An Oral Solution for Partial Small Bowel Obstruction

Abstract & Commentary

By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus, Huntsville. Dr. Wilke reports no financial relationship to this field of study.

Synopsis: The use of a laxative, a digestive aid, and a surfactant leads to speedier recovery from partial small bowel obstruction with less need for surgery.

Source: Chen SC, et al. Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial. CMAJ. 2005;173:1165-1169.

Chen and colleagues in Taipei conducted this single-blind, randomized control study of a combination of oral magnesium oxide (a laxative), Lactobacillus acidophilus (a digestive aid), and simethicone (a surfactant) in the treatment of partial small bowel obstruction (PSBO) secondary to adhesions. Criteria for admission into the study were: signs and symptoms consistent with PSBO (pain, distention, nausea, vomiting, and constipation), a history of abdominal surgery at least 4 weeks before enrollment, and a plain upright abdominal X-ray that showed dilated loops of small bowel, air-fluid levels, and colonic gas. In this study, 128 patients were identified. They excluded patients with no X-ray evidence of gas in the colon, signs of intestinal strangulation or peritonitis, fever, intractable pain, or leukocytosis.

Patients were also excluded if adhesions were not the cause of the PSBO (eg, inflammatory bowel disease, hernia, cancer, or irradiation). All patients had a thorough history and physical and had a complete blood count and abdominal X-ray. They all received intravenous Ringer's lactate and a nasogastric tube for decompression. They were randomized to a usual conservative therapy group (nothing by mouth) or the intervention group (MgO 250 mg 2 tablets, plus Lactobacillus acidophilus 0.3 mg tablet, plus simethicone 40 mg tablet 3 times daily). All patients had daily abdominal X-rays. The decision to take a patient to surgery was made if the patient became toxic (fever, leukocytosis, intractable pain, signs of peritonitis) or if the PSBO persisted for 5 days. Discharge criteria were no pain, tolerating solids, and an abdominal X-ray showing no gas in the small bowel. Patients were followed for 6 months post discharge.

The 2 groups were well matched with a slight preponderance of males. Average age was 54 years (range, 18 to 83). The intervention group underwent surgery less frequently (9.2% vs 23.8%; number-needed-to-treat, 7) and had shorter length of stay (LOS) (1.0 vs 4.2 days). Both results were statistically significant. Complications and recurrence of PSBO were low and not statistically different between the 2 groups.

Commentary

Every so often a really neat clinical trial comes across my desk. This one had a tightly focused clinical question whose results are important to patients and third-party payers. It's not surprising that the control group had longer LOS; after all, they had a higher rate of surgery with the subsequent postoperative recovery period. What I found surprising was the speed at which symptoms in the intervention group resolved. This therapeutic regimen has the potential of saving a great deal of money, based on a difference of 3.2 days of hospitalization, no operating room charges, and, presumably, less time off work. In the long term, because the vast majority of PSBO is caused by adhesions from prior abdominal surgery,1 perhaps there will be fewer recurrences in the non-operative group, although this was not demonstrated in this study during the 6-month follow-up period.

One obstacle to adoption of this treatment in the United States is the dosing of L. acidophilus. A search of the US Pharmacopeia2 failed to find any reference for L. acidophilus. The tablets (sold as Bacid®, Kala®, Lactinex®, MoreDophilus®, Pro-Bionate®, Superdophilus®) are available at on-line pharmacies, but usually the dosage is not listed, and when it is, it is given as the number of live organisms. Becton Dickinson, the manufacturer of Lactinex®, reports that each tablet contains 1 million CFUs, which equates to 0.5 grams.3 The hospital where I admit patients does stock it; I suggest you check with your hospital pharmacy before trying this regimen. MgO, L. acidophilus, and simethicone are dirt cheap. MgO 250 mg tablets are available in 200-tablet bottles for less than $10.00; Lactinex® comes in bottles of 50 tablets and also sells for less than $10.00. Simethicone (Flatulex®, Mylicon®, Gas-X®, and others) is even cheaper.

This is not the first time an oral regimen has been advanced for treating PSBO. A Cochrane Review4 from January 2005 found that the use of a water-soluble contrast (eg, Gastrografin®) predicts non-operative resolution of adhesive small bowel obstruction and appears to reduce hospital stay, but does not cause resolution of PSBO. Interestingly, the lead author of the Cochrane Review was the second author of a study5 published in August 2005 that found that Gastrografin® accelerates resolution of PSBO.

References

1. Ellis H. The clinical significance of adhesions: focus on intestinal obstruction. Eur J Surg Suppl. 1997;(577): 5-9.

2. www.usp.org. Accessed November 29, 2005.

3. Andrus M. Personal communication. November 28, 2005.

4. Abbas S, et al. Oral water soluble contrast for the management of adhesive small bowel obstruction. Cochrane Database Syst Rev. 2005;(1):CD004651. Review.

5. Burge J, et al. Randomized controlled trial of Gastrografin in adhesive small bowel obstruction. ANZ J Surg. 2005;75:672-674.