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Difficulty: EasyPreoperative and Postoperative Care

A 62-year-old man is evaluated on postoperative day 8 following an open bilateral inguinal hernia repair. Yesterday, he began experiencing progressive abdominal bloating, nausea, and bilious emesis. He has not passed flatus or stool for the past 48 hours. Two hours ago, his abdominal discomfort abruptly transitioned into severe, constant, and unremitting pain. Current vital signs show a temperature of 38.9°C (102.0°F), pulse of 122/min, respirations of 22/min, and blood pressure of 98/60 mm Hg. Physical examination reveals a markedly distended abdomen with diffuse rigidity, involuntary guarding, and rebound tenderness. Laboratory evaluation demonstrates a leukocyte count of 19,500/mm³ and a serum lactate of 4.5 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Placement of a nasogastric tube and bowel rest
  2. Immediate exploratory laparotomyAnswer
  3. C
    Collection of blood, urine, and sputum cultures
  4. D
    Initiation of empiric piperacillin-tazobactam and admission to the intensive care unit
  5. E
    Infusion of sodium bicarbonate to correct metabolic acidosis

Answer

Immediate exploratory laparotomy is the appropriate intervention for this patient with peritonitis and signs of bowel strangulation.
The correct answer is immediate exploratory laparotomy. This patient presents with a small bowel obstruction (SBO), evidenced by bilious emesis, obstipation, and characteristic upright abdominal radiograph findings. However, he has also developed fever, hemodynamic instability (tachycardia, hypotension), an acute surgical abdomen (rigidity, rebound tenderness), leukocytosis, and elevated serum lactate. This constellation of findings indicates bowel ischemia or strangulation (a complicated SBO). When an SBO is complicated by signs of ischemia or peritonitis, conservative management must be bypassed, and the patient must be taken immediately to the operating room for an exploratory laparotomy to resect necrotic bowel and achieve source control.

Step-by-Step Solution

1
Identify the primary diagnosis based on imaging and history.
The history of prior abdominal surgery, absence of flatus, bilious emesis, and radiograph showing dilated small bowel with air-fluid levels confirm a small bowel obstruction (SBO).
Establishing the baseline diagnosis is necessary before risk-stratifying the severity.
2
Evaluate for complications or 'red flag' symptoms.
The patient has fever, tachycardia, hypotension, severe constant pain, peritonitis (rigidity, rebound), leukocytosis, and elevated lactate.
These findings distinguish a simple SBO from a complicated (strangulated or ischemic) SBO.
3
Determine the management pathway based on the presence of complications.
Because signs of strangulation/ischemia are present, conservative management is abandoned in favor of emergent surgery.
Ischemic bowel requires immediate operative resection to prevent systemic sepsis and death.

Key Concept

Emergent surgical exploration is required for a small bowel obstruction complicated by signs of bowel ischemia or strangulation, such as peritonitis, fever, tachycardia, leukocytosis, and metabolic acidosis.
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Topics

Preoperative and Postoperative Care

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