A surgical triage team is evaluating four patients presenting to the emergency department with acute abdominal pain. Match each patient's clinical and radiologic presentation with the most appropriate next step in management.
- A 45-year-old man with a history of an appendectomy presents with crampy abdominal pain and obstipation. Vitals are normal. Abdomen is distended but soft, without guarding. Computed tomography (CT) shows dilated small bowel loops, a transition point in the ileum, and normal bowel wall enhancement.Placement of a nasogastric tube, intravenous fluid resuscitation, and serial abdominal examinations.
- A 62-year-old woman with a prior open hysterectomy presents with acute, constant abdominal pain. Temperature is 38.5°C (101.3°F) and heart rate is 118/min. Examination reveals focal rigidity. CT demonstrates a bowel transition point with a "whirl sign" and a segment of bowel with absent mucosal enhancement.Immediate exploratory laparotomy with evaluation of bowel viability.
- A 78-year-old man with peripheral arterial disease presents with sudden, excruciating periumbilical pain. His abdomen is completely soft and non-tender to deep palpation. Laboratory studies show mild lactic acidosis. Upright abdominal radiography is unremarkable.Computed tomography (CT) angiography of the abdomen and pelvis.
- A 60-year-old man presents with left lower quadrant pain and fever. Vitals are stable. Examination reveals localized tenderness without rebound. CT scan demonstrates sigmoid diverticular inflammation and a 2-cm localized pericolic fluid collection containing scattered microbubbles of air.Admission for intravenous broad-spectrum antibiotics and bowel rest without invasive intervention.
Answer
The correct matches align uncomplicated small bowel obstruction with conservative management, strangulated obstruction with immediate laparotomy, early mesenteric ischemia with CT angiography, and a small diverticular abscess with antibiotics alone.
Correctly matching these scenarios requires distinguishing between surgical emergencies and conditions that mandate conservative or diagnostic steps. Strangulated bowel (fever, rigidity, no CT enhancement) demands immediate laparotomy. Conversely, uncomplicated obstruction is managed with gastric decompression and hydration. Acute mesenteric ischemia without peritonitis requires CT angiography to map the vasculature, whereas taking the patient straight to surgery without mapping is reserved for those with generalized peritoneal signs. Finally, complicated diverticulitis with a very small (<3 cm) abscess is managed nonoperatively with antibiotics, as it is too small for percutaneous drainage.
Step-by-Step Solution
Key Concept
Triage of the acute surgical abdomen depends on identifying signs of bowel ischemia, peritonitis, or uncontained perforation to differentiate patients needing immediate laparotomy from those suitable for imaging, percutaneous drainage, or conservative management.