Question

Difficulty: HardGastroenterology and Hepatology

A 28-year-old woman is brought to the emergency department due to a 2-day history of worsening, diffuse abdominal pain and recurrent vomiting of greenish material. She reports that her pain was initially crampy and intermittent but has become constant and severe over the past 6 hours. She has not had a bowel movement or passed flatus since the symptoms began. Her medical history is significant for stricturing ileal Crohn's disease, for which she was previously treated with infliximab, but she discontinued all medications a year ago. Her temperature is 38.8∘C38.8^\circ\text{C} (101.8∘F101.8^\circ\text{F}), pulse is 124/min124/\text{min}, blood pressure is 88/54 mmHg88/54 \text{ mmHg}, and respirations are 22/min22/\text{min}. Physical examination reveals a distended, tympanitic abdomen with absent bowel sounds. There is diffuse tenderness with marked guarding and rebound tenderness in the right lower quadrant. Laboratory studies show a leukocyte count of 21,000/mm321,000/\text{mm}^3 with 15%15\% bands, and a serum lactate level of 4.8 mmol/L4.8 \text{ mmol/L}. An abdominal CT scan with intravenous contrast demonstrates markedly dilated loops of small intestine with a distinct transition point in the terminal ileum. There is circumferential thickening of the terminal ileum, pneumatosis intestinalis, and moderate free fluid in the pelvis. Which of the following is the most appropriate next step in management?

  1. Urgent exploratory laparotomyAnswer
  2. B
    Nasogastric tube decompression and intravenous fluids
  3. C
    Intravenous high-dose corticosteroids and biologic therapy
  4. D
    CT angiography of the mesenteric vessels
  5. E
    Diagnostic colonoscopy with terminal ileum intubation

Answer

Urgent exploratory laparotomy
This patient is presenting with a small bowel obstruction (SBO) complicated by bowel ischemia and strangulation. The classic presentation of SBO includes crampy abdominal pain, vomiting, abdominal distension, and obstipation. While uncomplicated SBO can often be managed conservatively, the presence of fever, tachycardia, hypotension, significant leukocytosis with bandemia, elevated lactate, peritonitis (guarding and rebound tenderness), and pneumatosis intestinalis on CT scan strongly indicates bowel ischemia and necrosis. In the setting of a strangulated SBO, immediate surgical intervention with an urgent exploratory laparotomy is required to resect necrotic bowel and prevent catastrophic outcomes such as overwhelming sepsis and death. Even though the underlying etiology is likely a stricture from her Crohn's disease, the acute complication is a surgical emergency.

Step-by-Step Solution

1
Analyze the clinical presentation and physical examination findings.
The patient has cardinal signs of a bowel obstruction (vomiting, obstipation, distension) combined with signs of clinical deterioration: fever, tachycardia, hypotension, and localized peritonitis (guarding and rebound tenderness).
To differentiate between an uncomplicated obstruction and one that has progressed to ischemia or strangulation.
2
Interpret the laboratory and imaging data.
Marked leukocytosis with bandemia, elevated lactate, and CT scan showing pneumatosis intestinalis strongly confirm bowel ischemia and impending or frank necrosis.
Objective data solidifies the severity of the bowel compromise, ruling out the possibility of conservative management.
3
Determine the definitive next best step in management.
The presence of a strangulated small bowel obstruction necessitates emergent surgical exploration to resect non-viable bowel and prevent fatal peritonitis and sepsis.
Delaying surgery for conservative measures, further imaging, or medical therapies is life-threatening in the setting of strangulation.

Key Concept

Management of complicated small bowel obstruction (SBO)
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