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Difficulty: HardGastroenterology and Hepatology

A 4242-year-old man is brought to the emergency department due to severe, generalized abdominal pain and recurrent, bilious vomiting for the past 2424 hours. He has a 1010-year history of stricturing Crohn's disease, for which he takes adalimumab. The patient reports that he has not passed flatus or had a bowel movement for the last two days. Two days prior to symptom onset, he sustained a blunt abdominal trauma after tripping and falling against a low wall, but he did not seek medical care at that time.

His temperature is 39.2∘C39.2^\circ \text{C} (102.6∘F102.6^\circ \text{F}), heart rate is 128128/min, blood pressure is 82/5082/50 mm Hg, and respiratory rate is 2424/min. Physical examination reveals a distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory studies show:
Leukocyte count: 22,000/μL22,000/\mu \text{L}
Hemoglobin: 11.2 g/dL11.2 \text{ g/dL}
Platelet count: 350,000/μL350,000/\mu \text{L}
Serum lactate: 5.8 mmol/L5.8 \text{ mmol/L}

Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Insertion of a nasogastric tube and intravenous fluid resuscitation
  2. B
    Contrast-enhanced computed tomography scan of the abdomen and pelvis
  3. Immediate exploratory laparotomyAnswer
  4. D
    Intravenous administration of broad-spectrum antibiotics and serial abdominal examinations
  5. E
    Intravenous hydrocortisone and continuation of biologic therapy

Answer

Immediate exploratory laparotomy
This patient with a history of stricturing Crohn's disease presents with a classic triad of small bowel obstruction (SBO): severe abdominal pain, bilious vomiting, and obstipation. Crucially, he exhibits 'hard signs' of complicated SBO (such as strangulation, severe ischemia, or frank perforation), which include hemodynamic instability (hypotension, tachycardia), high fever, severe leukocytosis, elevated serum lactate, and signs of generalized peritonitis (rigid abdomen, rebound tenderness, guarding). Regardless of the exact underlying etiology—whether a strangulated stricture, ischemic bowel, or a delayed viscus perforation from his recent blunt trauma—the presence of peritonitis combined with hemodynamic shock dictates that the most appropriate next step is immediate surgical exploration (exploratory laparotomy) alongside aggressive intravenous fluid resuscitation.

Step-by-Step Solution

1
Identify the primary clinical syndrome from the patient's history and symptoms.
The patient presents with colicky abdominal pain, bilious vomiting, obstipation, and a history of stricturing Crohn's disease, indicative of a small bowel obstruction (SBO).
Recognizing the classic triad of SBO is the first step in determining the diagnostic and therapeutic algorithm.
2
Assess the patient's hemodynamic status and physical examination findings.
The patient exhibits hemodynamic instability (hypotension, tachycardia), high fever, marked leukocytosis, elevated lactate, and a rigid abdomen with rebound tenderness.
These are 'hard signs' of a complicated SBO (strangulation, ischemia, or perforation) or an acute surgical abdomen, which dictate immediate management.
3
Determine the most appropriate next intervention based on stability.
Due to the presence of peritonitis and shock, conservative medical management and advanced imaging (CT scan) are contraindicated. The patient must be taken to the operating room.
Unstable patients with an acute surgical abdomen require immediate exploratory laparotomy for source control and definitive treatment.

Key Concept

Patients with signs of complicated small bowel obstruction (fever, hemodynamic instability, metabolic acidosis, and peritonitis) require immediate exploratory laparotomy, regardless of underlying etiologies or recent trauma.
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Topics

Gastroenterology and Hepatology

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