Contemporary diagnosis and management of patients with adhesive small bowel obstruction.

Adhesive small bowel obstruction (aSBO) remains one of the most common causes of surgical admission and morbidity. With advancements in imaging and the advent of water-soluble contrast, management has become increasingly non-operative. Although this is successful in a majority of patients, patients who fail this trial without operation may face worse outcomes. Delays to surgical intervention are associated with increased rates of bowel ischemia, resection, infectious complications, and mortality. Optimal management therefore depends on early risk stratification, disciplined non-operative trials, and timely escalation to operation when indicated. This review summarizes contemporary evidence regarding pathogenesis, pathophysiology, epidemiology, diagnostic evaluation, management, and outcomes of aSBO, with a focus on practical decision-making. The evaluation of each patient's obstruction consists of subjective clinical findings in combination with objective data including labs and imaging. CT with intravenous contrast remains a cornerstone of diagnosis, allowing identification of obstruction severity and features concerning for ischemic physiology that mandates immediate operative exploration. In the absence of these findings, a structured trial of non-operative management may be pursued, including nasogastric decompression, intravenous resuscitation, electrolyte correction, and inpatient admission with close oversight from a surgical team. Water-soluble contrast studies serve as both a prognostic and therapeutic adjunct, as failure of contrast to reach the colon within 24 hours is strongly predictive of unsuccessful non-operative management. Operative management should be undertaken promptly in patients with clinical deterioration, imaging evidence of ischemia, or failure of non-operative therapy. Although open laparotomy remains the standard approach, laparoscopy may be considered in carefully selected patients in experienced hands. Across management strategies, early surgical ownership and avoidance of prolonged non-operative trials in high-risk patients are critical to optimizing outcomes. aSBO is best managed through structured algorithms that prioritize early diagnosis, time-sensitive reassessment, and decisive operative intervention when indicated.