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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 64-year-old man is evaluated on the surgical ward due to a change in his clinical status. He was admitted 24 hours ago for a small bowel obstruction secondary to adhesions from a prior open sigmoidectomy. On admission, he reported intermittent, crampy abdominal pain. He was placed on nil per os (NPO) status, and treatment with intravenous fluid resuscitation and nasogastric tube decompression was initiated. Over the past 4 hours, the patient reports that his abdominal pain has worsened, becoming severe and continuous rather than colicky. His temperature is 38.6°C (101.5°F), blood pressure is 105/65 mm Hg, and pulse is 118/min. Physical examination reveals a distended abdomen with focal rigidity, guarding, and marked rebound tenderness in the periumbilical region. Bowel sounds are absent. Laboratory studies show a leukocyte count of 17,500/mm317,500/mm^3 with 15% bands, and a serum lactate level of 4.2 mmol/L4.2 \text{ mmol/L}. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Administration of intravenous piperacillin-tazobactam and clinical reassessment in 6 hours
  4. D
    Administration of water-soluble enteral contrast via the nasogastric tube
  5. E
    Replacement of the nasogastric tube with a nasoenteric decompression tube

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient initially presented with an uncomplicated small bowel obstruction (SBO) and was appropriately managed with a trial of conservative therapy (nasogastric decompression, NPO status, intravenous fluids). However, he has now developed the classic triad of findings indicating a strangulated SBO: fever, tachycardia, and continuous, severe abdominal pain (replacing the previous colicky pain). The presence of peritonitis (rigidity, rebound tenderness), marked leukocytosis with bandemia, and lactic acidosis confirms that the bowel has become ischemic. A strangulated bowel obstruction is an absolute surgical emergency. Conservative management must be abandoned immediately in favor of emergent exploratory laparotomy to resect necrotic or compromised bowel, re-establish continuity, and prevent overwhelming sepsis.

Step-by-Step Solution

1
Evaluate the patient's baseline presentation and recent clinical changes.
A patient with an uncomplicated small bowel obstruction has developed severe, continuous pain, fever, tachycardia, and localized peritonitis over a 4-hour period.
Tracking clinical trajectory is essential to identify failure of conservative management.
2
Interpret the objective vital signs and laboratory findings.
The patient demonstrates systemic inflammatory response (fever, tachycardia, severe leukocytosis with a left shift) and tissue hypoperfusion/ischemia (elevated serum lactate).
These findings distinguish a simple obstruction from a strangulated obstruction.
3
Determine the definitive treatment based on the diagnosis of a strangulated small bowel obstruction.
The patient requires emergent surgical exploration to resect ischemic or necrotic bowel.
Conservative management is no longer appropriate and will lead to bowel perforation, sepsis, and death if surgery is delayed.

Key Concept

Recognition and surgical management of a strangulated small bowel obstruction.
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Topics

Gastrointestinal and Abdominal Surgery

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