A 74-year-old female is transported to the acute care unit from a skilled nursing facility… — USMLE Step 2 CK

A 74-year-old female is transported to the acute care unit from a skilled nursing facility after staff noted her vomiting dark, foul-smelling fluid for the last day. The patient has advanced Alzheimer disease and cannot provide a meaningful history. Her past medical records indicate no prior intra-abdominal procedures. Vital signs show a temperature of $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), pulse of $118$ /min, and blood pressure of $92/54$ mmHg. Abdominal assessment demonstrates marked distension with generalized tenderness to palpation. A prominent, firm, $4$ -cm swelling is identified in the right groin, situated medial to the femoral vein and inferior to the inguinal ligament. The skin over this area appears dusky and is warm to the touch. Complete blood count reveals a leukocyte level of $19,200$ /mm $^3$ with a left shift. Serum lactate is $4.8$ mmol/L. Supine and upright plain films reveal centrally located, dilated loops of small intestine with prominent air-fluid levels and absent gas in the rectum. Which of the following is the most appropriate next step in management?

A
Nasogastric intubation and serial abdominal examinations
B
Computed tomography of the abdomen and pelvis with intravenous contrast
Immediate operative explorationAnswer
D
Bedside manual reduction of the groin mass
E
Upper gastrointestinal endoscopy

Answer

Immediate operative exploration

The correct answer is immediate operative exploration. This patient presents with a mechanical small bowel obstruction (SBO) secondary to an incarcerated femoral hernia, as evidenced by the firm, tender groin mass located medial to the femoral vein and inferior to the inguinal ligament. Furthermore, the patient exhibits clear signs of bowel strangulation and ischemia, including dusky skin over the hernia, fever, tachycardia, hypotension, pronounced leukocytosis, and an elevated serum lactate level. When an SBO is complicated by signs of clinical deterioration, peritonitis, or bowel infarction, conservative management is strictly contraindicated. The only appropriate next step to prevent impending sepsis and death is emergent surgical exploration with hernia repair and likely bowel resection.

Step-by-Step Solution

Identify the primary clinical syndrome from the patient's presentation.

The patient has a mechanical small bowel obstruction (SBO) evidenced by bilious/feculent emesis, abdominal distension, and classic radiographic findings.

Establishing the core diagnosis is the necessary first step in evaluating an acute abdomen.

Determine the etiology of the obstruction based on physical exam findings.

A firm, exquisitely tender mass medial to the femoral vein and inferior to the inguinal ligament in a patient with a virgin abdomen indicates an incarcerated femoral hernia.

Identifying the specific cause guides the targeted anatomical intervention.

Assess for critical complications such as bowel ischemia or necrosis.

Dusky overlying skin, fever, tachycardia, hypotension, pronounced leukocytosis, and an elevated lactate level all strongly point to strangulation.

The presence of ischemia drastically alters the management timeline from a conservative approach to a surgical emergency.

Select the most appropriate definitive management based on the patient's clinical stability and findings.

Immediate operative exploration is required.

Strangulated bowel is a surgical emergency; delaying for imaging or attempting conservative measures increases mortality risk.

Key Concept

Surgical management of strangulated femoral hernias presenting as complicated small bowel obstructions

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