Small Bowel

Obstruction
Presented by
Crystal Vasquez, MS
Dietetic Intern
Small Bowel
Obstruction
Normal flow of small
intestines is interrupted
Can be due to abnormal
intestinal physiology or
mechanical obstruction
Acute or Chronic
Partial or complete
Complete, Closed-loop
Intestine is obstructed at two
locations (creating a segment
with no proximal or distal outlet
(Bordeianou & Dante Yeh, 201
Obstructive Physiology
Can lead to bowel dilation and retention of fluid
proximal to the obstruction and decompression of the
lumen distal to the obstruction
Air and gas from bacterial fermentation can add to
bowel distention
Bowel wall becomes edematous
Normal absorptive function of small intestine is lost
leading to nutrient deficiencies
Ongoing emesis can lead to fluid loss Fluid loss can
lead to hypovolemia
Can eventually lead to necrosis of intestinal cells
(Bordeianou & Dante Yeh, 201
Prevalence

Common surgical emergency

Over 300,000 laparotomies performed in the US each
year for adhesion-related obstructions
Incidence is similar for males and females
For patients with a history of prior bowel obstruction,
whether managed medically or surgically, the
likelihood of recurrent obstruction increases with an
increasing number of episodes

(Bordeianou & Dante Yeh, 201

 Risk Factors and Causes
Risk Factors:
Prior abdominal or pelvic surgery
Abdominal wall or groin hernia
Intestinal inflammation
History of, or increased risk for neoplasm
Prior irradiation
History of foreign body ingestion
Common causes of blockages
Bands of scar tissue
Tumors
Hernia
Inflammatory bowel disease
Twisting of intestines
(RelayHealth, 2014; Bordeianou & Dante Yeh, 20
Signs and Symptoms
Nausea
Vomiting (associated
w/proximal obstructions)
Diarrhea (early symptom,
associated with partial
blockage)
Constipation (late symptom)
Abdominal distention
Abdominal pain
Fever and tachycardia

(RelayHealth, 2014; Bordeianou & Dante Yeh, 20

Diagnosing
Physical exam
Abdominal distention
Muffled bowel sounds
Rectal exam can identify fecal impaction
Laboratory
Complete blood count, BUN and creatinine, Lactate
dehydrogenase tests, urinalysis, phosphates, creatine kinase,
liver panels
Not specific for small bowel obstruction but can assess presence
of hypovolemia, leukocytosis, metabolic abnormalities and
anemia

(RelayHealth, 2014; Bordeianou & Dante Yeh, 20

Diagnosing (cont)
Abdominal Imaging
Radiography
Abdominal CT
Other Studies
Abdominal ultrasonography
Magnetic resonance
enterography
Small Bowel Contrast
Contrast Enema

(Bordeianou & Dante Yeh, 201

Intestinal Pseudo-Obstruction

Difficult to diagnose
Motility disorder that mocks symptoms of small bowel
obstruction
Mechanical obstruction cannot be identified
Common symptoms
Dysphagia, GERD, abdominal pain, nausea, vomiting, bloating,
abdominal distension, constipation/diarrhea, and weight loss
Medical therapies and MNT similar

(Gabbard & Lacy, 2013)

Common Medical Therapies
Initial treatment
Aggressive fluid resuscitation
Bowel decompression (through NG tube for suctioning)
Analgesia and antiemetic
Antibiotics
Partial blockage/Pseudo-Obstruction
Continued NG suction for up to 3 days
Treatment varies based on etiology
Complete blockage
Laparoscopic surgery is generally needed

(Bordeianou & Dante Yeh, 2016

Medical Nutrition Therapy
Enteral Nutrition
Can be used in partial and pseudo-obstructions if oral intake is
inadequate
Generally contraindicated in complete bowel obstructions
If blockage occurs above the jejunum, a PEJ may be used for enteral
nutrition
A G/J-tube can also be placed to allow for decompression of the stomach
through the g-tube and feeding through the J-tube
Total Parenteral Nutrition
Use in cases of complete blockage, until blockage can be removed
Can be used in partial and pseudo-obstructions if EN is not tolerated
In cases of partial and pseudo-obstructions, oral intake should be
encouraged, as tolerated, while receiving TPN
In terminally ill patients, TPN may prolong life by more than 60 days.
(Duerksen, et al., 2004 ; National Institutes of Health, 2
MNT after Small Bowel Obstruction
Clear Liquid Diet Full Liquids Low Fiber/Low Residue Diet
Regular Healthy Diet
Low Reside Diet
Avoid Foods high in fat and fiber
Avoid seeds
Avoid whole grains
Avoid most raw fruits and vegetables
Milk and Dairy in moderation
Lean meats
Other diet considerations:
Frequent small meals
Add foods back into diet slowly
Avoiding foods that cause gas, loose stools and/or constipation
(Nelms, Sucher, & Lacey, 201
Multivitamin supplementation (National Institutes of Health, 201
Case Study
Patient history
55-year-old male
Discharged from hospital previous day for sepsis and UTI
Medical history
Multiple strokes
Diabetes with neuropathy
CKD Stage 3
Hypertension
Peripheral vascular disease
Dementia
B/L paresis
Neurogenic bladder
History of seizures
History of alcohol dependence
Surgical History: G-tube placement
Admission & Medical Diagnosis

Presented to ER with shortness of breath and possible

aspiration
Coffee ground emesis
Patient unable to communicate
Intubated in ER, sedation and vasopressors
ER diagnosis
Possible GI bleed
Possible bowel obstruction
Medical Treatment Plan

Gastric decompression
Determine if blockage is present and location
Determine if surgery is appropriate
Place PICC line for TPN
J-tube placement when stable
Pertinent Medications

Antibiotics: Piperacillin Tazobactam

Anti-Emetics: Zofran
Anti-GERD: Prilosec
Lipid Lowering: Zocor
Sedatives: Versed, Fentanyl
Steroids: Albuterol
Insulin: Humalog: Supplemental: Low dose
Surgical Consult
Results
CT scan revealed bilateral aspiration
pneumonia
Abdominal scan revealed
Giant dilation of stomach
1st & 2nd portions of duodenum dilation
Bowel from ligament of Treitz to ileocecal
valve: decompressed and small
Colon: very small, consistent with
chronic disuse
Large Rectum: full of stool
Possible proximal jujunal obstruction
Operative Report
No evidence of gastric obstruction, possible motility disorder
Superficial antral ulcers
Duodenum slightly dilated
Nutrition Care Process
ASPEN TPN Recommendations for
Critically Ill Patients
Calories: 25-30 kcal/kg IBW

Protein: 1.2-2.0 g/kg IBW

Fluids: 30 ml/kg or Per MD

Initial Assessment, Day 2 of admit
Anthropometrics
Height: 71 in
Weight 153.9 lbs
BMI: 22
IBW= 172 lbs / % IBW=89%
UBW = 180 lbs / % UBW 85% x 1 month
Pertinent Labs: Albumin 3.3L, Creatinine 1.5H, Magnesium 1.4L,
Phosphorus 1.8L, FSBG 92-105 (WNL), All other nutrition-related labs
WNL
Last Bowel Movement: unknown
Skin status: Intact
Edema: none
Diet Order: NPO - intubated
Initial Assessment, Day 2 of admit
Estimated Nutrition Needs (based on actual body weight)
1748-2097 kcal/day (25-30 kcal/kg)
84-140g protein/day (1.2-2.0 g/kg)
2097 ml fluid/day (30ml/kg)
Nutrition Status: Nutrition risk related to intubation/ventilation as
evidenced by NPO status
PES Statements
Inadequate intake: Protein-energy related to intubation/ventilation as
evidenced by NPO status
Inadequate intake: Probiotic related to high risk antibiotic therapy as
evidenced by diet lacking in probiotics
Nutrition Interventions/Recommendations
Defer recommendations until ability to initiate TF/TPN is established
Nutrition Follow-up, Day 3 of admit
Patient is expected to not have use of his GI tract for an
extended period of time; MD would like TPN to be initiated
PICC line now in place
Patient is sedated and no vasopressors required
Pertinent Labs: Albumin 3.1L, Potassium 3.4L, Creatinine 1.5H,
Magnesium 1.4L, Phosphorus 1.9L, All other nutrition-related labs
WNL
Nutrition Interventions/Recommendations
Initiate TPN, Day 1
Standard @ 35 ml/hr
30 grams lipid/day
Total TPN provides: 1100 total kcal, 42 g protein, 1.7mg carb/kg/min, 30 g
fat
Nutrition Follow-up, Day 4 of admit
Patient is tolerating TPN
Patient is alert
Pertinent Labs: Phosphorus has dropped to 1.6 MD agreed to
hang phosphorus
Nutrition Interventions/Recommendations
Continue TPN
Standard @ 75 ml/hr
30 grams lipid/day
Total TPN provides: 1884total kcal, 90g protein, 30 g fat
Monitor/Plan:
Monitor TPN tolerance, nutrition related labs, skin integrity, GI status and all
other nutrition-related parameters, need for custom TPN
Nutrition Follow-up, Day 5 of admit
Patient is tolerating TPN
Patient is sedated and intubated
Pt will have J-tube placed for feeding and G-tube for venting this
week
Pertinent Labs: Phosphorus is now WNL. K is slightly low (3.4)
and KCl is hanging. Magnesium is slightly low
Nutrition Interventions/Recommendations
Continue TPN
Monitor/Plan:
Monitor TPN tolerance, nutrition related labs, skin integrity, GI status and all
other nutrition-related parameters, J-tube placement and ability to initiate
tube feeding
Nutrition Follow-up, Day 6 of admit
Patient is tolerating TPN
Patient is sedated and intubated
Pertinent Labs: Electrolytes now WNL
Nutrition Interventions/Recommendations
Continue TPN
Monitor/Plan:
Monitor TPN tolerance, nutrition related labs, skin integrity, GI status and all
other nutrition-related parameters, J-tube placement and ability to initiate
tube feeding
Nutrition Follow-up, Day 7 of admit
Patient is tolerating TPN
Patient extubated and on BiPap
G-J tube will not be placed for a few more days
Pertinent Labs: Albumin drops to 2.4L, all other nutrition-related
labs WNL
Nutrition Interventions/Recommendations
Continue TPN
Monitor/Plan:
Monitor TPN tolerance, nutrition related labs, skin integrity, GI status and all
other nutrition-related parameters, J-tube placement and ability to initiate
tube feeding
 Nutrition Follow-up, Day 8-18 of
admit
Patient is tolerating TPN
Patient no longer on BiPap
Pertinent Labs: NaCl was d/c after Cl trended upwards Cl
returned to within normal limits, FSBG monitored for need to
adjust insulin
Nutrition Interventions/Recommendations
Continue TPN
Monitor/Plan:
Monitor TPN tolerance, nutrition related labs, skin integrity, GI status and all
other nutrition-related parameters, J-tube placement and ability to initiate
tube feeding
Nutrition Follow-up, Day 19 of admit
Patient is tolerating TPN
J-tube has been placed
Patient cleared to start trickle tube feedings
Patient has previously been on home tube feedings with bolus
feedings, however due to J-tube patient requires continuous
feedings
Pertinent Labs: Albumin 2.2, Sodium 135L, Glucose 133H,
Magnesium 1.6L, FSBG 132-209
Last Bowel Movement: 4 days prior
Nutrition Follow-up, Day 19 of admit
Nutrition Interventions/Recommendations
Initial Tube Feeding
Glucerna 1.2 @ 65ml/hr x 22 hours, Water Flushes: 200ml every 8 hours
Initiate at 20ml/hour x 12 hours, if patient tolerates advance formula 10ml
every 4 hours until at goal rate
Tube Feed Regimen Provides
1716 Total Kcal (30kcal/kg/day), 85 g protein (1.5 g/kg/day), 1158ml free
water (1758ml free water, including free water flush)
114% Recommended Dietary Intake Vitamins/Minerals

Monitor/Plan:
Monitor tube feeding tolerance and ability to advance to goal rate. If
tolerated, discontinue TPN tomorrow
Nutrition Follow-up, Day 20
of admit
Patient tolerating tube feeding
Patient to be discharged home today
Patient has received 100% of nutritional needs for 16
days
Family provided with home regimen
Glucerna 1.2
Begin feeding @ 1800
Stop feeding @ 0900
Goal rate: 90 ml/hr x 15 hours a day
Family given outpatient dietitians contact information
References
Bordeianou, L., & Dante Yeh, D. (2016, 1). Epidemiology, clinical features, and
diagnosis of mechanical small bowel obstruction in adults. Retrieved 1 14, 2017,
from Wolters Kluwer: http://www.uptodate.com/contents/epidemiology-clinical-
features-and-diagnosis-of-mechanical-small-bowel-obstruction-in-adults
Duerksen, D. R., Ting, E., Thomson, P., McCurdy, K., Linscer, J., Larsen-Celhar, S., &
Brennenstuhl, E. (2004). Is There a Role for TPN in Terminally Ill Patients With
Bowel Obstruction? Nutrition, 20, 760-763.
Gabbard, S. L., & Lacy, B. E. (2013, 6). Chronic Intestinal Pseudo-Obstruction.
Nutrition in Clinical Practice, 28(3), 307-316.
National Institutes of Health. (2016, 9 17). Intestinal or bowel obstruction -
discharge . Retrieved 1 14, 2017, from US National Kibrary of Medicine:
https://medlineplus.gov/ency/patientinstructions/000150.htm
Nelms, M., Sucher, K. P., & Lacey, K. (2015). Nutrition Therapy and
Pathophysiology (Third ed.). Boston, MA: Cengage Learning.
RelayHealth. (2014). Bowel Obstruction: Small Bowel. Retrieved 1 14, 2017, from
Summit Medical Group:
http://www.summitmedicalgroup.com/library/adult_health/aha_small_bowel_obstru
ction/