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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 55-year-old woman is evaluated in the emergency department due to a 2-day history of diffuse, crampy abdominal pain, accompanied by multiple episodes of green-tinged vomiting and an inability to pass flatus or stool. Her surgical history includes a total abdominal hysterectomy performed 10 years ago. Her temperature is 37.1°C (98.8°F), pulse is 90/min, blood pressure is 128/82 mm Hg, and respirations are 14/min. Physical examination shows a protuberant, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 8,400/mm³, serum sodium of 137 mEq/L, potassium of 3.4 mEq/L, and normal serum lactate. An upright abdominal plain radiograph reveals multiple dilated loops of small intestine with prominent air-fluid levels and a lack of gas in the colon. What is the most appropriate initial management for this patient?

  1. A
    Diagnostic laparoscopy
  2. B
    Urgent colonoscopic decompression
  3. Nasogastric tube insertion and intravenous fluid resuscitationAnswer
  4. D
    Initiation of empiric broad-spectrum antibiotics
  5. E
    Immediate exploratory laparotomy

Answer

Nasogastric tube insertion and intravenous fluid resuscitation
The correct answer is nasogastric tube insertion and intravenous fluid resuscitation because the patient presents with classic features of a small bowel obstruction (SBO) but lacks 'red flag' signs of complications (such as peritonitis, fever, tachycardia, or lactic acidosis). The standard initial therapy for an uncomplicated adhesive SBO is non-operative management, which includes bowel rest, volume resuscitation with isotonic intravenous fluids, and decompression of the stomach and proximal bowel with a nasogastric tube to alleviate symptoms and reduce the risk of aspiration.

Step-by-Step Solution

1
Evaluate the patient's clinical presentation and imaging findings.
The patient has cardinal signs of an obstruction (colicky pain, bilious vomiting, obstipation) and imaging confirming dilated small bowel loops without colonic gas.
To establish the diagnosis of small bowel obstruction, likely due to adhesions from her prior hysterectomy.
2
Assess for signs of complications such as bowel ischemia, necrosis, or perforation.
The patient is hemodynamically stable with no fever, no significant tachycardia, normal lactate, and no peritoneal signs (guarding, rigidity, rebound).
To determine if the obstruction is uncomplicated or complicated, which dictates the need for emergent surgery.
3
Select the appropriate initial management for an uncomplicated small bowel obstruction.
Conservative management with gastrointestinal decompression and volume repletion is indicated.
Initial non-operative management successfully resolves a majority of uncomplicated adhesive small bowel obstructions.

Key Concept

Uncomplicated small bowel obstruction is initially managed conservatively with bowel rest, nasogastric tube decompression, and intravenous fluid resuscitation.
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Topics

Gastrointestinal and Abdominal Surgery

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