Examkin

Question

Difficulty: MediumGastrointestinal and Abdominal Surgery

A 55-year-old man arrives at the emergency department reporting three days of worsening, diffuse abdominal cramps associated with intractable bilious emesis and an inability to pass stool or gas. His medical history is significant for a ruptured appendix requiring an open appendectomy 20 years ago. He was initially evaluated at an urgent care center yesterday and discharged with antiemetics. Over the past 6 hours, his pain has transitioned from intermittent cramping to severe, relentless, and unyielding discomfort. His temperature is 38.9°C (102.0°F), pulse is 126/min, respirations are 24/min, and blood pressure is 92/58 mm Hg. On physical examination, the patient lies completely still. His abdomen is significantly distended, diffusely rigid, and exhibits profound rebound tenderness. Bowel sounds, which he noted were "rumbling" yesterday, are now absent. Laboratory investigations demonstrate a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. A plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and an absence of distal colonic gas. No pneumoperitoneum is identified. Which of the following is the most appropriate next step in the management of this patient?

  1. Urgent surgical explorationAnswer
  2. B
    Gastrointestinal decompression and serial clinical reassessments
  3. C
    Cross-sectional abdominopelvic imaging
  4. D
    Fluoroscopic evaluation of the small intestine with water-soluble contrast
  5. E
    Endoscopic evaluation of the lower gastrointestinal tract

Answer

Urgent surgical exploration
The correct answer is urgent surgical exploration. This patient presents with a classic small bowel obstruction (SBO), likely due to adhesions from a previous appendectomy. While many cases of SBO can be managed conservatively with gastrointestinal decompression and intravenous fluids, this patient has developed severe complications. The transition of his pain from crampy to severe and constant, along with the development of fever, tachycardia, hypotension, marked leukocytosis, an elevated lactate level, and diffuse peritonitis, are hallmark signs of a strangulated SBO with bowel ischemia. When bowel ischemia or peritonitis is clinically evident, immediate operative intervention is the definitive and lifesaving step. Delaying surgery for further imaging or observation in this scenario significantly increases morbidity and mortality.

Step-by-Step Solution

1
Identify the primary pathology based on the history and initial imaging.
The patient has a history of prior abdominal surgery, colicky abdominal pain, obstipation, bilious emesis, and an abdominal radiograph showing dilated small bowel loops with air-fluid levels.
These findings establish a diagnosis of a small bowel obstruction (SBO), most likely secondary to postoperative adhesions.
2
Assess for complications of the primary pathology.
The patient exhibits fever, tachycardia, hypotension, localized rigid peritonitis (rebound tenderness, lying still), significant leukocytosis, and an elevated serum lactate.
These "red flag" signs indicate that the simple obstruction has progressed to a strangulated obstruction, leading to bowel ischemia and systemic toxicity.
3
Determine the most appropriate management based on the patient's stability and complication status.
The presence of peritonitis and hemodynamic instability mandates immediate surgical intervention rather than conservative management or further diagnostic imaging.
Ischemic or necrotic bowel requires urgent resection to prevent fatal sepsis and perforation; delaying surgery for imaging or observation is contraindicated.

Key Concept

Patients with a small bowel obstruction who develop signs of strangulation, ischemia, or peritonitis (e.g., fever, tachycardia, metabolic acidosis, localized guarding) require immediate surgical exploration.
Estimated Time:1m 0s
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic