A 72-year-old man is brought to the emergency department from a skilled nursing facility d… — USMLE Step 2 CK

A 72-year-old man is brought to the emergency department from a skilled nursing facility due to severe abdominal pain and intractable vomiting over the past $24\text{ hours}$ . The accompanying documentation notes he has not had a bowel movement or passed flatus since yesterday. His medical history is significant for hypertension and benign prostatic hyperplasia. His temperature is $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), pulse is $118/\text{min}$ , and blood pressure is $96/58\text{ mmHg}$ . Physical examination reveals a significantly distended and tympanic abdomen. Examination of the groin shows a $5\text{-cm}$ , tense, erythematous bulge in the right inguinal region that is exquisitely tender to palpation. Attempts to gently reduce the mass are unsuccessful. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ and a serum lactate level of $4.1\text{ mmol/L}$ (normal: $0.5-2.2\text{ mmol/L}$ ). Which of the following is the most appropriate next step in management?

Urgent surgical explorationAnswer
B
Nasogastric tube decompression and serial abdominal examinations
C
Computed tomography (CT) scan of the abdomen and pelvis
D
Attempted manual reduction of the mass under procedural sedation
E
Intravenous broad-spectrum antibiotics and observation

Answer

Urgent surgical exploration

The correct action is urgent surgical exploration. This patient's clinical presentation is highly indicative of a strangulated right inguinal hernia resulting in an acute small bowel obstruction (SBO) and subsequent bowel ischemia. Strangulation occurs when the blood supply to the herniated tissue is compromised. Hallmarks of strangulation include an exquisitely tender, irreducible, erythematous mass, accompanied by systemic signs of sepsis and ischemia, such as fever, tachycardia, hypotension, marked leukocytosis, and an elevated serum lactate level. This is a surgical emergency. Immediate operative exploration is necessary to assess the viability of the herniated bowel, resect any necrotic segments, and repair the hernia defect to prevent further intra-abdominal sepsis and death.

Step-by-Step Solution

Identify the primary clinical syndrome from the patient's presentation.

The patient has symptoms of a complete small bowel obstruction (intractable vomiting, distension, failure to pass flatus/stool).

Recognizing the obstructive pattern is the first step in diagnosing an acute abdomen.

Determine the etiology of the obstruction and look for complications.

The patient has a tense, erythematous, irreducible inguinal hernia with systemic signs of toxicity (fever, tachycardia, hypotension, leukocytosis, elevated lactate).

These findings indicate the hernia is strangulated, meaning the blood supply is compromised and bowel ischemia/necrosis is occurring.

Select the appropriate management strategy based on the presence of ischemia.

Immediate surgical intervention is required to evaluate bowel viability, resect necrotic segments, and repair the hernia.

Strangulated bowel is a surgical emergency; any delay for imaging or conservative management increases mortality.

Key Concept

A strangulated hernia causing a small bowel obstruction presents with an irreducible, painful mass along with signs of ischemia (fever, leukocytosis, elevated lactate) and requires immediate surgical exploration.

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