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Adhesive small bowel obstruction is usually managed nonoperatively, but there is still debate over the optimal duration of nonoperative management and the factors that predict failure of medical treatment. The aim of this study was to evaluate an algorithm using CT-scans and Gastrografin® in the management of small bowel obstruction.In a prospective study, each patient admitted for small bowel obstruction underwent a physical examination, a plain film, and a CT-scan evaluation. Patients underwent emergency surgical exploration when bowel ischemia was suspected. Other patients received oral Gastrografin®, and a second plain abdominal radiograph was done after 12 hours. In patients with clinical improvement, the nasogastric tube was removed and an immediate liquid diet was resumed. Other patients were referred for surgery.In total, 118 patients with 123 episodes of small bowel obstruction were included. Thirty-six (29%) required immediate surgery because they presented clinical characteristics of bowel ischemia (36/36; 100%) or a defect in vascularization of the small bowel on CT-scan (5/36; 14%). The 87 remaining patients were managed nonoperatively, of which 28 deteriorated and were referred for surgery. The 59 other patients showed clinical improvement.This study demonstrated the diagnostic role of Gastrografin® in discriminating between partial and complete small bowel obstruction. CT-scans were disappointing in their ability to predict the necessity of emergent laparotomies. We therefore recommend the use of Gastrografin® in adhesive small bowel obstruction patients who do not have clinical evidence of bowel ischemia. CT-scans should not be routinely performed in the decision-making process except when clinical history, physical examination, and plain film are not conclusive for small bowel obstruction diagnosis.