Clinical Commander

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gi.small-bowel-obstruction.core.v1

Small Bowel Obstruction

gastroenterologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is full (WSES 2017 Bologna + EAST 2012 + ACR 2020 + Branco 2010 + Abbas 2024 + Zielinski 2017 + SnapSBO 2025) with 8 phenotypes (adhesive partial/complete, hernia, malignant, strangulation, early-postop, Crohn, gallstone-ileus) and full medication/dosing tables. Problem-package at small-bowel-obstruction/ has all atoms; no `_design-brief.md`. Workup `sbo_partial_complete` is registered in clinical-tools-registry. NEWS2, qSOFA, anion gap, BMI, corrected calcium calculators wired. Gaps for INTEGRATED: no design brief md file; evidence.pmids array empty (manifest cites guideline labels but no numeric PMIDs); no engine-specific test_files. No regimen_axes — IV fluids, ondansetron, morphine/hydromorphone, gastrografin, pip-tazo, ceftriaxone+metronidazole, enoxaparin, octreotide, dexamethasone, methylpred, K replacement all in manifest.medications without RxCUI verification through regimen-builder.

Entry points (4)

  • symptom
    Colicky abdominal pain + distension (WSES Bologna 2017)
    colicky_abdominal_pain
  • symptom
    Vomiting (bilious/feculent) + obstipation (WSES Bologna 2017)
    vomiting_obstipation
  • imaging
    CT/XR showing dilated small bowel + transition point (ACR Appropriateness Criteria 2020)
    sbo_on_imaging
  • symptom
    Tender / irreducible hernia (EAST 2012)
    incarcerated_hernia

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Surgical risk; malignancy probability rises with age (WSES Bologna 2017)
  • sbprequired
    vital • used at CONTEXT
    Hypotension in strangulation / sepsis (EAST 2012; WSES Bologna 2017)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia / SIRS / strangulation (WSES Bologna 2017)
  • temperaturerequired
    vital • used at CONTEXT
    Fever in strangulation / ischemia (WSES Bologna 2017)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis / left shift in strangulation (Zielinski 2017; WSES Bologna 2017)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Bowel ischemia marker; elevated → emergent OR (EAST 2012; Zielinski 2017)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Dehydration / contrast safety / abx dosing (NICE 2024)
  • electrolytesrequired
    lab • used at INITIAL_WORKUP
    Hypokalemia / metabolic alkalosis from emesis (WSES Bologna 2017)
  • ct_abdomen_pelvis_iv_contrastrequired
    imaging • used at INITIAL_WORKUP
    First-line per ACR Appropriateness Criteria 2020; transition point + strangulation signs
  • water_soluble_contrast_study
    imaging • used at BRANCHING_WORKUP
    Diagnostic + therapeutic for adhesive SBO; contrast in colon at 24h predicts resolution (Branco 2010; Abbas 2024 meta-analysis)
  • prior_abdominal_surgeryrequired
    history • used at CONTEXT
    Adhesive SBO is most common cause (~65-75%) (WSES Bologna 2017; EAST 2012)
  • hernia_historyrequired
    history • used at CONTEXT
    Hernia-related SBO ~10-15% (WSES Bologna 2017)
  • malignancy_history
    history • used at CONTEXT
    Malignant SBO — peritoneal carcinomatosis, palliative options (NICE 2024)
  • crohns_history
    history • used at CONTEXT
    Crohn-related stricture — medical optimization first (WSES Bologna 2017)
  • recent_surgery_within_30d
    history • used at CONTEXT
    Early postoperative SBO — prolonged NOM acceptable (EAST 2012; WSES Bologna 2017)

12-phase flow (12)

  1. 1FRAME
    Confirm SBO scope; distinguish from large-bowel obstruction, paralytic ileus, Ogilvie, mesenteric ischemia (WSES Bologna 2017; EAST 2012)
    inputs: age
    advance: mechanical SBO confirmed
  2. 2ENTRY
    Recognize colicky pain + distension + vomiting + obstipation, or imaging finding (WSES Bologna 2017)
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, prior abdominal surgery, hernias, malignancy, Crohn, recent surgery, opioid use, last flatus/BM (EAST 2012; WSES Bologna 2017)
    inputs: sbp, hr, temperature, prior_abdominal_surgery, hernia_history, malignancy_history, crohns_history, recent_surgery_within_30d
    advance: context captured
  4. 4RED_FLAGS
    Strangulation / peritonitis, closed-loop, pneumatosis / portal venous gas, absent bowel wall enhancement, free fluid + mesenteric haziness, hemodynamic instability, elevated lactate / acidosis, incarcerated hernia (Zielinski 2017; WSES Bologna 2017; EAST 2012)
    inputs: sbp, lactate, temperature
    actions: calc.qsofa
    advance: strangulation excluded or routed to emergent OR
  5. 5INITIAL_WORKUP
    CBC, BMP, lactate, lipase, type and screen, CT abdomen/pelvis with IV contrast (first-line per ACR Appropriateness Criteria 2020)
    inputs: wbc, lactate, creatinine, electrolytes, ct_abdomen_pelvis_iv_contrast
    actions: panel.cbc, panel.renal, sbo_partial_complete
    advance: CT + labs complete
  6. 6BRANCHING_WORKUP
    Water-soluble contrast (Gastrografin 100 mL) at 24-48h for adhesive SBO if NOM continuing — contrast in colon by 24h predicts resolution (sens 96%, PPV 99%) (Branco 2010; Abbas 2024 meta-analysis); ABG if strangulation
    inputs: water_soluble_contrast_study
    actions: acute_abdomen
    advance: phenotype identified (adhesive partial / adhesive complete / hernia / malignant / strangulation / early-postop / Crohn / gallstone-ileus)
  7. 7DIFFERENTIAL
    Adhesive > hernia > malignant > Crohn stricture > volvulus > intussusception > gallstone ileus > radiation > paralytic ileus > LBO > acute mesenteric ischemia > Ogilvie (WSES Bologna 2017 frequency ranking)
    advance: etiology identified
  8. 8RISK_STRATIFICATION
    Partial vs complete; simple vs strangulated; operative vs non-operative (WSES Bologna 2017; EAST 2012); NEWS2; qSOFA for sepsis
    inputs: sbp, hr, lactate
    actions: calc.news2
    advance: classification + operative decision documented
  9. 9TREATMENT
    NPO + NGT + IV fluids + electrolyte correction + DVT prophylaxis (WSES Bologna 2017); water-soluble contrast challenge for adhesive (Branco 2010; Abbas 2024); emergent OR for strangulation/closed-loop/incarcerated hernia/perforation (EAST 2012); strictureplasty for Crohn; palliative for malignant (NICE 2024); broad-spectrum abx if ischemia
    inputs: creatinine
    advance: NOM trial or surgical plan in motion
  10. 10DISPOSITION
    OR for strangulation / closed-loop / incarcerated hernia / failed NOM; ICU for septic / strangulated; floor for stable NOM (WSES Bologna 2017; EAST 2012)
    inputs: sbp
    advance: destination set
  11. 11MONITORING
    Serial abdominal exams q4-6h, NGT output, strict I&O, vitals q4h, electrolytes daily, serial lactate if ischemia concern, passage of flatus/BM (WSES Bologna 2017; NICE 2024)
    inputs: wbc, lactate, electrolytes
    advance: resolution or escalation by 48-72h
  12. 12FOLLOWUP
    Surgery consult on admission, post-op diet advancement, discharge criteria for NOM, outpatient follow-up 2 weeks, recurrence education (WSES Bologna 2017; NICE 2024)
    advance: follow-up scheduled