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Difficulty: EasyGastrointestinal and Abdominal Surgery

A 74-year-old man is brought to the emergency department from a long-term care facility due to progressive abdominal distension, severe pain, and recurrent vomiting for the past 48 hours. He has not had a bowel movement or passed flatus for 3 days. His medical history is significant for an open ventral hernia repair 8 years ago. On arrival, his temperature is 39.4°C (102.9°F), blood pressure is 85/50 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended abdomen with diffuse rigidity, severe rebound tenderness, and absent bowel sounds. Laboratory studies show a leukocyte count of 24,000/mm³ and a serum lactate level of 6.8 mmol/L. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Nasogastric tube decompression and intravenous fluids
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Intravenous broad-spectrum antibiotics and clinical observation
  5. E
    Intravenous administration of sodium bicarbonate

Answer

Immediate exploratory laparotomy is required for a small bowel obstruction presenting with signs of peritonitis and hemodynamic instability.
The correct answer is immediate exploratory laparotomy. This patient presents with a classic small bowel obstruction (SBO) complicated by strangulation and bowel ischemia, evidenced by fever, hypotension, a rigid abdomen with rebound tenderness (peritonitis), significant leukocytosis, and elevated serum lactate. When an SBO is complicated by peritonitis or hemodynamic instability, the bowel is assumed to be ischemic or perforated. Emergent surgical exploration is the definitive standard of care to relieve the obstruction, control the infectious source, and resect any non-viable intestine.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation and initial imaging.
The patient's symptoms (vomiting, obstipation, distension), surgical history, and radiograph findings indicate a small bowel obstruction (SBO), likely due to adhesions from his prior hernia repair.
Establishing the mechanical cause of the symptoms is the first step in abdominal pain triage.
2
Assess the patient for complications of SBO such as ischemia, strangulation, or perforation.
The presence of fever, hypotension, diffuse rigidity, rebound tenderness, severe leukocytosis, and lactic acidosis points to a complicated SBO with compromised bowel viability.
Differentiating between uncomplicated and complicated SBO is critical because it dictates the urgency and type of treatment.
3
Determine the definitive next step in management for a complicated SBO in an unstable patient.
Immediate exploratory laparotomy is indicated for source control, decompression, and likely resection of necrotic bowel.
Hemodynamically unstable patients with peritonitis cannot undergo conservative management or time-consuming advanced imaging; they require emergent surgical intervention.

Key Concept

Management of complicated small bowel obstruction requires immediate surgical intervention when signs of peritonitis, strangulation, or hemodynamic instability are present.
Estimated Time:1m 0s
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Topics

Gastrointestinal and Abdominal Surgery

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