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Difficulty: EasyGastrointestinal and Abdominal Surgery

A 71-year-old woman presents to the emergency department with 18 hours of worsening, colicky lower abdominal pain and repeated bilious vomiting. She has not had a bowel movement or passed flatus since the symptoms began. Her temperature is 38.6°C (101.5°F), blood pressure is 92/60 mm Hg, and pulse is 118/min. Cardiopulmonary examination is unremarkable. Abdominal examination reveals a distended abdomen with diffuse rebound tenderness and involuntary guarding. A tender, erythematous, non-reducible bulge is palpated in the right groin, located inferior to the inguinal ligament and medial to the femoral artery pulse. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in management?

  1. Immediate surgical explorationAnswer
  2. B
    Placement of a nasogastric tube and serial abdominal examinations
  3. C
    Computed tomography scan of the abdomen and pelvis
  4. D
    Manual reduction of the groin bulge under conscious sedation
  5. E
    Administration of broad-spectrum intravenous antibiotics and observation

Answer

Immediate surgical exploration
The correct management for a patient presenting with an incarcerated hernia and signs of strangulation (fever, peritonitis, elevated lactate, leukocytosis) is immediate surgical exploration. The patient has a femoral hernia, which is notoriously prone to incarceration and strangulation due to the narrow femoral ring. The presence of peritonitis indicates that bowel ischemia or perforation has likely already occurred, making this an absolute surgical emergency. Delaying for imaging or attempting conservative measures would be fatal.

Step-by-Step Solution

1
Identify the primary clinical syndrome from the presentation.
The patient has symptoms of a small bowel obstruction (colicky pain, bilious vomiting, obstipation) associated with a tender, erythematous groin mass.
Recognizing the triad of obstruction symptoms and a localized mass points to an incarcerated hernia as the etiology.
2
Assess for signs of complications such as ischemia or strangulation.
The patient exhibits fever, tachycardia, hypotension, diffuse peritonitis (rebound tenderness, guarding), leukocytosis, and elevated lactic acid.
These findings are classic hallmarks of bowel ischemia, necrosis, and systemic toxicity, differentiating a simple obstruction from a surgical emergency.
3
Determine the appropriate management based on the clinical status.
Immediate surgical exploration is indicated.
Any patient with a small bowel obstruction complicated by signs of strangulation or peritonitis requires emergent laparotomy or groin exploration to resect necrotic tissue and relieve the obstruction.

Key Concept

Patients with a mechanical small bowel obstruction who develop signs of strangulation or peritonitis (fever, severe continuous pain, hemodynamic instability, metabolic acidosis, rigid abdomen) require immediate surgical exploration.
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Topics

Gastrointestinal and Abdominal Surgery

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