A 7-year-old girl is evaluated in the pediatric emergency department for severe abdominal … — USMLE Step 2 CK

A $7$ -year-old girl is evaluated in the pediatric emergency department for severe abdominal pain and vomiting. She underwent a laparoscopic appendectomy for perforated appendicitis $6$ days ago and was discharged home on postoperative day $3$ . Over the past $12$ hours, she has developed intense, colicky abdominal pain and repeated episodes of bilious emesis. Her parents note she has not passed stool or flatus since yesterday. On presentation, the child appears toxic, pale, and lethargic. Vital signs reveal a temperature of $39.0^\circ\text{C}$ ( $102.2^\circ\text{F}$ ), heart rate of $145\text{/min}$ , respiratory rate of $30\text{/min}$ , and blood pressure of $85/50\text{ mm Hg}$ . Physical examination demonstrates a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with a left shift and a serum lactate of $4.6\text{ mmol/L}$ . An upright plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of colonic gas. Following the initiation of aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A
Evaluation of surgical incisions and obtaining a urinalysis to determine the source of fever
B
Insertion of a nasogastric tube and serial abdominal assessments
Immediate exploratory laparotomyAnswer
D
Transport to the radiology suite for a computed tomography scan of the abdomen
E
Initiation of intravenous broad-spectrum antibiotics and medical observation

Answer

Immediate exploratory laparotomy

The correct intervention is immediate exploratory laparotomy. This patient presents with an acute adhesive small bowel obstruction (SBO) secondary to her recent appendectomy. While many postoperative adhesive SBOs can be managed conservatively with bowel rest and nasogastric tube decompression, this patient exhibits classic 'red flag' signs of bowel strangulation and ischemia. These signs include systemic toxicity, fever, hemodynamic instability (shock), a rigid abdomen indicative of peritonitis, significant leukocytosis, and an elevated serum lactate level. In the setting of a complicated or strangulated SBO, immediate surgical exploration is mandatory to relieve the mechanical obstruction, resect any non-viable intestine, and prevent progression to bowel perforation and fatal sepsis.

Step-by-Step Solution

Identify the primary clinical syndrome from the patient's presentation, history, and radiographic findings.

The patient has a mechanical small bowel obstruction (SBO), indicated by bilious emesis, obstipation, severe abdominal distension, dilated bowel loops with air-fluid levels on x-ray, and a recent history of abdominal surgery (putting her at high risk for adhesions).

Establishing the underlying mechanical diagnosis is necessary before assessing for life-threatening complications.

Evaluate the patient's clinical status for signs of complications or clinical deterioration.

The patient demonstrates signs of shock (hypotension, tachycardia), severe systemic inflammation (fever, marked leukocytosis), tissue hypoperfusion (elevated serum lactate), and overt peritonitis (rigid abdomen, rebound tenderness).

Differentiating between a simple SBO and a complicated (strangulated) SBO dictates the urgency and modality of the required intervention.

Determine the most appropriate management based on the presence of bowel strangulation.

Immediate surgical intervention (exploratory laparotomy) is selected to relieve the mechanical obstruction and resect any necrotic bowel.

Strangulated bowel obstruction is a surgical emergency; attempting conservative management or delaying surgery for further imaging significantly increases the risk of bowel perforation, profound sepsis, and mortality.

Key Concept

Management of Complicated Small Bowel Obstruction (Strangulation)

Estimated Time:1m 30s

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