Small bowel obstruction Diagnosis and management Abdominal computed tomography Obtain a CT scan of abdomen and pelvis in all patients with SBO, as it can provide incremental information over abdominal XRs in differentiating grade, severity, and etiology of SBO, and may lead to changes in management strategies. A Abdominal magnetic resonance imaging and ultrasound Consider obtaining MRI and ultrasound as alternatives to CT, recognizing that these modalities suffer from several logistical limitations in the evaluation of patients with SBO. C Setting of care Consider admitting patients with SBO to a surgical service, as this has been shown to be associated with a shorter length of stay and lower mortality as compared with admission to a medical service. C Indications for surgery Q Does the patient show generalized peritonitis on physical examination? Q Are CT findings consistent with bowel ischemia? Yes to any Perform timely surgical exploration in patients with SBO and generalized peritonitis on physical examination or with other evidence of clinical deterioration such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain. A Consider using a lower threshold for operative intervention if CT findings are consistent with bowel ischemia. C No to all Abdominal computed tomography EAST Q Is a nonperative management strategy chosen? Q Has the patient improved after 48h of nonoperative management? No Continue management and follow-up as clinically appropriate. Yes Consider a water-soluble contrast study in patients who fail to improve after 48 hours of nonoperative management, because a normal contrast study can rule out SBO requiring surgical intervention. C Indications for surgery Q Has the patient improved by days 3-5 of nonoperative management? Yes Continue management and follow-up as clinically appropriate. No Consider performing surgery in patients without resolution by days 3-5 of nonoperative management.