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Difficulty: EasyGastroenterology and Hepatology

A 62-year-old woman is evaluated in the emergency department for severe abdominal pain, nausea, and vomiting that began 24 hours ago. She has not passed flatus or had a bowel movement since the symptoms started. Her past medical history includes an open hysterectomy 5 years ago. Her temperature is 38.8°C (101.8°F), blood pressure is 90/60 mmHg, and pulse is 120/min. Physical examination reveals a markedly distended abdomen. Bowel sounds are absent. There is diffuse abdominal tenderness with marked rigidity and rebound tenderness. Laboratory studies demonstrate a leukocyte count of 19,000/mm³. Upright abdominal radiography shows multiple dilated loops of small bowel, prominent air-fluid levels, and no gas in the rectum. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Placement of a nasogastric tube for decompression
  3. C
    Computed tomography scan of the abdomen and pelvis
  4. D
    Administration of broad-spectrum intravenous antibiotics and observation
  5. E
    Intravenous administration of a prokinetic agent

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient presents with a small bowel obstruction (SBO) that has progressed to strangulation and ischemia. Classic signs of an SBO include abdominal pain, vomiting, obstipation, and distension, often with a history of prior abdominal surgery predisposing to adhesions. When a patient develops fever, tachycardia, leukocytosis, and localized peritonitis (rigidity, rebound tenderness), the obstruction is considered complicated. In this setting, the bowel is rapidly becoming ischemic and necrotic. Therefore, conservative management must be abandoned in favor of emergent surgical exploration to resect the non-viable bowel and relieve the mechanical obstruction.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation and radiographic findings.
The patient has a mechanical small bowel obstruction, likely due to adhesions from her prior abdominal surgery.
Symptoms of bilious vomiting, obstipation, and abdominal distension, combined with air-fluid levels on X-ray, are classic for small bowel obstruction.
2
Evaluate the patient for signs of complicated bowel obstruction (ischemia, necrosis, or perforation).
The presence of fever, tachycardia, leukocytosis, and peritoneal signs (rigidity and rebound tenderness) indicate a complicated obstruction (strangulation).
Recognizing strangulation is critical because it fundamentally changes the management strategy from conservative to surgical.
3
Determine the most appropriate next step in management based on patient stability and complications.
Immediate exploratory laparotomy is indicated.
Conservative management is contraindicated in the setting of strangulated small bowel obstruction; emergent surgery is required to prevent death from sepsis and bowel necrosis.

Key Concept

Patients presenting with a small bowel obstruction complicated by peritonitis, hemodynamic instability, or signs of bowel ischemia require emergent surgical exploration.
Estimated Time:1m 0s
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Topics

Gastroenterology and Hepatology

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