In another review, out of 329 patients with SBO 43% were successfully treated conservatively, whereas 57% failed conservative treatment and underwent surgery [42]. Overall, there were eight early deaths, four in each group (2.8% conservative vs. 2.1% surgical; p = ns). Out of these patients presenting with SBO, 63% had abdominal surgery and 37% had no prior abdominal surgery before developing a small bowel obstruction. In conclusion, the most recent meta-analyses [43–45] showed that the patients who had surgery within the six weeks before the episode of small bowel obstruction, patients with signs Nocodazole in vivo of strangulation or GS-4997 concentration peritonitis (fever, tachycardia and leucocytosis), patients

with carcinomatosis, patients with irreducible hernia and patients who started to have signs of resolution at the time of admission are not candidate for conservative treatment +/- Water Soluble Contrast Medium administration. Also the EAST MI-503 research buy guidelines on SBO management recommend that the patients with plain film finding of small bowel obstruction and Clinical markers (fever, leukocytosis, tachycardia, metabolic acidosis and continuous pain) or peritonitis on physical exam warrant exploration [46]. The second question is who can be safely managed with initial conservative management and which factors can reliably predict surgery Complete SBO (no evidence of air within

the large bowel) and increased serum creatine phosphokinase predicts NOM failure (Level of Evidence 2b GoR C) Free intraperitoneal fluid, mesenteric edema, lack of the ”small bowel feces sign” at CT, and history of vomiting, severe abdominal pain (VAS > 4), abdominal guarding, raised WCC and devascularized bowel at CT predict the need for emergent laparotomy at the time of admission (Level HAS1 of Evidence 2c GoR C) The appearance of water-soluble contrast in the colon on abdominal X ray within 24 hours of its administration predicts resolution of ASBO (Level of Evidence 1a GoR A) Among

patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult. Several recent studies have tried to focus on identifying predictive factors for failure of NOM and need for surgery. In conservatively treated patients with ASBO, the drainage volume through the long tube on day 3 (cut-off value; 500mL) was the indicator for surgery [47]. In 2010 Komatsu et al. have developed a simple model for predicting the need of surgery in patients who initially undergo conservative management for ASBO. The model included 3 variables: age >65 years, presence of ascites on CT scan and drainage volume from NGT or LT > 500 mL on day 3. PPV of this model in the high-risk class was 72% with specificity of 96%, whereas NPV in the low risk class was 100% with sensitivity of 100% [48].