The decision to operate depends on the index of suspicion for bowel strangulation, closed-loop obstruction, and ischemic bowel. It is difficult to make the diagnosis of strangulation and ischemic bowel with just history and physical examination.
Clearly, abdominal pain associated with fever, leukocytosis, acidosis, peritoneal sign, and shock are all indications of bowel necrosis and necessitate surgical exploration. Generally speaking, even in the absence of these physical signs, unrelenting and increasing abdominal pain with obstipation and radiographic signs of SBO indicate surgery. Unless there are extenuating circumstances to the contrary, complete bowel obstruction should not be dismissed without exploratory surgery.