International Journal of Colorectal Disease (2023) 38:224

https://doi.org/10.1007/s00384-023-04512-8

RESEARCH

Management of adhesive small bowel obstruction: the results

of a large retrospective study
E. Maienza1 · G. Godiris‑Petit1 · S. Noullet1 · F. Menegaux1 · N. Chereau1

Accepted: 10 August 2023

© The Author(s) 2023

Abstract
Background Postoperative adhesive small bowel obstruction (SBO) is a frequent cause of hospital admission in a surgical
department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive SBO
can be managed nonoperatively. Many studies have investigated benefits of using oral water-soluble contrast to manage
adhesive SBO. Treatment recommendations are still controversial.
Methods We conducted an observational retrospective monocentric study to test our protocol of management of SBO using
­Gastrografin®, enrolling 661 patients from January 2008 to December 2021. An emergency surgery was performed in patients
with abdominal tenderness, peritonitis, hemodynamic instability, major acute abdominal pain despite gastric decompression,
or CT scan findings of small bowel ischemia. Nonoperative management was proposed to patients who did not need emer-
gency surgery. A gastric decompression with a nasogastric tube was immediately performed in the emergency room for four
hours, then the nasogastric tube was clamped and 100 ml of nondiluted oral G ­ astrografin® was administered. The nasogastric
tube remained clamped for eight hours and an abdominal plain radiograph was taken after that period. Emergency surgery
was then performed in patients who had persistent abdominal pain, onset of abdominal tenderness or vomiting during the
clamping test, or if the abdominal plain radiograph did not show contrast product in the colon or the rectum. In other cases,
the nasogastric tube was removed and a progressive refeeding was introduced, starting with liquid diet.
Results Seventy-eight percent of patients with SBO were managed nonoperatively, including 183 (36.0%) who finally
required surgery. Delayed surgery showed a complete small bowel obstruction in all patients who failed the conservative
treatment, and a small bowel resection was necessary in 19 patients (10.0%): among them, only 5 had intestinal ischemia.
Conclusions Our protocol is safe, and it is a valuable strategy in order to accelerate the decision-making process for manage-
ment of adhesive SBO, with a percentage of risk of late small bowel resection for ischemia esteemed at 0.9%.

Keywords Small bowel obstruction · Water-soluble contrast agent · Diagnostic protocol · Oral gastrografin

Introduction when signs of gravity are already present, such as strangu-

Postoperative adhesive small bowel obstruction (SBO) is a
frequent cause of hospital admission, accounting for 16–20%
of hospitalizations for acute abdominal pain in a surgical
department [1–4]. The Bologna Guidelines for Diagnosis
and Management of Adhesive Small Bowel Obstruction,
revised in 2018 [5], recommend an initial medical treat-
ment for 72 h before proposing surgical treatment, except
* N. Chereau
nathalie.chereau@aphp.fr
1
Department of General and Endocrine Surgery, Hospital
Pitié Salpêtrière, APHP, Sorbonne University Paris, 47‑83
Boulevard de l’Hôpital, 75651 Paris Cedex 13, France
lation, peritonitis, and intestinal ischemia. This therapeu-
tic strategy for adhesive SBO remains controversial since
a 30–40% risk of failure of nonoperative management has
been documented [6, 7]. Many studies have investigated ben-
efits of using oral water-soluble contrast (OWSC) such as
diatrizoate meglumine-diatrizoate sodium (­ Gastrografin®,
Bayer Schering Pharma) to manage adhesive SBO and pre-
dict the need for surgery [8–11]. However, the optimal tim-
ing for ­Gastrografin® administration remains controversial.
In a previous publication in 2009 [12], we conducted a
prospective study using G ­ astrografin® with a 32% rate of
delayed surgery after failure of a nonoperative manage-
ment. We found that ­Gastrografin® was a useful diagnostic
tool in decision-making for surgery, but we were not able

13
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to prove that this protocol had a direct therapeutic impact.
Based on our previous results, we defined a new protocol to
optimize the management of patients with SBO with a fast
decision-making process in order to reduce the risk of the
need for surgery and length of hospital stay. The aim of this
observational study was to evaluate safety and effectiveness
of the protocol of a nonoperative management of adhesive
SBO with the help of ­Gastrografin® administration, and to
identify risk factors of failure.
Patients and methods
Study cohort
From January 2008 to December 2021, we performed a
chart review from a database of patients who were diag-
nosed with adhesive SBO in a single center. According to
the Helsinki declaration, an observational study based on
a retrospective chart review built exclusively on data, do
not need the approval of “committees for the protection of
individuals.” All patients were seen on an individual basis
preoperatively by the surgeon and provided with verbal and
written information.
Patients with hernias, inflammatory bowel disease, sus-
pected or documented history of peritoneal carcinomatosis,
pregnancy, or allergy to a component of ­Gastrografin® were
excluded from the study.
An emergency surgery was performed in patients with
abdominal tenderness, peritonitis, hemodynamic instability,
major acute abdominal pain despite gastric decompression,
or CT scan findings of small bowel ischemia (group 1). A
laparotomy was usually performed, sometimes a laparoscopic
approach, depending on the intestinal distension, the medical
history of patient and personal experience of the surgeon.
Nonoperative management was proposed to patients
who did not need emergency surgery (group 2). A gastric
decompression with a nasogastric tube was immediately per-
formed in the emergency room. The stomach was aspirated
for four hours, then the nasogastric tube was clamped and
100 ml of nondiluted oral ­Gastrografin® was administered.
The nasogastric tube remained clamped for eight hours and
an abdominal plain radiograph was taken after that period
(8 h after oral G­ astrografin® administration). Emergency
surgery was performed in patients (group 2a) who had per-
sistent abdominal pain, onset of abdominal tenderness or
vomiting during the clamping test, or if the abdominal plain
radiograph did not show contrast product in the colon or the
rectum. In other cases, the nasogastric tube was removed
after 8-h clamping test (group 2b). A progressive refeeding
was introduced, starting with liquid diet. Figure 1 presents
the flow chart of our study management protocol.
13
International Journal of Colorectal Disease (2023) 38:224
Statistical analysis
Results are reported as the median (range) or as the mean ± 1
standard deviation. We used the chi-square test or Student’s
t test, as appropriate. The first analysis compared group 1
(patients who immediately underwent surgery after admis-
sion without Gastrografin® administration) with group 2
(patients managed nonoperatively). A second analysis com-
pared group 2a (patients managed firstly nonoperatively who
underwent delayed surgery) with group 2b (patients man-
aged exclusively nonoperatively). The following variables
were studied: age, sex, ASA physical status classification,
body mass index (BMI), prior abdominal surgery (open
or laparoscopic), clinical presentation, blood tests results:
serum lactate (mmol/L), white blood cell count (­ 109 cells/L),
C-reactive protein level (mg/L), and CT scan features. Sta-
tistical significance was defined as p < 0.05. All analyses
were performed with SPSS statistics software version 13.0.
Results
A total of 661 patients with adhesive SBO were included
in our study (Table 1): 299 males (45%) and 362 females,
with a median age of 65 years (range: 19–104 years), and
a median BMI of 22 kg/m 2 (range: 12–53 kg/m 2). All
patients admitted to the emergency room with SBO diagno-
sis received an abdomen CT scan. CT scan finding of free
diffuse peritoneal fluid is present in 66,9% of the operative
group (group 1) and in the 35.0% of the conservative group
(group 2) (p value < 0.001). Radiological findings of bowel
devascularization was detected in 33.1% of the operative
group, while no one of the patients who underwent the con-
servative management showed such sign (p < 0.001).
Patients who underwent immediate emergency surgery
(group 1) were older than patients who were managed non-
operatively (group 2): 66.0 years vs. 62.2 (p = 0.025). Addi-
tionally, patients who experienced a prior SBO were more
likely to be managed nonoperatively (p = 0.002) (Table 1).
One hundred forty-eight patients (22%) underwent
emergency surgery (group 1) because of abdominal ten-
derness (66 patients, 10%), ischemia of the small bowel
on CT scan (51 patients, 7.7%), hemodynamic instability
(5 patients, 3.3%), and multiple organ failure (8 patients,
5.4%); among them, 67 patients required small bowel
resection (46%) for irreversible ischemia or necrosis.
Patients of group 1 had more intense abdominal pain
(p < 0.001). There was no difference for biologic results
(white blood cells count and C reactive protein), except for
serum lactates which were higher in patients who needed
immediate surgery (p < 0.001) (Table 1).
International Journal of Colorectal Disease (2023) 38:224
Fig. 1  Study management flowchart
A total of 513 patients (78%) were managed nonopera-
tively (group 2), including 183 (36%) who finally required
surgery (group 2a). Rapidly in front of the persistence of
an acute abdominal pain (n = 45; 25%) or the occurrence of
vomiting after clamping the nasogastric tube (n = 68; 37%),
or later, after plain radiograph (8 h after the administration
of Gastrografin) did not show contrast medium in the colon
or the rectum (n = 66; 36%). Delayed surgery showed a com-
plete small bowel obstruction in all cases in group 2a, and a
small bowel resection was necessary in 19 patients (10%).
In those 19 patients, 5 underwent a small bowel resection
for intestinal necrosis (2.7%). Among the other 14 patients,
intestinal resection was needed in 8 cases for consequent
intestinal damage after adhesiolysis, in 3 cases for intestinal
stenosis, in 2 cases for tumoral lesions and in 1 case for
Meckel’s diverticulum.
The 330 remaining patients (group 2b, 64%) were suc-
cessfully treated nonoperatively showed a progressive clini-
cal improvement and were discharged after a median delay
of 3 days (range: 1–29).
Page 3 of 7 224
In the second analysis, we compared patients who were
successfully treated nonoperatively (group 2b, n = 330) with
patients who required surgery after the initial attempt at
medical management with Gastrografin (group 2a, n = 183)
(Table 2). We observed significant differences between
groups 2a and 2b in the previous SBO (p = 0.003): 37.2% of
patients who responded to the conservative treatment had
already had at least one precedent episode of SBO, versus
24.6% of patients who required delayed surgery.
We also found a statistically significant difference con-
cerning the presence of moderate to large diffuse peritoneal
effusion which was higher in the group of patients who had
delayed surgery after failure of conservative treatment: 100
patients (30.3%) in group 2B versus 80 patients (43.7%) in
group 2A (p = 0.002).
A significative statistic difference was underlined
between the group treated conservatively with Gastro-
grafin and the group who underwent immediate surgery
concerning inhalation pneumonia, which was lower in the
conservative group (0.97% vs 5.40%, p < 0.001). In the
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Table 1  Baseline characteristics Baseline characteristics Patients Patients P value

of the study population. Group 1 (148) Group 2 (513)
Comparison between patients
who underwent immediate Age (years) 66.0 (21–104) 62.2 (19–99) 0.025
emergency surgery (group 1)
Gender (male) 61 (41.2%) 238 (46.3%) 0.265
and patients who were managed
nonoperatively (group 2) BMI (kg/m2) 23.4 (14–44) 22.8 (12–53) 0.167
Comorbidity 143 (96.2%) 507 (98.8%) 0.064
Abdominal cancer antecedents 35 (23.6%) 132 (25.7%) 0.608
Abdominal radiotherapy antecedents 4 (2.7%) 36 (7.0%) 0.052
Abdominal previous surgery 126 (85.1%) 496 (96.6%) 0.025
Only previous laparoscopy 117 (79.0%) 442 (86.1%) 0.796
Prior SBO 29 (19.5%) 168 (32.7%) 0.002
Prior surgery for SBO 19 (12.8%) 90 (17.5%) 0.174
Abdominal tenderness 56 (37.8%) 10 (1.9%) < 0.001
Blood test
White blood cells ­(109/L) 11,039 (2000–42,000) 10,539 (1300–63,000) 0.325
C-reactive protein (mg/L) 29.1 (1.0–575.0) 20.6 (1.0–424.0) 0.088
Lactates (mmol/L) 1.6 (0.5–22.0) 1.2 (0.5–8.0) < 0.001
Abdominal CT scan
Devascularized small bowel 49 (33.1%) 0 (0%) < 0.001
Peritoneal effusion 99 (66.9%) 180 (35.0%) < 0.001

Continuous variables are reported as medians, minimum, and maximum values

BMI body mass index, SBO small bowel obstruction

group of patients who failed conservative treatment we inhalation pneumonia, 3 of which occurred in the group
could observe 3 cases of inhalation pneumonia. In our case of patients who required immediate surgery and 1 in the
series, we observed overall 4 deceases presumably due to group treated conservatively.

Table 2  Comparison of baseline Baseline characteristics Patients Patients P value

characteristics between patients Group 2a (183) Group 2b (330)
in group 2a and patients group
2b Age (years) 60.8 (19–99) 63.1 (19–97) 0.178
Gender (male) 91 (49.7%) 147 (44.5%) 0.260
BMI (kg/m2) 22.4 (12.0–37.0) 23.0 (12.0–53.0) 0.189
Comorbidity 181 (98.9%) 326 (98.7%) 0.904
Abdominal previous surgery 168 (91.8%) 301 (91.2%) 0.819
Only previous laparoscopy 157 (85.8%) 285 (86.3%) 0.583
Type of surgery
Digestive 116 (63.4%) 235 (71.2%) 0.026
Gynecological 47 (25.7%) 87 (26.3%) 0.814
Urological 27 (14.7%) 42 (12.7%) 0.544
Vascular 16 (8.7%) 16 (4.8%) 0.085
Other 1 (0.5%) 1 (0.3%) 0.675
Prior SBO 45 (24.6%) 123 (37.2%) 0.003
Prior surgery for SBO 29 (15.8%) 61 (18.4%) 0.452
Abdominal tenderness 4 (2.2%) 6 (1.8%) 0.773
Blood test
White blood cells (­ 109/L) 10,365 (1600–301,00) 10,636 (1300–630,00) 0.590
C Reactive protein (mg/L) 21.8 (1.0–355.0) 20.0 (1.0–424.0) 0.669
Lactates (mmol/L) 1.2 (0.5–8.0) 1.2 (0.5–4.6) 0.359
Abdominal CT scan
Devascularized small bowel 2 (1.0%) 0 (0%) 0.057
Diffuse peritoneal effusion 80 (43.7%) 100 (30.3%) 0.002

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International Journal of Colorectal Disease (2023) 38:224
Discussion
Adhesive SBO is a common cause of emergency depart-
ment visits and it frequently occurs after abdominal surgery
[13]. It remains a relevant clinical issue, in terms of costs
and morbidity, with an increase of mortality documented
in the elderly population [1, 14]. Most SBO patients can
be managed safely with initial nonoperative management
[15]. Despite the relevance of the frequency of SBO, the
recommended therapeutic strategy remains controversial.
An ideal management plan would prioritize immediate
operative exploration when signs of gravity are present at
admission, ensure early identification of patients who will
fail to respond to conservative management, and decrease
the number of nontherapeutic abdominal explorations with
the use of a water-soluble oral contrast tests. The last edited
guidelines for the management of SBO recommend an initial
medical treatment for 72 h before proposing surgical treat-
ment, except when signs of gravity are already present [5].
However, delayed surgery seems to be associated with an
increased morbidity and mortality rates [16, 17]. The chal-
lenge is to find a way to accelerate the identification of those
patients who will fail the nonoperative management.
Clinical features and hemato-chemical values can highlight
the severity of the SBO, as well as CT findings [18, 19].
In our series, 22% of SBO patients underwent immediate
surgery. There were several factors predicting the need for
emergency surgery, such as major and persisting abdominal
pain, elevated serum lactate levels, and ischemia of the small
bowel on CT scan images.
In the systematic review and meta-analysis by Li et al. [20],
the pooled sensitivity and specificity of CT for ASBO were 91%
and 89%, respectively. Concerning CT findings, in our study, we
observed that free peritoneal fluid was present in the 66.9% of
the patients who underwent immediate surgery, and in the 35.0%
of the patients of the conservative group (p < 0.001).
Seventy-eight percent of patients who came in the emer-
gency department for symptoms of adhesive SBO had an
initial nonoperative management. Among them, 37% finally
needed surgery. This rate is comparable with other case
series reporting rates ranging from 20 to 40% [6]. We chose
a waiting time of 8 h to decide whether the patient should
go to surgery, after the administration of Gastrografin. No
evidence in the literature is available for the optimal time to
wait before surgery [6].
Concerning the intraoperative findings, of all the 183
patients who underwent deferred surgery, 157 (85.5%)
underwent laparotomic adhesiolysis for a single band or
matted adherence, while 19 patients had a bowel resection.
It is relevant to note that although 10% of patients initially
managed nonoperatively had a small bowel resection during
delayed surgery, only 2.7% of them had intestinal ischemia.
Page 5 of 7 224
Among those, it is interesting to note that 2 of them suffered
from diabetes mellitus and 2 other consulted to emergency
room respectively 48 h and 5 days after the onset of the
symptoms of intestinal occlusion. The late consulting and
the presence of a comorbidity such as diabetes which can
camouflage symptoms and signs of gravity may be two con-
ditions of failure of the conservative treatment.
Concerning the prediction of failure of conservative treat-
ment, we found a significant correlation with the peritoneal
effusion: 44% of patients with SBO who failed to respond to
medical treatment exhibited a moderate or an important intra-
peritoneal effusion on the CT scan compared with 30% in
the group with successful medical treatment. In the group of
patients who needed a small bowel resection for ischemia, in
2 cases, we found a major peritoneal effusion on the CT scan.
Although abdominal effusion frequently occurs in patients with
SBO without being a gravity sign, a significant diffuse perito-
neal effusion corresponds to the beginning of small bowel wall
suffering, predicting a failure of medical management [13, 21].
Tabchouri et al. [22] published a retrospective study with
a series of 154 patients that showed an increase of post-
operative mortality and recurrence rate of SBO in patients
who failed conservative treatment, with a rate of mortality
of 22% in patients who failed medical treatment versus 0%
in the group of patients who had emergency surgery. We did
not find such results in our study: when comparing patients
who had immediate surgery with delayed-surgery patients,
the length of the hospital stay was similar (mean: 9 days),
and postoperative complications rate seems higher in case
of emergency surgery (surgical and medical complications
of 14.8% and 34.4% versus 9.3% and 18.0%, respectively).
For patients who were successfully managed nonopera-
tively, length of hospital stay was way shorter (median of
3 days). This suggests that the use of Gastrografin acceler-
ates return home for patients who do not need surgery and
shortens the surgical decision-making time when conserva-
tive management fails; in our study, we are unable to prove
that Gastrografin exerted a direct therapeutic effect, but it
is a useful diagnostic tool for facilitating a rapid decision-
making process in the management of patients with SBO.
Although our study was not focused on comparing
recurrence rate, we observed in our series that patients
managed nonoperatively tended to have a higher risk of
subsequent recurrence of SBO: the group managed con-
servatively had a recurrence rate of 29.9% versus 8.8% of
the group treated surgically. This result is coherent with
evidence in literature [23]: Meier et al. [24] reported a
long-term follow-up of patients treated with surgical
versus conservative approach for SBO for a period of
4.7 years, finding a recurrence rate of 29.4% in the con-
servative group and of 14.0% in the surgical group. In our
study, we observed also that patients who had previous
13
224 Page 6 of 7
SBO were more likely to respond to a conservative treat-
ment (p = 0.003).
In our case series, sixty-six patients presenting with SBO had
no previous surgery. Among them, twenty-two were operated
immediately, while forty-four were treated conservatively. Non-
operative management with Gastrografin was only effective in
twenty-nine patients with virgin abdomen (65.9%). In literature,
there are few studies reporting the use of oral water-soluble con-
trast in the management of SBO of virgin abdomen: in the study
of Fukami et al., OWSC seems to be equally effective in the
management of SBO both in patients with virgin abdomen and
patients with previous surgery [25]. Collom et al. showed in his
study that the use of OWSC reduced significantly the need for
operative intervention in patients with virgin abdomen [26, 27].
Our results show that management of SBO with Gastrografin is
feasible in patients with virgin abdomen, without augmenting
the risk of deferred surgery.
In conclusion, in our case series we found that a man-
agement of adhesive SBO based on clinical and CT scan
features is relevant. Immediate surgery was performed in
emergency in case of major persisting abdominal pain,
hemodynamic instability, and signs of small bowel ischemia
on imaging procedures. Besides these conditions, most of
the other patients could be managed nonoperatively. Use of
Gastrografin after a 4-h period of nasogastric decompression
showed to be helpful for management of adhesive SBO and
to reduce the duration of the hospitalization stay.
In our study, we included and analyzed a large cohort of
661 patients in a period of 14 years; our protocol was homog-
enously and rigorously applied by our surgical team in all
patients enrolled in the study who underwent an initial medical
treatment. The same surgical team was responsible for follow-
ing the patients along the entire time of the protocol applica-
tion, assuring the respect of waiting time of 4 h of aspiration by
nasogastric tube, dispensation of Gastrografin, and systematic
surveillance after Gastrografin administration. Among 513
patients who were treated medically, only 5 (0.9%) needed a
small bowel resection for intestinal ischemia.
In conclusion, the aim of this observational study was to
evaluate safety and effectiveness of the protocol of a non-
operative management of adhesive SBO with the help of
­Gastrografin® administration. We find that our protocol is
simple, cheap, feasible, and easily reproducible.
Author contribution Conceptualization: Maienza E, Godiris-Petit G.,
Noullet S, Menegaux F, Chereau N.; methodology: Maienza E, Men-
egaux F, Chereau N.; validation: Maienza E, Godiris-Petit G., Noullet
S, Menegaux F, Chereau N.; formal analysis: Maienza E, Chereau N.;
investigation: Maienza E, Godiris-Petit G., Noullet S, Menegaux F,
Chereau N.; data curation: Maienza E, Menegaux F, Chereau N.; writ-
ing—original draft: Maienza E, Menegaux F, Chereau N; writing—
review and editing: Maienza E, Godiris-Petit G., Noullet S, Menegaux
F, Chereau N.; supervision: Menegaux F, Chereau N. All authors read
and approved the final manuscript.
13
International Journal of Colorectal Disease (2023) 38:224
Availability of data and materials Data is available on request from the
corresponding author.
Declarations
Ethics approval and consent to participate No ethical approvals are
required for this study.
Consent for publication All authors consent for this version of the
paper to be published.
Competing interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
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