4 Step Bowel Obstruction Diet

For the nutritional management of bowel obstruction related to cancer

Who is this advice for?

The information in this advice sheet is for you if you:

Have been diagnosed with bowel obstruction
Are at risk of developing bowel obstruction
Have a mass in your small or large intestine (bowel) and are at risk of a blockage
Have delayed emptying of the stomach

What information is provided here?

Why is it important to eat the right sort of foods?
How to use this information
The 4-step bowel obstruction diet
- Step 1: Clear fluids only
- Step 2: All thin liquids
- Step 3: Smooth and puréed low fibre foods
- Step 4: Soft sloppy low fibre foods
After step 4
References / further reading
Contact details

Why is it important for me to eat the right sort of foods with bowel obstruction?

If you have a mass in your small or large intestine (also known as bowel or gut), or it is narrower than normal, you may be at risk of a blockage. You may have already been admitted to hospital with a blockage (when you are not able to open your bowels).

Some foods pass through our body without being broken down properly. They can pass through in big pieces and can increase your risk of a blockage by getting caught in a narrow space. For example:

the skins, pips and seeds of fruit and vegetables
fibrous fruits e.g. rhubarb, celery
raw or undercooked vegetables
vegetables that humans are unable to digest e.g. mushrooms, sweetcorn, lettuce and other salad leaves
bread and bread products e.g. crumpets, muffins, doughnuts, since they form a bolus (ball) and may not pass through a narrowed space.

Fibre also makes our stools form a ‘bulk’ and makes them solid. When you are at risk of bowel obstruction it is better to avoid stools that are too solid. This is why you are encouraged to have a low fibre diet.

Certain foods may also lead to symptoms such as pain, bloating, feeling full, feeling sick and tightness across your abdomen (stomach). You may also find it harder to pass a bowel motion.

You have been given this booklet because changing your diet can lower your risk of a blockage. Eating the right foods for you may help to reduce your symptoms.

How do I use this information?

This advice is only to be given to you under the care of a Registered Dietitian. The information needs to be carefully explained to you so that you know how to use it.

There is limited evidence to establish the best diet to follow when you are diagnosed with the risk of bowel obstruction. Everyone is different and no day is the same.

Depending on your situation, you may need to make more changes than others. This booklet is divided into 4 steps. You will find it helpful to read carefully through the information provided so that you understand what to do. You may also find it helpful to write down any questions you have about the diet. Please always ask your dietitian if you are not sure about what to do.

You will have to eat very differently with this diet. It is important not to eat or drink large amounts of food or fluid in one sitting. You may find it hard to change the habit of ‘3 meals per day’. If you are at risk of bowel obstruction eating and drinking ‘little and often’ will help with your symptoms.

Your dietitian will let you know which stage you should be following. They will also advise you when you can move to the next step.

You may find that you have to go backwards and forwards through the steps depending on your symptoms. For example, if you are in pain or your bowels stop working, you will have to return to liquids for a while until your symptoms settle again.

You are likely to need to use nutritional supplement drinks at certain times to make sure that you are meeting your nutritional needs.

The 4 step Bowel Obstruction diet

Step 1	Clear fluids only
Step 2	ALL thin liquids
Step 3	Smooth or puréed foods only Low fibre
Staep 4	Soft sloppy foods Low fibre

Please ask your nurse/ doctor for help if you are concerned.

Make a note of your healthcare professional’s phone number and email address.

Step 1: Clear fluids ONLY

What can I drink for Step 1?

You need to follow Step 1 if you have had a complete blockage. When your bowels start to open regularly again you will be encouraged to start to sip on CLEAR LIQUIDS only.

You will need to follow Step 1 if you have proceeded to Step 2, 3 or 4 and start to develop symptoms.

Only clear liquids are allowed. Examples are:

Water
Black tea
Black coffee
Squash
Smooth clear fruit juice e.g. apple, cranberry juice
Flavoured water
Oasis®, Rubicon® (still), Vimto®
Coconut water
Herbal and fruit teas
Clear consommé soup (no bits)
Clear miso soup
Hot cup of Marmite® or Bovril®
Hot cup of water with a dissolved stock cube or stock pot
Still isotonic sports drinks e.g. Lucozade Sport®, Gatorade Sport®, Powerade®

You can also suck on boiled sweets and mints. These must not be chewed and swallowed in pieces.

Try to sip on small amounts of drinks through the day. This is the easiest way to increase your intake of liquids. It will help to stop you getting dehydrated.

Which supplement drinks do I need during Step 1?

It is not possible to meet your nutritional needs on clear fluids so your dietitian or doctor will prescribe nutritional supplements.

Step 2: All thin liquids

What can I drink for Step 2?

If your bowels have been opening regularly and your symptoms from bowel obstruction have settled, you will be advised to move to Step 2. This means that you can have ALL forms of liquids.

It is important to introduce the drinks in Step 2 very gradually. This will let your body tell you if you can tolerate the changes and continue with Step 2. Each day add one extra drink. If you increase slowly you are more likely to be able to stay on Step 2 and will not get symptoms that mean you need to go back to Step 1.

Please remember:

The liquids need to be a thin consistency i.e. no thicker than whole milk.
The liquids need to be completely smooth with no bits.
The liquids need to be low in fibre e.g. thin smooth fruit juice with no bits – no smoothies.

The following drinks provide energy, protein and vitamins and minerals. Always use whole milk where possible.

Whole milk / milk with Nesquik® or Milo®	Milky coffee / latté / cappuccino
Yoghurt drinks	Hot chocolate
Thin milkshakes e.g. Frijj®, Yop®, Yazoo®	Horlicks® / Ovaltine®
Thin smooth soups e.g. chicken, oxtail, sweet potato, butternut squash	Thin smooth fruit juice (no bits)
Thin custard	Jelly / milky jelly
Smooth ice cream, smooth frozen yoghurt, sorbet (no bits)	Ice lollies, Mini Milk® lollies, frozen yoghurt lollies

You can also suck on boiled sweets, mints and smooth chocolate. These must not be chewed and swallowed in pieces.

You can also include the clear fluids from Step 1.

Try to sip on small amounts of drinks throughout the day. This is the easiest way to increase your intake of liquids. It will help to stop you getting dehydrated.

Which supplement drinks do I need during Step 2?

It may not be possible to meet your nutritional needs on liquids only so your dietitian or doctor will prescribe nutritional supplements.

What do I do if my symptoms return?

If you start to experience any of the following, please contact your doctor or dietitian immediately.

Nausea (feeling sick)
Vomiting
Feeling full after drinking
Your bowels do not open for more than 2 days
A feeling of ‘tightness’ across your stomach
Feeling bloated
Abdominal (tummy) swelling
Abdominal (tummy) pain.

These symptoms could be a sign that your bowel may be blocked. It is important to speak to your dietitian so that they can advise you what to do. If you are unable to speak to them immediately, return to Step 1 and clear fluids only.

Step 3 Smooth or puréed low fibre foods

What can I eat and drink for Step 3?

If your bowels are opening regularly and you are not in any pain after several days of Step 2 drinks, your dietitian or doctor will ask you to move to Step 3.

This means that you can start to eat smooth or puréed low fibre foods, as well as all liquids in Step 1 and 2.

It is important to introduce the foods in Step 3 very gradually. This will let your body tell you if you can tolerate the changes and continue with a smooth / purée diet. Each day add only one extra food. If you increase slowly you are more likely to be able to stay on Step 3 and not get symptoms that mean you need to go back to Step 1.

Always eat small portions several times during the day. A usual meal pattern is not appropriate. Larger meals may increase your risk of symptoms returning.
Aim to eat at least 6 times each day.
All food needs to be smooth or should be able to melt in your mouth.
All food should be able to ‘fall off’ a spoon easily.
All food should be swallowed without needing to chew it.
All food should be low in fibre.
You can have one portion of fruit and one portion of vegetables each day ONLY. Some fruit and vegetables must be completely avoided. See the end of this information for a list of foods allowed and foods to avoid.

Tips for following a soft smooth/purée diet

Equipment: Using a hand blender is the simplest way of producing puréed foods.
Puréed foods can look more appetising if they are presented separately e.g. separate a puréed meat casserole from the (allowed) vegetables and potatoes.
Colour is also important e.g. try serving brightly coloured vegetables such as puréed carrots with mashed potato and puréed chicken and sauce/gravy.
Cooked foods should be cut into small pieces then liquidised, blended or mashed, and if necessary sieved to a smooth consistency.
You will need to add extra liquid to most foods before or after they have been puréed. To improve the taste and nutritional value; add whole milk, melted butter, cream or creamy soup instead of water.

What foods do I need to avoid during Step 3?

Some foods need to be completely avoided (even if puréed). These include the pips, skins and seeds of fruits and vegetables, wholegrains, pulses and beans, which are not easily digested and may get caught in your bowel. Bread and bread products e.g. crumpets, muffins, doughnuts, also need to be avoided. They can form a bolus (ball) and may not pass through a narrowed space. This can increase your risk of an obstruction. Please look at the lists in this information for more details.

What can I eat for breakfast during Step 3?

‘Soggy’ cereal e.g. corn flakes or Rice Krispies® soaked in whole milk
Small bowl of Ready Brek® made with milk
Puréed sweetened fruit – tinned pears, stewed fruit, fruit compote (one portion of fruit per day)
Full fat smooth (no lumps) yoghurt or fromage frais, Petit filou®, Skyr® yoghurt, Coconut collaborative® natural yoghurt
Glass of fruit juice (no bits)
Milkshake (see Stage 2 for options)
Smooth scrambled egg.

Add sugar, syrup, honey, jam, cream, butter or full cream milk to add extra nutrition.

What can I eat for my meals during Step 3?

Mashed potatoes / mashed sweet potatoes served with
- puréed meats and gravy
- puréed mince dishes
- puréed fish and white or cheese sauce
- puréed fish pie
- puréed stew (made with root vegetables)
- blended gammon or ham with white or cheese sauce
Jacket potato (no skin) mashed with
- cheese and butter
- puréed tuna mayonnaise
- puréed egg mayonnaise
- smooth tikka or curry sauce
Scrambled egg with added butter and grated cheese
Bowl of smooth soup
- Soup can be homemade, bought fresh or tinned
- Choose soups that contain vegetables from the ‘allowed’ lists on page 20
- Always blend soup so that it is smooth
- Creamy soups have extra nutrition

You can add one (puréed) portion of the allowed vegetables to meals that do not already contain vegetables e.g. carrots, parsnips, butternut squash, heads of broccoli or cauliflower.

Try one of the following to add flavour: redcurrant jelly, mint jelly, soy sauce, tomato sauce, Worcestershire sauce, smooth mustard, Tabasco® sauce.

Add butter, spread, cream, grated cheese, cream cheese and crème fraiche to add extra nutrition.

What can I eat for pudding during Step 3?

Smooth milk puddings e.g. plain or chocolate custard, ground rice pudding, semolina, tapioca
Sponge or other cakes blended with chocolate sauce, cream, custard or ice cream e.g. Madeleines, Battenberg, Madeira, Angel Slices, caramel cake bars, mini chocolate rolls, lemon slices
Blancmange, mousse, fruit fool, milk jelly, Angel Delight®, instant whip
Tinned or stewed fruit with added cream, yoghurt, crème fraiche, custard or ice cream (one portion of fruit per day)
Apple pie blended to a smooth consistency with added cream, yoghurt, ice cream or custard (one portion of fruit per day)
Full fat smooth yoghurt, fromage frais, egg custard, crème caramel
Smooth ice cream, sorbet, frozen yoghurt, Mini Milk®, mini Magnum®

Add sugar, syrup, honey, seedless jam or marmalade, lemon curd, treacle, cream, custard, ice cream, crème fraiche, evaporated or condensed milk to add extra nutrition.

What can I eat for a snack during Step 3?

Puddings can be eaten at any time of the day as a snack.

Choose ‘full fat’ products for extra nutrition.

‘Dunked’ plain biscuits in a warm milky drink e.g. rich tea, Nice®, malted milk, custard creams
Sponge cake blended with chocolate sauce, cream, custard or ice cream
Ready-made smooth desserts, chocolate mousse, ground rice pudding
Bowl of cornflakes or Rice Krispies® soaked in whole milk
Crisps that ‘melt-in-the-mouth’ e.g. Skips®, Wotsits®, Quavers® or Pom Bears®, Pringles®
- Add smooth dips e.g. sour cream, smooth guacamole, taramasalata
Melt in the mouth Ritz® crackers or Tuc® biscuits with plain cream cheese (ensure this is well chewed before swallowing)
Spoonful of smooth nut butter e.g. almond butter, peanut butter
Spoonful of hazelnut spread or Nutella®
Portion of soft cheese (no bits) e.g. Laughing Cow®, Dairylea®, Philadelphia®, Primula®, Quark® or cream cheese

What can I drink during Step 3?

It is important to drink plenty of fluid each day to prevent dehydration. You can choose any of the liquids listed in Stage 1 or Stage 2 on pages 6 and 7.

Which supplement drinks do I need during Step 3?

It may not be possible to meet your nutritional needs with diet alone in Stage 3, so your dietitian or doctor may prescribe nutritional supplements.

If you start to experience any of the following, please contact your doctor or dietitian immediately.

Nausea (feeling sick)
Vomiting
Feeling full after drinking
Your bowels do not open for more than 2 days
A feeling of ‘tightness’ across your stomach
Feeling bloated
Abdominal (tummy) swelling
Abdominal (tummy) pain.

Step 4 – Soft sloppy low fibre

What can I eat and drink for Step 4?

If your bowels are opening regularly and you are not in any pain after several days on Stage 3 consistencies, your dietitian or doctor will ask you to move to Stage 4.

This means that you can start to eat soft sloppy low fibre foods, as well as all liquids and soft smooth foods from Steps 1, 2 and 3.

It is important to introduce the foods in Step 4 very gradually. This will let your body tell you if you can tolerate the changes and continue with a soft sloppy low fibre diet. Each day add only one extra food. If you increase slowly you are more likely to be able to stay on Step 4 and not get symptoms that mean you need to go back to Step 1.

Always eat small portions several times during the day.
All food needs to be soft and sloppy.
All food should be chewed well before you swallow each mouthful.
Make sure all your meals have additional sauce or gravy to moisten them.
All food should be low in fibre.
You can have one portion of fruit and one portion of vegetables each day ONLY. Some fruit and vegetables must be avoided. See below for a list of foods allowed and foods to avoid.

Tips for following a soft sloppy diet

Taking foods little and often is advisable.
Aim for small frequent meals and snacks, rather than 3 meals per day.
Using sauces, butter, gravy, cream or custard can help to soften foods and keep them moist.
Foods can be softened by chopping, mincing and mashing.
Small sips of a drink can help with swallowing foods.
Avoid foods that need a lot of chewing or do not break down well when chewed.

What foods do I need to avoid during Step 4?

What can I eat for breakfast during Step 4?

‘Soggy’ cereal e.g. corn flakes or Rice Krispies® soaked in whole milk
Ready Brek® with plenty of whole milk
Puréed sweetened fruit – tinned pears, stewed fruit, fruit compote (one portion of fruit per day)
Full fat smooth yoghurt, fromage frais, Petit filou®, Skyr® yoghurt, Coconut collaborative® natural yoghurt
Glass of fruit juice (no bits)
Milkshake (see Stage 2 for options)
Omelette, scrambled, poached or soft, boiled egg.

Add butter, sugar, syrup, honey, jam, cream or full cream milk to add extra nutrition.

What can I eat for my meals during Step 4?

You are unlikely to be able to manage your normal portions at meals. In fact it is better to eat a very small plate every time you eat. Leave it an hour, and then come back to have another small plate of the same meal. This will allow the food to pass through your gut and will reduce the chance of symptoms of pain and bloating returning.

Lancashire hotpot (make sure the meat is very tender and chewed well before swallowing)
Cottage pie / shepherd’s pie with plenty of gravy
Corned beef hash with plenty of gravy

Mashed potatoes / mashed sweet potatoes / peeled boiled potatoes / polenta / white couscous served with
- Minced cooked meats with plenty of gravy or sauce
- Poached fish in sauce (check for bones)
- Fish pie, fish mornay
- Tinned fish (tuna, salmon – no bones) with plenty of mayonnaise or sauce
- Stews and casseroles
Eggs
- Scrambled egg with extra butter and cheese
- Cheese omelette with extra cheese
- Soft poached or boiled egg
- Fillings from quiche (no onions/or products from the avoid lists)
- Soufflés e.g. cheese, salmon
Pasta (always use white pasta), dried or fresh
- Well cooked small pasta shapes served with plenty of sauce e.g. cheese sauce, smooth tomato sauce, Bolognese sauce (made with passata)
- Sloppy macaroni cheese
- Tinned spaghetti or ravioli
Noodles
- Egg, rice, vermicelli or udon noodles
- Add a small portion of noodles to a smooth soup or broth (no vegetables)
- Wontons in clear soup or broth
Rice (always use white rice e.g. long grain, risotto or basmati)
- Served with curry with small pieces of tender meat or fish (more sauce than rice)
- Served with plenty of Bolognese sauce (more sauce than rice)
Jacket potato (no skin) mashed with
- cheese and butter
- tuna mayonnaise
- egg mayonnaise
- tikka or curry sauce
- coronation chicken (more sauce than chicken)
Bowl of creamy smooth soup
- Chicken, oxtail, carrot and coriander, butternut squash
- Avoid soups with lots of vegetables or soups that contain beans or lentils
‘Melt-in-the-mouth’ crisps, crackers or breadsticks with
- dips e.g. sour cream, taramasalata, smooth guacamole
- Tuna, salmon or egg mayonnaise
- Tinned spaghetti or ravioli
- Avocado with flaked crab meat or prawns in a cocktail sauce

If there are no vegetables in your dish, then you can add one portion of ‘allowed’ foods to your meal.

Try one of the following to add flavour: redcurrant jelly, mint jelly, soy sauce, tomato sauce, Worcestershire sauce, smooth mustard, Tabasco® sauce.

Add butter, spread, cream, grated cheese, cream cheese or crème fraiche to add extra nutrition.

What can I eat for pudding during Step 4?

Milk puddings e.g. plain or chocolate custard, rice pudding, semolina, tapioca
Sponge pudding or cake with cream, smooth ice cream or custard to soften. E.g. Madeleines, Battenberg, Madeira, Angel Slices, caramel cake bars, mini chocolate rolls, lemon slices
Blancmange, mousse, fruit fool, trifle (no pips), milk jelly, Angel Delight®, instant whip
Tinned or stewed fruit with added cream, yoghurt, crème fraiche, custard or ice cream (one portion of fruit per day)
Apple crumble (no oats or dried fruit) softened with added cream, yoghurt, ice cream or custard (one portion of fruit per day)
Full fat smooth yoghurt, fromage frais, egg custard, crème caramel
Smooth ice cream, sorbet, frozen yoghurt, Mini Milk®, mini Magnum®
Add sugar, syrup, honey, seedless jam or marmalade, lemon curd, treacle, cream, custard, ice cream, crème fraiche, evaporated or condensed milk to add extra nutrition.

What snacks can I eat between meals during Step 4?

Puddings can be eaten at any time of the day as a snack.

Choose ‘full fat’ products for extra nutrition.

‘Dunked’ plain biscuits in a warm milky drink e.g. rich tea, Nice®, malted milk, custard creams
Fruit fools, mousses, instant whips or crème caramel
Bowl of corn flakes or Rice Krispies® soaked in whole milk
Milky puddings e.g. individual pots of custard, rice pudding
Yoghurt or fromage frais
Smooth ice-cream, mini ice-creams, choc ices, frozen yoghurt
Smooth chocolate bars
Crisps that ‘melt-in-the-mouth’ e.g. Skips®, Wotsits®, Quavers®, Pom Bears® or Pringles®
- Add smooth dips e.g. sour cream, smooth guacamole, taramasalata
Melt in the mouth Ritz® crackers or Tuc® biscuits with plain cream cheese (ensure this is well chewed before swallowing)
Spoonful of smooth nut butter e.g. almond butter, peanut butter
Spoonful of hazelnut spread or Nutella®
Portion of soft cheese (no bits) e.g. Laughing Cow®, Philadelphia®, Primula®, Quark® or cream cheese.

What can I drink during Step 4?

It is important to drink plenty of fluid each day to prevent dehydration. You can choose any of the liquids listed in Stage 1 or Stage 2.

Which supplement drinks do I need during Step 4?

It may not be possible to meet your nutritional needs on diet alone, so your dietitian or doctor will prescribe nutritional supplements.

If you start to experience any of the following, please contact your doctor or dietitian

immediately.

Nausea (feeling sick)
Vomiting
Feeling full after drinking
Your bowels do not open for more than 2 days
A feeling of ‘tightness’ across your stomach
Feeling bloated
Abdominal (tummy) swelling
Abdominal (tummy) pain.

After Step 4

What can I eat and drink after Step 4?

If you have had previous episodes of bowel obstruction you may need to continue with Step 4 for an extended period of time. If you are doing well it may be possible to move on from Step 4. Please always speak to your dietitian before making any changes. They will advise you if it is possible to include other foods and how to do this.

Which foods can increase my risk of a blockage?

It is important to completely avoid the foods that may increase your chance of getting a blockage. We advise that you follow a strict LOW FIBRE diet. This is because fibre is not easily digested and can pass through your bowel in large lumps. It also bulks your stools and makes them solid.

The foods you are allowed to eat may need to be mashed or puréed. Always check with your dietitian if you are unsure.

Some of the foods on the ‘allowed’ lists may not be suitable in some of the Stages. Always check with your dietitian if you are unsure.

What fruit can I eat?

Foods allowed – limit to ONE portion per day

ALWAYS CHECK IF THESE NEED TO BE PURÉED

Foods to avoid

Apples (peeled)
Apricots (fresh, peeled)
Bananas
Mango
Melon
Nectarines (peeled)
Papaya
Pears (Peeled)
Peaches (peeled)
Plums (peeled)
Watermelon (no pips)

Other

Fruit juice (no bits)
Puréed, stewed or cooked fruit (without skins, pips or stones)
Tinned fruit
Fruit sauces and coulis with pips removed e.g. sieved raspberry coulis, apple sauce

Blackberries
Blackcurrants
Blueberries
Cherries
Clementines
Coconut
Cranberries (fresh and dried)
Dates
Dried apricots
Figs
Grapefruit
Grapes
Kiwi
Mandarins
Oranges
Passion fruit
Pineapple
Pomegranate
Prunes
Raisins
Raspberries
Redcurrants
Rhubarb
Satsumas
Strawberries