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Difficulty: MediumGastrointestinal and Abdominal Surgery

Emergency medical services bring a 72-year-old female resident of a skilled nursing facility to the acute care clinic due to progressive abdominal swelling, intractable vomiting, and profound weakness over the past day. Her past medical history includes an open total abdominal hysterectomy five years ago. On initial assessment, her temperature is 39.1°C (102.4°F), pulse is 128/min, respirations are 26/min, and blood pressure is 78/45 mm Hg. The patient is poorly responsive. The abdominal examination demonstrates severe distension, generalized rigidity, and diffuse rebound tenderness with absent bowel sounds. Initial laboratory analysis shows a white blood cell count of 22,000/mm³ and a serum lactate concentration of 6.2 mmol/L. Which of the following is the most appropriate next step in management?

  1. Emergent laparotomyAnswer
  2. B
    Computed tomography of the abdomen with intravenous contrast
  3. C
    Insertion of a nasogastric tube, intravenous fluid administration, and serial examinations
  4. D
    Initiation of broad-spectrum antibiotics and deferral of intervention until culture sensitivities return
  5. E
    Obtaining an upright chest radiograph to evaluate for a cardiopulmonary exacerbation

Answer

Emergent laparotomy
The patient's presentation of severe abdominal distension, rigidity, and absent bowel sounds in the setting of prior abdominal surgery strongly suggests a complicated small bowel obstruction (SBO). The presence of fever, tachycardia, hypotension (septic shock), and elevated lactate indicates that the obstruction has progressed to bowel ischemia, necrosis, or perforation. In any patient with an acute abdomen and hemodynamic instability, the most appropriate definitive step is emergent laparotomy to obtain source control and resect nonviable tissue.

Step-by-Step Solution

1
Analyze the vital signs and patient presentation.
The patient has hypotension (78/45 mm Hg), tachycardia (128/min), fever (39.1°C), and altered mental status, indicating septic shock.
To determine the hemodynamic status, which dictates the urgency and safety of diagnostic testing.
2
Evaluate the physical examination and laboratory findings.
Rigid abdomen with rebound tenderness indicates peritonitis. Leukocytosis and elevated lactate (6.2 mmol/L) suggest bowel ischemia or perforation.
To localize the source of shock and differentiate between uncomplicated and complicated intra-abdominal pathology.
3
Determine the definitive management strategy.
The combination of an acute surgical abdomen (peritonitis) and hemodynamic instability requires immediate surgical exploration (laparotomy).
Patients with peritonitis and shock require immediate operative source control; delaying for further imaging or managing conservatively increases mortality.

Key Concept

Patients presenting with a suspected small bowel obstruction who develop signs of peritonitis, ischemia (elevated lactate), or hemodynamic instability require emergent laparotomy rather than conservative management or further imaging.
Estimated Time:1m 15s
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Topics

Gastrointestinal and Abdominal Surgery

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