IO diagnosis [2].
Nausea and vomiting. Nausea or vomiting are characteristic but non-obligatory symptoms of IO, although the nature of vomiting sometimes makes it possible to judge the level and duration of the obstruction. The presence and volume of vomitus are taken into account in several prognostic scales of surgical tactics [37,38]. Fecal vomiting is characteristic of distal obstruction and significant disease duration [4], but its prognostic value for surgical treatment has not been determined. In a study by Bizer L.S. et al., 1981, fecal vomiting correlated with strangulation [39].
Delayed stool and gas passage is a criterion for IO, although in some patients IO is accompanied by loose stools [5].
Fever, like systemic inflammatory response syndrome (SIRS), is indicated among the signs associated with intestinal ischemia [40]. In a recent study, fever was found in only 3% of patients with strangulated IO [3]. Also, fever may be a consequence of infectious gastroenteritis masquerading as IO [2].
2.2 Physical Examination
Emergency surgery without additional instrumental examination is recommended for patients with IO and obvious clinical signs of intestinal ischemia (including strangulated IO) and peritonitis [41,42].
GRL CLEL 5Grade of Recommendation C (Level of Evidence 5).
Comments: IO with bowel ischemia is always fatal without surgery, and early surgery aims to prevent the consequences of intestinal ischemia – bowel necrosis, perforation, and peritonitis.
Palpation.
Examination of all possible hernia rings and postoperative scars is recommended for all patients with IO to rule out an incarcerated hernia [7].
GRL CLEL 4Grade of Recommendation C (Level of Evidence 4)
IO is largely a clinical diagnosis, i.e., surgical tactics are based on the surgeon's clinical suspicion [4]. The preoperative diagnosis of strangulation cannot be reliably established or excluded by any known clinical parameter, combination of parameters, or based on the judgment of an experienced clinician [43]. The presence of abdominal muscle guarding is indicated as an independent prognostic factor for strangulation in multivariate analysis [40]. It should be noted that sharp pain upon palpation of dilated bowel loops and peritoneal signs (Shchetkin-Blumberg sign) are often determined in IO patients. In the expert consensus statement, these symptoms were not recognized as indications for immediate surgery in IO patients. Moreover, except for incarcerated hernia, experts could not name other reliable clinical signs of intestinal ischemia [36]. Digital rectal examination is recommended as a routine examination method to rule out tumor obstruction.
Auscultation. Peristalsis may be enhanced, and patients may note increased pain during a peristaltic wave. However, the prognostic value of the nature of peristalsis for establishing the diagnosis (enhanced, weakened, "ringing") has not been established [2].
Organ dysfunction.
Assessment of severity and identification of organ dysfunction are recommended in all patients with IO [7].
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
Comments:In elderly or unstable patients, it is necessary to assess vital functions and identify hypovolemic and septic shock. Abnormal vital signs or general appearance: facial expression, skin color, temperature, altered consciousness, indicate a critical condition of the patient. Signs of shock include hypotension, tachycardia, tachypnea, decreased extremity temperature, skin cyanosis, delayed capillary refill, oliguria, etc. [7]. Symptoms of systemic inflammatory response and organ dysfunction in patients with IO are associated with sepsis or hypovolemia, which in itself can have catastrophic consequences [44]. Acute kidney injury is one of the possible consequences of hypovolemia, which is why IO patients require diuresis monitoring. Unstable patients require special attention due to possible intestinal ischemia and peritonitis [7]. For rapid assessment of organ dysfunction upon admission, the quickSOFA (Sequential Organ Failure Assessment) scale is used, which takes into account respiratory rate (1 point), systolic blood pressure (1 point), and altered consciousness (1 point). Two or more points indicate a high probability of an adverse outcome and require treatment in the intensive care unit [45]. Concomitant cardiopulmonary, renal, or hepatic diseases increase surgical risks and must be taken into account when choosing a treatment strategy [7]. Most young patients will tolerate surgery well, while many of the elderly will die [46].
2.3 Laboratory Diagnostics
Clinical evaluation and laboratory tests, including complete blood count, general biochemical blood test, and acid-base balance and blood gas analysis, are recommended for all patients with IO to diagnose hypovolemia, organ dysfunction, and intestinal ischemia [2, 15, 23].
GRL CLEL 4Grade of Recommendation C (Level of Evidence 4)
Systemic inflammatory response, acidosis, hyperlactatemia, and organ dysfunction in all patients with IO are recommended to be considered as possible manifestations of intestinal ischemia; however, these signs cannot be recommended as absolute criteria for intestinal ischemia and indications for emergency surgery [23,47].
GRL CLEL 4Grade of Recommendation C (Level of Evidence 4).
Comments: clinical, laboratory, and instrumental factors must be taken into account when deciding on surgery [2]. Peritoneal signs, fever, and leukocytosis are indicated as criteria for early surgery [15]. Low serum bicarbonate and arterial blood pH levels, high lactate levels, and elevated leukocyte counts are indicated as criteria for intestinal ischemia [23]. At the same time, abnormal laboratory tests are a frequent cause of overdiagnosis of intestinal ischemia and unjustified surgery [48], and normal laboratory parameters do not rule out intestinal ischemia in IO patients [37].
Dozens of studies have shown low accuracy of clinical and laboratory tests for diagnosing strangulated bowel obstruction [49]. The specificity of leukocytosis for intestinal ischemia is reported at around 50% [50]. Hypochloremic, hypokalemic metabolic alkalosis often develops against a background of repeated vomiting, while metabolic acidosis develops against a background of severe hypovolemia [2], which may be one of the causes of acute kidney injury. Diagnosing organ dysfunction is one of the goals of laboratory evaluation, which is important for choosing surgical tactics [36]. Based on clinical and laboratory signs, prognostic scales for early surgery have been proposed [51,52]. However, no significant progress in improving the accuracy of laboratory diagnosis has been achieved to date [53].
Monitoring of clinical and laboratory parameters.
With prolonged non-operative treatment of IO patients, clinical and laboratory monitoring is recommended every 12 hours [36].
GRL CLEL 5Grade of Recommendation C (Level of Evidence 5)
Comments: nasogastric tube output of more than 500 ml by the 3rd day is indicated as a criterion for terminating non-operative treatment [38]. Doubling of creatinine is indicated as an indication for terminating non-operative treatment [36]. A persistently high lactate level after adequate fluid resuscitation has been associated with irreversible intestinal ischemia [54]. At the same time, persistently normal laboratory parameters do not rule out intestinal ischemia [3]. Strangulation must be suspected in all patients until complete resolution of IO [2].
2.4 Instrumental Diagnostics
Screening methods
Plain radiography and abdominal ultrasound are recommended for patients with suspected intestinal obstruction as screening methods that can establish the fact of obstruction, but generally fail to determine its etiology [28, 30, 31].
GCR CLOCE 5Grade of Recommendation C (Level of Evidence Catch 5)
Comments: radiological signs of intestinal obstruction include bowel dilation and pneumatization, and intestinal arcades with fluid levels. The absence of contents in the distal bowel is characteristic of complete intestinal obstruction [28]. Radiography detects small bowel obstruction in 50–60% of patients; findings are inconclusive in 20–30%; and findings are misleading in another 10–20% [55]. The sensitivity and specificity of radiography for diagnosing large bowel obstruction are 84% and 72%, respectively [56]. There is a trend toward abandoning radiography in favor of computed tomography (CT) [42, 47].
Ultrasound signs of small bowel obstruction include an increase in the small bowel lumen diameter of more than 25 mm, bowel wall edema, visualization of small bowel mucosal folds, and pendular movement of bowel contents. The detection of free fluid in the abdominal cavity can be useful for diagnosing intestinal ischemia [57]. A meta-analysis established the acceptable accuracy of the "whirlpool" sign for diagnosing intestinal volvulus [58]. The advantages of ultrasound are the possibility of bedside diagnostics and the absence of radiation. Among the disadvantages of ultrasound, operator dependence is noted. In a recent study involving four emergency clinics in Moscow, the accuracy of ultrasound in small bowel obstruction was similar to that of radiography, and in none of the 39 cases was the diagnosis of strangulation established. From this, the authors concluded that ultrasound had no value as a diagnostic method for strangulated obstruction [57].
Computed tomography.
Abdominal computed tomography (CT) is the most accurate method for diagnosing intestinal obstruction and its etiology, as well as intestinal ischemia, and when technically feasible, is recommended for all patients with intestinal obstruction [42].
GRL CLEL 5Grade of Recommendation C (Level of Evidence 5).
Comments: the accuracy of CT in the differential diagnosis of mechanical and dynamic intestinal obstruction is 83–94%, with the cause of obstruction identified in 85–87%, and strangulation in 90%. CT criteria for strangulation include a "closed-loop" bowel, an apparent "transition point", impaired contrast enhancement of the bowel wall, mesenteric edema, free fluid in the abdominal cavity, etc. [59] CT is cited as the most likely cause of reduced mortality and shorter time to surgery in patients with intestinal obstruction in the USA [53], however, in the Russian Federation, no more than 20% of surgeons routinely use this method for diagnosing intestinal obstruction [47].
Limitations of the method are related to radiation exposure, which is often considered a contraindication in pregnant women, and contrast-induced renal failure. According to current guidelines, CT can be performed at any stage of pregnancy, as the benefits of its use outweigh the risks of teratogenic effects. With rare exceptions, radiation exposure from radiography, computed tomography, or nuclear medicine imaging modalities is at a dose significantly lower than that associated with fetal harm. [60] Contrast-enhanced CT is permissible even in the presence of an allergic reaction with appropriate premedication [4].
Patients with signs of intestinal ischemia (including strangulated intestinal obstruction) and peritonitis established by CT are recommended to undergo emergency surgery [41, 42].
GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5).
Comments: CT has been used to build more accurate models for predicting the need for surgery. In a well-known study, intraperitoneal free fluid, mesenteric edema, the absence of the "small bowel feces" sign on CT, and the presence of vomiting showed 96% sensitivity and 90% positive predictive value for the need for surgery [2]. Overall, CT remains the most accurate method for diagnosing intestinal ischemia with the prospect of improvement as techniques improve and staff gain experience [47, 61, 62].
Magnetic resonance imaging (MRI) of the abdominal cavity cannot be recommended for mandatory use, but in the absence of CT and when technically feasible, it is recommended for diagnosing intestinal obstruction [63–68].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
Comments: the accuracy of MRI is comparable to CT and ultrasound. The sensitivity and specificity of MRI for diagnosing intestinal obstruction are 86–100%. The diagnostic accuracy regarding the etiology of intestinal obstruction is 60–73%. The high resolution of MRI allows differentiation of the etiology of bowel wall changes characteristic of tumor, inflammation, ischemia, and necrosis, and makes it possible to assess small bowel motility. Nevertheless, the clinical significance of the method requires further evaluation [63–68].
Prediction of the need for surgical treatment.
Contrast challenge test (contrast media according to the ATC classification).
Patients with small bowel obstruction without obvious signs of bowel ischemia (low suspicion of strangulation on CT) and peritonitis are recommended to undergo a water-soluble contrast challenge test (V08A Iodine-containing contrast media), the progression of which should be assessed every 6–12 hours [42, 69, 70].
GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2).
During non-operative management of small bowel obstruction, the failure of the contrast agent to reach the colon within 24 hours of administration is recommended to be considered as an indication for surgical treatment [42, 69, 70].
GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2).
Comments: the use of the method is based on the hypothesis that the failure of the contrast agent (CA) (contrast media according to the ATC classification) to reach the colon 24 hours after administration indicates complete intestinal obstruction and a low probability of non-operative resolution. The detection of CA in the colon on follow-up radiography (CT) is a predictor of obstruction resolution with a sensitivity and specificity of 96–97% [70]. However, the failure of the CA to reach the colon within 24 hours does not appear to be an absolute indication for surgery. In a recent study, non-operative resolution of intestinal obstruction occurred in nearly 30% of patients between 24 and 48 hours after CA administration [71]. According to a recent survey, nearly half of the surveyed Russian surgeons perform surgery after 2 to 8 hours of monitoring CA dynamics, thereby depriving the majority of patients of a chance for non-operative resolution of intestinal obstruction [47].
The use of water-soluble contrast medium allowed to reduce the length of hospital stay in non-operated patients [72], predicted the need for surgery, and correlated with a decreased need for surgical intervention and duration of hospital stay [70]. It should be noted that a recent RCT and meta-analysis did not establish a clear effect of the water-soluble contrast medium challenge on the need for surgery, duration of hospital stay, and mortality in patients with uncomplicated adhesive small bowel obstruction [73, 74].
Currently, the generally accepted practice is to use water-soluble CA (V08A Iodine-containing contrast media), administered in doses ranging from 50 to 150 ml via a nasogastric tube or orally [75]. In the absence of a water-soluble CA (V08A Iodine-containing contrast media), it is possible to use Barium sulfate** [47, 76]
The optimal timing for monitoring CA dynamics has not been determined; nevertheless, performing the first radiological and CT follow-up earlier than 8 hours after CA administration is considered impractical [71].
There is no clear evidence supporting the utility of CA for assessing colonic patency. To rule out complete large bowel obstruction, a barium enema or water-soluble contrast enema (V08A Iodine-containing contrast media) is recommended, which does not require a long wait for the contrast to reach the colon [77].
2.5 Other Procedures
Not provided
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1. Non-operative Management
Stable patients with intestinal obstruction without signs of intestinal ischemia (including strangulated obstruction) and peritonitis are recommended initial non-operative management [34, 41, 42, 46].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
Comments:v recent past, surgical treatment was considered mandatory in the management of adhesive intestinal obstruction[53].Currently, the majority of specialists recognize that in the absence of indications for emergency surgery, initial treatment should be non-operative, which allows avoiding surgery in 50–90% of patients with adhesive small bowel obstruction[34, 41, 42, 46].Non-operative management (NOM) of bowel obstruction without obvious signs of intestinal ischemia for 48–108 hours is practiced by the majority of leading surgical communities worldwide [41, 42]. First and foremost, the advantages of NOM are obvious for adhesive bowel obstruction[78].Lower mortality, complication rates, and length of hospital stay are reported compared with surgery[79],especially among patients with low physiological reserve, comorbid, and elderly patients [80 81].
It should be noted, however, that in a Canadian study, NOM was accompanied by a higher rate of obstruction recurrence, more frequently required readmission, and had a higher total cost of treatment over a 5-year follow-up period than early surgery performed by the end of the first to the beginning of the second day of hospitalization [82].
If CT is technically unavailable in patients with bowel obstruction without obvious signs of strangulated obstruction and peritonitis, the choice of treatment method should be guided by clinical symptoms, laboratory test dynamics, and abdominal radiography with a contrast agent, which is recommended to be performed at least every 12 hours until complete resolution of the bowel obstruction or surgery [2, 36].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: it should be noted that many researchers in the treatment of bowel obstruction [39, 51, 83, 84] did not use CT in their diagnostic algorithm. The main condition for the safety of NOM is stated to be the ongoing stability of patients [85], which is understood as the absence of organ dysfunction.
Upon the appearance or progression of organ dysfunction, pain intensity, and systemic inflammatory response syndrome against the background of persisting bowel obstruction, it is recommended to discontinue non-operative management and perform surgery [75].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: the following are proposed as criteria for discontinuing non-operative management:
persisting or new-onset SIRS, organ dysfunction, lactic acidosis, renal failure, despite ongoing treatment;
failure of the water-soluble contrast agent (V08A Iodinated water-soluble contrast media) to reach the colon on follow-up radiography performed 24–36 hours after contrast administration;
persisting nasogastric tube output of more than 500 ml by the 3rd day of hospital stay [75].
A consensus statement by Italian authors identified suspicion of intra-abdominal complications, high lactate and leukocytosis levels (greater than 18×10⁹/L), body temperature above 38.5 °C, and rising creatinine levels (doubling of the baseline value) as criteria for discontinuing NOM [36].
Due to the impossibility of accurately diagnosing intestinal ischemia, non-operative management is systematically mistakenly applied in patients requiring early surgery; therefore, all patients undergoing non-operative management are recommended to have careful and continuous monitoring with control of clinical, laboratory, and instrumental data for the earliest possible detection of intestinal ischemia and peritonitis [2].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: due to diagnostic difficulties, in 15–30% of patients with strangulation, surgery is performed later than 24 hours of hospital stay [86]. Delayed surgery in patients with strangulation was not associated with mortality [83]; nevertheless, in these patients, one should strive for early surgery, the indications for which can be established after initial NOM and vigilant monitoring [2].
As methods of non-operative management for bowel obstruction, infusion therapy, intestinal decompression using a nasogastric (or intestinal) tube, and aspiration prevention are recommended [4, 69].
GCR CLEL 5 Grade of Recommendation C (Level of Evidence 5).
Comments: organ dysfunction in patients with bowel obstruction is a consequence of hypovolemia or sepsis and requires early goal-directed therapy. Regardless of the etiology of bowel obstruction, initial fluid replenishment is necessary for all patients with bowel obstruction. The term "fluid resuscitation" most accurately reflects the meaning of infusion therapy. The main infusion drugs are crystalloid solutions, such as Sodium lactate solution, compound [Potassium chloride + Calcium chloride + Sodium chloride + Sodium lactate]** or Sodium chloride** solution 0.9% [4]. No benefits from the use of colloid solutions have been obtained in critically ill patients [87]. Patients with bowel obstruction often require correction of water and electrolyte disturbances. Potassium preparations should be prescribed with caution due to the risk of acute renal failure.
Nasogastric (NG) or nasointestinal (NI) tube decompression in bowel obstruction is indicated by surgical communities as a useful option [41, 42]. Several recent studies have shown the superiority of NI decompression over NG decompression in the non-operative management of adhesive small bowel obstruction [69, 78].
It should be noted that the use of NG and NI decompression lacks sufficient pathogenetically substantiated evidence. In a recent systematic review, the effect of nasogastric decompression on the success rate of NOM, bowel resection, and mortality was not established; nevertheless, the authors acknowledged that there are currently insufficient grounds to abandon the method [88]. A selective approach to tube placement is suggested only for patients with persistent vomiting [89]. There is evidence that the tube, by disrupting the function of the upper and lower esophageal sphincters, increases the risk of aspiration by 30% [90].
To prevent aspiration complications, patients with bowel obstruction are recommended to have an elevated head of the bed at an angle of 30 degrees and the administration of antiemetic drugs [4].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: aspiration pneumonia develops in 7% of patients with small bowel obstruction, increasing mortality, duration, and cost of hospital stay [91].
Surgical tactics for rare forms of intestinal obstruction
In early adhesive bowel obstruction, immediate surgery is recommended for patients with intestinal ischemia (including strangulated bowel obstruction) and peritonitis [92].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
Patients with early adhesive bowel obstruction without obvious intestinal ischemia and peritonitis are recommended initial non-operative management [92].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
Comments: early adhesive bowel obstruction must be differentiated from intestinal paresis against the background of postoperative inflammatory changes. CT is the most accurate diagnostic method. The presence of a "transition point" on CT indicates the mechanical nature of the obstruction. The incidence of strangulation in early adhesive bowel obstruction is 8–10%. [93, 94]. In patients without strangulation, prolonged NOM can be successful, which is effective in 50–80% of patients. In the study [92] repeated surgery on the 5th day from the onset of bowel obstruction symptoms was required in 42% of patients with early adhesive bowel obstruction. NOM combined with prolonged total parenteral nutrition lasting up to 6 months had advantages over surgery, which was more frequently accompanied by bowel resection, enterotomy, creation of stomas and intestinal fistulas [95]. The timing elapsed since the last prior surgery is noted to be of great importance for choosing surgical tactics. By 10–14 days, the structure of adhesions undergoes remodeling: loose fibrinous adhesions transform into fibrous ones, which, in the event of surgery, is accompanied by an increase in the enterotomy rate from 5 to 17% [96], therefore, surgeries in the interval from 10 to 45 days should preferably be avoided.
Patients with gallstone ileus are recommended surgical treatment—enterotomy and removal of the calculus [97].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: enterotomy is preferably performed in the area with the least changes in the intestinal wall distal to the site of obstruction. Disconnection of the biliodigestive fistula and cholecystectomy can be performed simultaneously or electively, depending on the patient's condition and the readiness of the surgical team [98]. In some patients, due to an asymptomatic course, fistula disconnection is not performed at all [97], and in 50% of patients, spontaneous closure of the fistula occurs [99].
In bowel obstruction due to bezoar obturation, initial non-operative management is recommended in the absence of signs of intestinal ischemia [18, 100].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
In bowel obstruction due to bezoar obturation with no effect from non-operative management, surgery is recommended: fragmentation and pushing of the bezoar into the colon or its removal via enterotomy [18, 100].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: according to a systematic review including 44 patients, a sweet carbonated beverage (Coca-Cola™ in the study) demonstrated efficacy in dissolving gastric phytobezoars in 50% of cases. When combined with additional endoscopic methods, the success rate reached 90% [101]. CT is indicated as the basis for selecting clinical treatment. Mesenteric "haziness" in the presence of a bezoar in the small intestine on CT is indicated as an independent factor for the failure of conservative treatment and a sign of ischemia [100]. The incidence of irreversible bowel ischemia due to bezoar obstruction is reported to be 4% [18]. It should be noted that delayed surgery is cited as a cause of increased mortality [102]. Surgical treatment options include fragmentation and advancement of the bezoar into the cecum, or extraction of the bezoar via enterotomy [18].
For small or large bowel intussusception, surgical treatment is recommended [103].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
Comments: in a recent study involving 44 patients, the diagnosis of intussusception was established preoperatively using ultrasound or CT in 42 patients. Surgery was performed in 41 patients, excluding frail and comorbid patients. In the majority, intussusception occurred against the background of primary tumors or carcinomatosis [103].
For patients with intestinal obstruction due to Crohn's disease in the absence of ischemia and peritonitis, prolonged non-operative management (NOM) is recommended [104].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: the duration of nasogastric decompression can reach several weeks, during which patients may receive medical therapy that often leads to the resolution of intestinal obstruction [104].
3.2. Surgical treatment
Routine administration of antibiotic therapy to patients with intestinal obstruction without perforation, peritonitis, and sepsis is not recommended [105, 106].
AGR CLEL 5Authors' Recommendation Grade C (Level of Evidence 5).
In the absence of individual contraindications, preoperative prophylaxis of infectious complications with systemic antimicrobial agents (recommended for patients with intestinal obstruction) is indicated (J: Systemic anti-infectives 30 minutes before surgery) [105, 106].
AGR CLEL 5Authors' Recommendation Grade C (Level of Evidence 5).
Comments: in a recent study involving 192 operated patients with small bowel obstruction, the effect of antibiotic therapy and antibiotic prophylaxis on the incidence of infectious complications was not established [107].
For patients with irreversible intestinal ischemia, perforation, or sepsis, initiation of antibiotic therapy as early as possible is recommended [108].
GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2).
Surgical intervention
Small bowel obstruction.
Surgical treatment of small bowel obstruction is recommended via laparotomy or laparoscopic approach [81, 109, 110].
GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)
Laparoscopic adhesiolysis is recommended for stable patients with small bowel obstruction [81, 109, 110].
AGR BLEL 2Authors' Recommendation Grade B (Level of Evidence 2).
Comments: laparotomy remains the primary approach in the treatment of intestinal obstruction. Potential benefits of laparoscopic adhesiolysis (LA) in adhesive intestinal obstruction include reduced adhesion formation, postoperative pain, hospital stay, complications, and mortality [42]. Laparoscopy may be attractive for stable patients in whom intestinal obstruction is associated with a single adhesion. In this case, the success rate is 74–95% [104]. It should be noted that the only RCT "Lasso", comparing LA and open approach, found no significant differences in outcomes except for a small advantage in hospital stay duration [109]. At the same time, data indicate that the incidence of iatrogenic bowel perforation during LA is 6.3–26.9% [46, 111, 112]. Although LA may have advantages for certain patients, surgeons must carefully select candidates for LA, weighing the risks of surgery [113]. Predictors of successful LA include: ≤ 2 previous laparotomies, appendectomy only in medical history, no midline laparotomy, single adhesion. Nevertheless, the only absolute contraindication to LA is the risk of cardiopulmonary failure associated with pneumoperitoneum [114]. Additional difficulties may be presented by LA in patients after radiation therapy [115]. In general, the surgeon should approach LA being well-informed about potential risks [113], and have a low threshold for conversion to laparotomy [4]. The success and safety of LA are related to the surgeon's experience. A recent publication suggests performing the technique exclusively by an expert surgeon, as mass application of LA by untrained surgeons, according to the authors, may have negative consequences [110].
Surgical technique for intestinal obstruction.
During surgery for adhesive intestinal obstruction, separation of all abdominal adhesions and scars is not recommended; only the separation of adhesions causing the obstruction or those necessary to provide access to them is recommended [114].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: separation of all adhesions present in the abdominal cavity may increase the duration and invasiveness of the surgery, although there is no rigorous evidence of the benefit of local adhesiolysis. A survey of Russian surgeons showed that about half of them divide all adhesions [47]. To find the site of obstruction, it is suggested to examine the collapsed bowel in the direction from the ileocecal valve to the obstruction site. During LA, to avoid enterotomy, one should endeavor to grasp and hold bowel loops by the mesentery and avoid rough grasping of the bowel wall. Manipulation of the dilated bowel is dangerous due to the risk of enterotomy. Upon completion of adhesiolysis, bowel revision should be performed to check for potential injuries and bleeding [4, 81].
For stable patients with small bowel obstruction and irreversible ischemic bowel damage, bowel resection followed by intestinal anastomosis is recommended [116].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
For unstable patients with irreversible ischemic bowel damage, obstructive bowel resection with subsequent planned relaparotomy and reconstructive surgery upon stabilization within 24–48 hours is recommended [116].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
In cases of questionable viability, but without clear evidence of irreversible ischemic bowel damage, reoperation with assessment of bowel viability is recommended in 24–36 hours [4].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: visual inspection of the incarcerated bowel may be uninformative due to edema and serosal hematoma, and pulsation of mesenteric vessels may be absent due to hypotension or vasospasm. Ischemic damage without overt irreversible bowel damage may be a rationale for programmed relaparotomy for reassessment in 24–48 hours [4, 117]. In addition, supplemental methods for assessing bowel perfusion may be useful, such as perfusion fluorometry and laser fluorescence angiography (LFA) with indocyanine green (ICG) [118].
Resection of the small intestine in patients with small bowel obstruction is recommended to be performed within visually viable tissue, preserving maximum bowel length [4].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: normal small bowel length ranges from 300 to 800 cm. Patients with a remaining small bowel length of less than 180 cm are at risk of developing short bowel syndrome. An intact ileocecal valve is equivalent to an additional 50 cm of small bowel as it increases intestinal transit time. A bowel length of less than 120 cm without the colon, or less than 60 cm of small bowel with a preserved colon, will likely require permanent parenteral nutrition [119]. It is reported that short bowel syndrome occurs in 15% of patients undergoing bowel resection, 75% of which are associated with extensive small bowel resection in a single surgery [120]. Currently, there is no clear evidence of the benefits of resecting extended segments of the proximal bowel [121], which was previously recommended.
Intraoperative small bowel decompression using a nasointestinal tube is not recommended for all patients with small bowel obstruction due to the lack of scientific evidence of its benefit [122].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: according to a recent survey, about 2/3 of Russian surgeons considered the placement of a nasointestinal tube mandatory during surgery for intestinal obstruction [47]. However, the use of both nasointestinal and gastric tubes lacks strong scientific evidence [122]. A significant number of observational clinical studies exist on this issue. In one of them, which included 166 patients and 178 surgeries, the use of a modified intestinal tube (n = 95) resulted in a hospital stay that was 6 days longer (p < 0.05) compared to cases without its use (n = 83), with no differences in mortality and complication rates between the groups [123]. Recent literature reviews have not provided new clinical studies and have failed to draw definitive conclusions regarding the benefits of nasointestinal decompression [69, 124, 125]. Prophylactic placement of a nasogastric tube in the postoperative period increased the risk of aspiration pneumonia and adverse outcomes [126]. As an alternative to nasointestinal decompression, retrograde milking of small bowel contents into the stomach followed by evacuation via a nasogastric tube is considered. However, as shown by an RCT, routine manual bowel decompression with content removal via a nasogastric tube during open surgery had no advantages over patients whose contents were left untreated and who subsequently resumed a normal diet. There were no differences between the groups in the rate of respiratory complications, bacterial translocation, wound infection, and postoperative hospital stay [127].
Diagnostic and treatment features of non-tumor colonic obstruction
Abdominal CT is recommended for all patients with colonic obstruction to determine the etiology of intestinal obstruction, including the exclusion of pseudo-obstruction, provided technical feasibility [77].
GRL CLEL 5Grade of Recommendation C (Level of Evidence 5).
Colonoscopy or barium enema with water-soluble contrast media (V08A Iodinated radiocontrast media) is recommended for patients with colonic obstruction when CT cannot be performed [77].
GCR CLEL 5Grade of Recommendation C (Level of Evidence 5).
Comments: colonoscopy and barium enema, in the absence of CT, can be used to diagnose the etiology of non-tumor colonic obstruction (pseudo-obstruction). Colonoscopy is used as a treatment method for colonic volvulus (see Therapeutic colonoscopy).
Features of treatment for colonic volvulus.
Surgical treatment involving segmental bowel resection is recommended for patients with colonic volvulus, perforation, and signs of bowel non-viability [4].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Endoscopic detorsion of the volvulus is recommended as initial treatment for patients with sigmoid volvulus without overt signs of bowel ischemia and peritonitis [128].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: it is reported that endoscopic decompression was successful in 78% of 562 patients with sigmoid volvulus [129].
Segmental resection of the colon is recommended for patients with cecal or right colon volvulus [4].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Segmental resection or detorsion with transanal bowel decompression is recommended for patients with sigmoid volvulus [4].
GCR CLEL 5Grade of Recommendation C (Level of Evidence 5).
Formation of a colostomy or primary anastomosis is recommended as options for completing segmental colonic resection, depending on the patient's condition and the surgical team's expertise [4, 129].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
One-stage restoration of colonic continuity is not recommended for unstable patients with colonic volvulus [4, 129].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4).
Comments: Segmental resection with primary anastomosis or colostomy (Hartmann's procedure) showed comparable outcomes in sigmoid volvulus [129]. The choice of the method for completing segmental resection remains a subject of debate. A significant decrease in the quality of life of patients with a colostomy is noted [4]. When creating a colorectal anastomosis, decompression of the dilated proximal segments of the colon is performed using colonic lavage or manual decompression. In unstable patients with signs of organ dysfunction and sepsis, one-stage reconstruction should be avoided in favor of a colostomy due to the high risk of complications [130].
POSTOPERATIVE TREATMENT
Infusion therapy is recommended in the postoperative period for patients with intestinal obstruction who are unable to tolerate oral intake of fluids and nutrition, in order to correct hypovolemia and metabolic disorders [4, 131].
GCR CLEL 5Grade of Recommendation C (Level of Evidence 5).
Comments: Postoperative intravenous fluid administration should be minimized, but it must be continued until oral fluid intake is sufficient to achieve an isovolemic status [131]. If patients are kept fasting for more than 7 days, taking into account the preoperative duration, parenteral nutrition is indicated [4].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
A daily output of less than 500 mL via the nasogastric tube is recommended as a criterion for discontinuing nasogastric (nasointestinal) decompression and initiating enteral nutrition [4].
GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).
Comments: The nasogastric tube was traditionally removed after the recovery of gastrointestinal function. At the same time, it has been shown that early tube removal reduces the risk of pulmonary complications and promotes the recovery of gastrointestinal function [131].
Forced postoperative mobilization is recommended for patients with intestinal obstruction. Independent ambulation from the first postoperative day is recommended for stable patients regardless of whether laparoscopic or open surgery was performed [131].
GCR CLEL 5Grade of Recommendation C (Level of Evidence 5).
Comments: In emergency surgery, protocols for patient mobilization on the same day of surgery or on postoperative day 1 are applied, whereas prolonged immobilization is associated with insulin resistance and an increase in thromboembolic and respiratory complications. Mobilization should be encouraged as early as possible, and all measures that can facilitate this should be taken, such as patient motivation, proper pain control, early removal of the urinary catheter and drains [131].
Frequent small meals with the restriction of single large portions of foods containing coarse fiber are recommended for all patients with adhesive small bowel obstruction that has resolved conservatively [30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence 5).
5. Prevention and Dispensary Observation
Surgical prevention of adhesion formation.
Intraoperative use of anti-adhesion barriers is recommended for the prevention of adhesion formation and adhesive small bowel obstruction [132].
GCR BLEL 2Grade of Recommendation B (Level of Evidence 2).
Comments: The main principles of preventing adhesions and associated complications are minimizing surgical trauma and using adjuncts to reduce adhesion formation. There is evidence of reduced adhesion formation in laparoscopic surgery compared to open surgery [132]. Risk factors for increased adhesion formation include foreign bodies such as glove starch or meshes used for abdominal wall reconstruction [133, 134]. The type of energy device used for tissue dissection also influences adhesion formation. Peritoneal trauma is less significant with bipolar electrocoagulation and ultrasonic dissectors than with monopolar electrocoagulation [135, 136]. A reduction in adhesion formation under conditions of experimental peritonitis has been established with the systemic and intraperitoneal use of certain systemic antibacterial drugs, in particular, metronidazole** [137, 138].
Adhesion barriers help reduce adhesion formation and the incidence of adhesive intestinal obstruction. When administered intraperitoneally, these agents minimize contact between the traumatized peritoneum and adjacent organs, ensuring healing without the formation of adhesions between them. Specifically, there is evidence of a reduced rate of reoperations for adhesive intestinal obstruction following colorectal surgery [139 - 141]. Adhesion barriers can be useful in preventing recurrences after surgical treatment of adhesive intestinal obstruction—significant benefits of 4% icodextrin in reducing the recurrence rate of adhesive intestinal obstruction were demonstrated in RCTs [142]. This medical device is currently the most thoroughly studied, although data exist on more effective adhesion barriers [42]. It should be noted that, according to a systematic review analyzing the results of 67 barrier agents, none of them are widely used, although at least 10 agents have shown efficacy in clinical practice [143].
6. Organization of Medical Care
Indications for inpatient hospitalization:
clinical and instrumental presentation of intestinal obstruction (cessation of stool and gas passage, abdominal distension, cramping abdominal pain, nausea, vomiting, small bowel dilation greater than 3 cm according to abdominal radiography (CT) and ultrasound) [30].
Indications for hospital discharge:
restored ability to tolerate oral intake; passage of stool and gas;
absence of signs of sepsis and organ dysfunction;
absence of pain syndrome requiring narcotic analgesics.
7. Additional Information
None.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1 | Evaluated by a surgeon upon detection of signs of intestinal obstruction | Yes/no |
2 | Plain radiography or CT of the abdominal organs performed | Yes/no |
3 | Complete blood count performed | Yes/no |
4 | Intestinal obstruction diagnosed in the presence of clinical and instrumental findings | Yes/no |
5 | Treatment strategy formulated: 1. indications for emergency surgery established in the presence of intestinal ischemia. 2. Non-operative management lasting up to 72 hours prescribed in the absence of overt signs of ischemia. | Yes/no |
6 | In case of surgery, prevention of infectious complications with systemic antimicrobials was performed 30 minutes before the surgical intervention | Yes/no |
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Appendix A1. Working Group Composition
Shapovalyants S.G. – MD, Professor, Head of the Working Group
Sazhin A.V. – Corresponding Member of the Russian Academy of Sciences, MD, Professor,
Darvin Vladimir Vasilyevich – MD, Professor
Demko Andrey Evgenievich – MD, Professor
Zemlyanoy Vyacheslav Petrovich – MD, Professor
Kotkov Pavel Alexandrovich – PhD
Larichev S.E. – MD, Professor
Melnikov-Makarchuk K.Yu. – PhD
Stradymov E.A. – PhD
Sigua B.V. – MD, Professor
Samartsev V.A. – MD, Professor
Tyagunov A.E. – MD, Professor
Shabrin A.V. – PhD, Associate Professor
There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
In these clinical guidelines, all data are ranked by level of reliability (evidence) depending on the quantity and quality of studies on the issue.
Target audience of these clinical guidelines:
surgeons
endoscopists
anesthesiologists-resuscitators
general practitioners
general practitioners
medical students and residents
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1. | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2. | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3. | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case report |
5. | Only justification of mechanism of action or expert opinion is available |
Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1. | Systematic review of randomized controlled trials with meta-analysis |
2. | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3. | Non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case report or case series, case-control study |
5. | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
Order of the Ministry of Health of the Russian Federation No. 922n dated November 15, 2012, "On Approval of the Procedure for Providing Medical Care to the Adult Population in the Field of 'Surgery'."
Appendix B. Physician Action Algorithms
Acute non-tumor intestinal obstruction
Appendix C. Patient Information
Intestinal obstruction (IO) is a condition characterized by the cessation of intestinal contents propulsion through the intestine. Despite medical advancements, mortality from this condition remains extremely high.
What causes acute intestinal obstruction? Factors predisposing to mechanical intestinal obstruction most commonly include: adhesion formation in the abdominal cavity from previous surgeries; intestinal tumors, less commonly foreign bodies, bezoars (masses of undigested food or hair), anatomical variations predisposing to volvulus, and hernias. Sometimes intestinal obstruction develops in the absence of a mechanical obstacle. In such cases, it is termed dynamic or functional. Its causes are also diverse: trauma, inflammatory processes in the abdominal cavity, significant metabolic disorders, hypokalemia, uremia, diabetes mellitus, intestinal vascular disorders, CNS diseases, etc.
What signs may indicate IO? An early sign of IO is abdominal pain, which can occur suddenly without any prodromal symptoms. Pain in IO is typically colicky in nature, meaning it appears or intensifies at intervals associated with intestinal peristalsis. The greatest danger is posed by the strangulated form of the disease, accompanied by intestinal gangrene, which is more characteristic of severe, constant pain. Other symptoms of IO include vomiting, abdominal distension, and constipation with failure to pass gas.
Why is IO dangerous? IO leads to dehydration, loss of vital electrolytes, and acid-base imbalance. Impaired food intake, digestion, and absorption rapidly cause dysfunction in virtually all organs and systems. Along with fluid and electrolytes, a significant amount of proteins essential for human vital activity is lost during intestinal obstruction. When blood supply to the intestine is impaired, necrosis (gangrene) of the intestinal wall and perforation occur, causing intestinal contents to leak into the abdominal cavity and leading to peritonitis and sepsis.
What must be done to save a person with IO? IO is an indication for immediate hospitalization in a surgical inpatient facility. One of the reasons for high mortality is delayed seeking of medical care. In the hospital, the treatment method is chosen depending on the cause, form, and duration of the disease. Depending on the type of IO, patients require surgery or non-operative treatment. The most accurate diagnostic method for IO is computed tomography.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
None provided.