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Three Part Question

In [adults with small bowel obstruction] is [nasogastric decompression] better than [no decompression] at [improving the process and outcome of care]?

Clinical Scenario

A 45-year-old male with a past medical history of prior open appendectomy, presents to the Emergency Department (ED) with a chief complaint of abdominal pain with associated nausea, vomiting and inability to pass flatulence. Imaging of the abdomen demonstrates loops of bowel with a transition point, consistent with small bowel obstruction (SBO). The patient refuses insertion of the nasogastric tube (NGT).

Search Strategy

Medline 1966-02/24 using PubMed, Cochrane Library (2024), and Embase
[(intestinal obstruction OR small bowel obstruction) AND (nasogastric tube)] LIMIT to English language.

Search Outcome

212 total articles were found, one systematic review was identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Klingbeil KD et al November 2022 USA	272 of 759 (36%) patients with a small bowel obstruction successfully managed without NGT	Systematic review	Operative rates	No significant difference (28.6% versus 16.5%, risk ratio 1.34)	Retrospective cohort studies may be skewed by selection bias. Lack of detailed treatment protocols. Unbalanced baseline patient characteristics. Single center studies limiting generalizability. Limited details on quality of life
			Mortality	No significant difference, risk ratio 1.98
			Rates of bowel resection	No significant difference, risk ratio 1.56

Comment(s)

Small bowel obstructions are a common diagnosis from the Emergency Department, however management with nasogastric decompression is controversial. Nasogastric tubes are associated with substantial pain and discomfort, and if mismanaged can lead to increased pulmonary complications. This article encompasses a systematic review of retrospective cohort studies, comparing patient’s diagnosed with small bowel obstruction managed with and without nasogastric tube placement. Overall, there was no significant evidence for routine nasogastric tube placement in patient’s with small bowel obstruction based on operation rates, mortality and bowel resections. However given the limitations of this systematic review, this data cannot be generalized to the general population and there are potential opportunities to investigate if certain subpopulations of patients with small bowel obstruction would be more appropriate for non-nasogastric decompression management.

Clinical Bottom Line

A subset of patients presenting with SBO may be safely treated without the use of NGT decompression.

References

1. Klingbeil KD, Wu JX, Osuna-Garcia A, Livingston EH. Management of small bowel obstruction and systematic review of treatment without nasogastric tube decompression. Surg Open Sci 2022 Nov 7;12:62-67