Eating during Times of Obstruction

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Motivation: I used to believe in the maxim, "For SBO, keep NPO" meaning that for patient with small bowel obstruction, eating was forbidden. In fact, for decompression, the stomach should be suctioned out with an NG tube. Last month, while caring for patients with bowel obstruction, I came across papers that challenged this hegemony. They suggested that laxatives might even be beneficial in some cases of partial SBO. I asked around. Nobody uses laxatives in SBO. But, should we be changing out ideas?

Paper: Chen, S-C. et. al. "Specific oral medications decrease the need for surgery in adhesive partial small-bowel obstruction." Surgery (2006) 139: 312-316.

Methods: A randomized controlled trial in Taiwan comparing standard vs. novel treatment in patients with partial adhesive small bowel obstruction, defined by (1) history of intra-abdominal operation, (2) clinical signs and symptoms of SBO, and (3) passage of contrast to colon within 24 hours of administration. Standard treatment consisted of IV hydration, NG tube decompression, and NPO. Novel treatment was IV hydration, NG tube decompression, and oral solution containing magnesium oxide (laxative), Lactobacillus acidophilus (digestant), and simethicone (defoaming agent). The primary outcome tracked was success of non-operative management.

Results:
Patients: Total of 236 patients were randomized. Both groups were similar in terms of age, gender, and presenting symptoms (abdominal pain, distension, constipation, vomiting).

Comparison of treatments: Non-operative management success rates were less with standard approach (77%) compared to treatment with oral therapy (90%, p<0.01). In other words, more patients kept NPO required surgery. The complication and recurrence rates were not different between the two treatment arms.

Discussion: This randomized study challenges the traditional assumption that bowel rest is the best treatment for any type of small bowel obstruction. One important flaw in the study is that while the attending surgeon was blinded to allocation, the rest of the staff was not blinded. This may have introduced some bias into the decision making process. Otherwise, the study contradicts the main fear that giving PO during obstruction leads to excess complications. In fact, giving the oral regimen significantly improved chances of non-operative management success. Importantly, this study only examined partial SBO from adhesions (the most common cause of SBO). It is unclear whether diseases like Crohn's have different benefits from bowel rest. The next time I see partial SBO from adhesions, I will try to convince my attending to give this regimen a try!