Challenges in diagnosing adhesive small bowel obstruction

Abstract

Adhesive small bowel obstruction (ASBO) is the most frequently encountered surgical disorder of the small intestine. Up to 80% of ASBO cases resolve spontaneously and do not require invasive treatment. It is important to identify such patients that will benefit from conservative treatment in order to prevent unnecessarily exposing them to the risks associated with surgical intervention, such as morbidity and further adhesion formation. For the remaining ASBO patients, timely surgical intervention is necessary to prevent small bowel strangulation, which may cause intestinal ischemia and bowel necrosis. While early identification of these patients is key to decreasing ASBO-related morbidity and mortality, the non-specific signs and laboratory findings upon clinic presentation limit timely diagnosis and implementation of appropriate clinical management. Combining the clinical presentation findings with those from other diagnostic imaging modalities, such as abdominal X-ray, computed tomography-scan and water-soluble contrast studies, will improve diagnosis of ASBO and help clinicians to better evaluate the potential of conservative management as a safe strategy for a particular patient. Nonetheless, patients who present with moderate findings by all these approaches continue to represent a challenge. A new diagnostic strategy is urgently needed to further improve our ability to identify early signs of strangulated bowel, and this diagnostic modality should be able to indicate when surgical management is required. A number of potential serum markers have been proposed for this purpose, including intestinal fatty acid binding protein and α-glutathione S transferase. On-going research is attempting to clearly define their diagnostic utility and to optimize their potential role in determining which patients should be managed surgically.

Keywords: Adhesive small bowel obstruction; Diagnosis; Clinical management; Biological markers; Intestinal fatty acid binding protein; α-glutathione S transferase

Core tip: Adhesive small bowel obstruction (ASBO) is a frequently encountered disorder of the small intestine following abdominal surgery. Accurately predicting whether ASBO patients can be treated conservatively is required to prevent exposing patients unnecessarily to surgery-related risks, including morbidity and further adhesion formation. Although recent technological developments have improved the ability to identify those patients most fit for conservative management, the remaining patients with moderate findings upon clinical presentation remain a problem. Serum markers of intestinal ischemia are promising candidates for improving early diagnosis and identification of patients with strangulated bowel, who will benefit most from surgical management.