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Difficulty: HardGastrointestinal and Abdominal Surgery

A 76-year-old woman is brought to the emergency department by her family with a 48-hour history of severe, colicky abdominal pain, intractable nausea, and bilious vomiting. She reports no passage of flatus or stool since the symptoms began. Her medical history includes hypertension and type 2 diabetes mellitus. She has never undergone abdominal surgery.

Her temperature is 38.6°C (101.5°F), blood pressure is 98/60 mm Hg, pulse is 115/min, and respiratory rate is 22/min. Physical examination reveals a distended, tympanic abdomen with high-pitched, hyperactive bowel sounds. There is mild, diffuse abdominal tenderness. Examination of the right groin reveals a 4-cm, firm, erythematous, and exquisitely tender mass located inferior to the inguinal ligament and medial to the femoral artery pulsation.

Laboratory studies demonstrate a leukocyte count of 17,200/mm³ and a serum lactate of 3.4 mmol/L (normal: 0.5-1.0 mmol/L).

Which of the following is the most appropriate next step in the management of this patient?

  1. Emergent surgical explorationAnswer
  2. B
    Nasogastric tube decompression and nonoperative observation
  3. C
    CT scan of the abdomen and pelvis
  4. D
    Attempted manual reduction under conscious sedation
  5. E
    Intravenous broad-spectrum antibiotics and observation

Answer

Emergent surgical exploration
The correct answer is emergent surgical exploration. This patient presents with a classic mechanical small bowel obstruction (SBO) caused by an incarcerated femoral hernia. The anatomical landmarks of a femoral hernia are a mass located inferior to the inguinal ligament and medial to the femoral vein and artery. Femoral hernias have a particularly high propensity for incarceration and strangulation due to the narrow, rigid borders of the femoral ring. This patient exhibits multiple signs of strangulation (ischemia), including fever, tachycardia, leukocytosis, an elevated serum lactate level, and an erythematous, exquisitely tender hernia sac. In the setting of a strangulated hernia, emergent surgical exploration is required to release the entrapment, resect any necrotic bowel, and repair the hernia defect.

Step-by-Step Solution

1
Identify the primary clinical syndrome from the patient's presentation.
The patient has cardinal signs of a small bowel obstruction (colicky pain, bilious vomiting, distension, obstipation).
Establishing the diagnosis of SBO is the first step in formulating a management plan.
2
Determine the etiology of the obstruction based on physical examination and medical history.
The patient has a virgin abdomen (no prior surgeries) and a tender groin mass below the inguinal ligament, identifying an incarcerated femoral hernia as the mechanical cause.
Adhesions are the most common cause of SBO overall, but in a virgin abdomen, hernias and tumors are the leading etiologies.
3
Assess for complications such as bowel ischemia, necrosis, or perforation.
Fever (38.6°C), tachycardia, leukocytosis (17,200/mm³), elevated lactate (3.4 mmol/L), and an erythematous, exquisitely tender hernia sac strongly indicate strangulation.
The presence of strangulation fundamentally shifts management from conservative or diagnostic evaluation to emergent surgical intervention.
4
Select the definitive management strategy based on the complication status.
Emergent surgical exploration is indicated to relieve the obstruction, assess bowel viability, and repair the hernia defect.
Any delay for imaging or attempts at manual reduction in a strangulated hernia significantly increases morbidity and mortality.

Key Concept

Patients presenting with a small bowel obstruction secondary to a strangulated hernia (evidenced by fever, leukocytosis, elevated lactate, and an erythematous/tender mass) require emergent surgical exploration. Manual reduction and advanced imaging should be avoided to prevent delay of definitive care.
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Topics

Gastrointestinal and Abdominal Surgery

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