Bowel obstruction — strangulation recognition

Working diagnosis. Adhesive small bowel obstruction (prior surgery + colicky pain + bilious vomiting + obstipation + tinkling sounds).^[1]

Initial management (simple SBO pathway).

• ABCDE; two large-bore IV; NBM; NG decompression.
• IV 0.9% saline (or balanced crystalloid) with potassium replacement; catheter; target UO ≥0.5 mL/kg/h.
• Analgesia morphine 5 mg IV; ondansetron 4 mg IV.
• Bloods: FBC, U&E, lactate, VBG, G&S; examine all hernial orifices; DRE.
• Urgent CT abdomen/pelvis with IV contrast for transition point, closed-loop and ischaemia signs.^[3]
• Surgical referral; trial of conservative care if no ischaemia/closed-loop/peritonitis; consider water-soluble contrast challenge in selected adhesive SBO.

If continuous pain + peritonism + lactate 3.5.

• Treat as strangulated / ischaemic bowel until proven otherwise.
• Immediate theatre pathway after rapid resuscitation — do not delay for contrast challenge.
• Broad-spectrum perioperative antibiotics (e.g. ceftriaxone 2 g IV ± metronidazole).
• CT only if it does not delay theatre in the clearly peritonitic patient.