Small bowel obstruction (SBO) occurs when the normal movements of the small bowel is
obstructed, most commonly due to adhesion related to previous abdominal surgery. This may
cause strangulation of the small bowel with reduced blood flow which is a surgical emergency
requiring prompt treatment in the operating room. If there are no signs of strangulation or
ischemia of the bowel at the time of diagnosis, international guidelines recommend initial
treatment with intravenous fluids and nasogastric tube placement. However, there is emerging
debate regarding non-selective treatment with nasogastric tube placement in patients with
SBO. This management started around 1930 as a means to reduce pain in patients with SBO, in
conjunction with other additions to management, like intravenous fluids. However the effect
and utility of routine nasogastric tube placement have not been prospectively evaluated.
There are a total of three retrospective observational studies in the past decade with a
total of 759 patients where 292 (36%) were managed without a nasogastric tube. There was no
difference in the rates of conservative treatment failure (requiring surgery), complications
(vomiting, pneumonia) or mortality between patients receiving a nasogastric tube and those
who didn't. However, the retrospective design of these studies limits their validity.
Furthermore, nasogastric tube placement has been shown to be one of the more painful
interventions patients may experience in-hospital. This calls into question the patient
benefit of routine nasogastric tube placement in patients with SBO and further studies are
needed to discern the utility of this intervention.
Definitive treatment for SBO is surgical adhesiolysis but there is debate regarding the
timing of surgery, particularly in older adults. A large proportion of patients may be
managed conservatively with oral contrast and repeated radiological evaluation and the
obstruction will resolve in many patients within 24 to 48 hours. This timeframe is dependent
on factors related to the disease itself as well as patient related factors like previous
surgery and comorbidities. Older patients are at high risk for complications but current
available data is insufficient to inform practice in this population. Frailty, a state of
increased vulnerability and susceptibility to adverse events, has been shown to be an
independent prognosticator in older adults in the Emergency Department(ED) and suggested as a
potential measure to risk stratify older adults with SBO. However to the authors knowledge
there is no available data on frailty in older adults with SBO and only one prospective
observational trial looking at older adults with SBO. Despite SBO being one of the most
common surgical emergencies in older adults.
To investigate the potential benefit of nasogastric tube placement in patients with SBO and
the ability of frailty to prognosticate outcomes in older adults better evidence is needed.