During the evening shift, a physician is called to review the status of a 45-year-old fema… — USMLE Step 2 CK

During the evening shift, a physician is called to review the status of a $45$ -year-old female admitted two days ago with a partial small bowel obstruction following a recent laparoscopic hysterectomy. Her initial management included intravenous fluids and continuous nasogastric suction. Recently, she reports a rapid exacerbation of her abdominal pain, which has become unremitting and localized. Vital signs indicate a temperature of $39.1^\circ\text{C}$ ( $102.4^\circ\text{F}$ ), blood pressure of $85/50 \text{ mmHg}$ , heart rate of $130/\text{min}$ , and respiratory rate of $28/\text{min}$ . Physical examination reveals a markedly distended abdomen with diffuse rigidity and severe rebound tenderness. Recent laboratory analysis displays a leukocyte count of $21,000/\text{mm}^3$ and a serum lactate of $6.2 \text{ mmol/L}$ . Which of the following is the most appropriate next step in the management of this patient?

A
Contrast-enhanced cross-sectional imaging of the abdomen
B
Maintenance of current supportive care with serial abdominal examinations
Direct transfer to the operating room for abdominal explorationAnswer
D
Administration of systemic antimicrobial agents without surgical intervention
E
Comprehensive infectious workup including blood, sputum, and urine cultures

Answer

Direct transfer to the operating room for abdominal exploration

This patient exhibits classic signs of a strangulated small bowel obstruction, marked by a rapid transition from intermittent to severe, unremitting abdominal pain, high fever, tachycardia, hypotension, significant leukocytosis, and elevated serum lactate. Most importantly, the physical examination reveals frank peritonitis (rigidity and rebound tenderness). The presence of peritonitis coupled with hemodynamic instability in the setting of a bowel obstruction represents a surgical emergency. Immediate abdominal exploration is mandated to assess bowel viability, resect necrotic or perforated segments, and prevent further clinical deterioration.

Step-by-Step Solution

Identify the primary diagnosis and baseline status

The patient is known to have a partial small bowel obstruction and is in the postoperative period.

Establishing the clinical context clarifies that the patient is at risk for progression to a complete or strangulated obstruction.

Evaluate the clinical deterioration

The shift from crampy to unremitting pain, along with high fever, tachycardia, hypotension, severe leukocytosis, and elevated lactate, indicates bowel ischemia or necrosis.

These are classic systemic signs of a strangulated obstruction and systemic inflammatory response syndrome (SIRS).

Assess the physical examination for indications of an acute abdomen

The presence of diffuse rigidity and severe rebound tenderness confirms frank peritonitis.

Peritonitis is a hard sign of a surgical emergency requiring operative source control.

Determine the definitive intervention

The patient requires immediate surgical exploration.

Hemodynamic instability combined with peritonitis mandates emergent laparotomy, rendering any further diagnostic imaging or conservative delays unsafe.

Key Concept

Management of complicated (strangulated) small bowel obstruction

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