EP.FRI.82 Using NCEPOD guidelines to develop an evidence based pathway for acute bowel obstruction

Bowel obstruction is a common presentation and poses a significant challenge for clinicians. This condition is associated with a high level of mortality and morbidity. The aim of this project was to assess the clinical pathway for patients presenting with bowel obstruction and improve the overall care they received. This was achieved using guidance from the 2020 NCEPOD report looking at bowel obstruction management. Best practice guidelines from the NCEPOD report were used to assess aspects of patient care such as the time to senior review, assessment of nutrition/fluid status and risk of mortality/morbidity assessment. This identified areas where the standard of care was good, such as the majority of patients being assessed by a consultant within 14 hours. However, it also identified areas such as hydration and nutritional status assessment, documentation of ceilings of care/treatment escalation plans and calculation of risk of mortality and morbidity, which required improvement. An admission checklist and nutritional scoring sheet was created to help prompt clerking doctors when admitting patients with acute bowel obstruction. All cases of bowel obstruction were then prospectively audited over a 2 month period to assess the impact of these changes. The findings were presented at the departmental meetings to increase clinician awareness. Following the audit period, local guidelines were amended to incorporate the NCEPOD recommendations, specific pathways were also made for adhesive small bowel obstruction and malignant large bowel obstruction due to the specific requirements of these conditions.

Value of the ultrasound research in the diagnostic of acute strangulated small bowel obstruction

Purpose. To identify and evaluate the effectiveness of sonographic signs of intestinal ischemia in patients with strangulated small bowel obstruction.Materials and methods. For the period 2017–2019, 115 patients with SIO were treated at the N.V. Sklifosovsky Federal Research Institute of Emergency Medicine. There were 64 women (55.6%) and 51 men (44.4%). The mean age was 62 ± 15 years. In all patients, the diagnosis was verified intraoperatively. All patients underwent ultrasound examination of the abdominal cavity in B-mode with the assessment of blood flow of the intestinal wall in the mode of CDI. Patients were divided on the basis of intraoperative data into 2 groups. The first group: 63 (54.8%) patients with signs of ischemia of the strangulated loop of the intestine. The second group consisted of 21 (18.1%) patients in whom intestinal necrosis was detected. The comparison group included 31 (26.7%) patients with adhesive small bowel obstruction without intestinal strangulation.Results. The most informative signs of ischemia of the strangulated intestine of the loop are infiltrative changes of its mesentery. In the second and third groups 9 (14.3%) and 12 (57.1%) participants, respectively, showed severity of intestinal ischemia, compared with 1 participant (3.2%) in the first group. The next informative criterion is the thickening of more than 0.4 cm and edema of the intestinal wall. In the second and third groups 30 (47.6%) and 14 (66.6%), in the comparison group 4 (12.9%), akinesis of the strangulated loop and paresis of the entire small intestine also directly correlated with intestinal ischemia. The absence of differentiation of intestinal wall layers occurs in (23.8%), the absence of blood flow in the intestinal wall in the CDI mode (19%), gas inclusions in the intestinal wall (4.3%).Conclusion. The assessment of sonographic symptoms allows to diagnose the presence of ischemic changes in the intestinal wall and perform surgery before the development of necrosis in the early period. In cases of late admission of the patient to the hospital, with the onset of intestinal necrosis and the associated erased clinical picture, ultrasound allows to establish indications for surgery before the development of peritonitis.