Prospective Evaluation of a Structured Management Protocol for Adhesive Small Bowel Obstruction: Gastrografin and Initial Severity Stratification

Abstract

Background: Adhesive small bowel obstruction (ASBO) is a frequent surgical emergency, and identifying patients who require early operative intervention remains challenging. Aim: This study evaluated outcomes under a structured management protocol incorporating initial severity stratification and selective Gastrografin use. Methods: A prospective, single-centre observational study included 32 patients aged ≥14 years with imaging-confirmed ASBO managed between January 2022 and December 2024. Patients underwent clinical, laboratory and radiological assessment, followed by nasogastric decompression and fluid resuscitation. Gastrografin was administered selectively to patients without severity criteria who did not improve with initial management. Results: Medical treatment alone resolved obstruction in 5 of 32 patients (15.6%). Seven patients underwent a Gastrografin challenge, of whom four (57.1%) avoided surgery. Overall, nine patients (28.1%) were managed conservatively, while 23 (71.9%) underwent laparotomy. Bowel resection was performed in eight of 23 operated patients (34.8%). All eight resections occurred among the 15 patients with a positive initial severity profile; none occurred among the 17 patients without such criteria (Fisher's exact test, p<0.001). Complications were recorded in five of 30 evaluable patients (16.7%). Median hospital stay was 4.5 days after conservative management and 6.5 days after surgery (p=0.053). Conclusion: The structured protocol permitted non-operative resolution in a subset of patients. Initial severity criteria were associated with bowel resection, although the small sample and non-random allocation limit interpretation.