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Difficulty: EasyGastrointestinal and Abdominal Surgery

Following three days of progressive obstipation and bilious vomiting, a 48-year-old man arrives at the emergency department. He states that his abdominal pain, which was initially intermittent and crampy, has abruptly become constant and excruciating within the last few hours. His surgical history includes a midline laparotomy for a ruptured appendix a decade ago. Vital signs show a temperature of 38.6°C (101.5°F), a pulse of 118/min, and a blood pressure of 96/60 mm Hg. The abdominal examination demonstrates widespread rigidity, diffuse rebound tenderness, and absent bowel sounds. Blood tests indicate a leukocyte count of 18,500/mm³ and an elevated serum lactate. Upright abdominal radiographs reveal prominent dilated loops of small bowel with multiple air-fluid levels and no free air. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Placement of a nasogastric tube and intravenous fluids for conservative management
  3. C
    Computed tomography scan of the abdomen and pelvis
  4. D
    Administration of broad-spectrum intravenous antibiotics and clinical observation
  5. E
    Diagnostic laparoscopy with attempted adhesiolysis

Answer

Immediate exploratory laparotomy is the most appropriate next step.
The correct answer is immediate exploratory laparotomy. This patient presents with a classic small bowel obstruction (SBO) likely secondary to adhesions from his previous laparotomy. While many SBOs can be managed conservatively with nasogastric decompression and intravenous fluids, this patient has developed clear signs of strangulation and peritonitis (constant severe pain, fever, tachycardia, hypotension, elevated lactate, and abdominal rigidity). These findings dictate that conservative management has failed or is contraindicated, and emergent surgical exploration is required to prevent bowel necrosis, sepsis, and death.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation and imaging.
The patient has a small bowel obstruction, evidenced by bilious vomiting, obstipation, prior abdominal surgery, and air-fluid levels on X-ray.
Establishing the underlying structural problem guides the treatment algorithm.
2
Assess for complications such as ischemia, strangulation, or perforation.
The transition to constant severe pain, fever, tachycardia, hypotension, lactic acidosis, and a rigid abdomen strongly indicate bowel strangulation and peritonitis.
Complicated small bowel obstructions require a different management pathway than uncomplicated cases.
3
Determine the most appropriate management based on the presence of complications.
Immediate exploratory laparotomy is required.
Patients with a strangulated bowel obstruction and peritonitis need emergent surgical exploration to resect ischemic bowel and prevent further clinical deterioration.

Key Concept

Indications for emergent laparotomy in small bowel obstruction
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Topics

Gastrointestinal and Abdominal Surgery

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