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Difficulty: HardGastrointestinal and Abdominal Surgery

A 28-year-old man comes to the emergency department due to a 24-hour history of progressively worsening crampy abdominal pain, intractable vomiting, and an inability to pass flatus or stool. He states that over the last 2 hours, his pain has transitioned from crampy to constant and severe. His medical history is significant for medically refractory ulcerative colitis, for which he underwent a total proctocolectomy with ileal pouch-anal anastomosis 3 years ago. His temperature is 39.1°C (102.4°F), blood pressure is 96/58 mmHg, pulse is 128/min, and respirations are 22/min. Physical examination reveals a markedly distended abdomen with absent bowel sounds. There is severe, diffuse abdominal tenderness with involuntary guarding and rebound tenderness. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels, but no free intraperitoneal air. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomyAnswer
  2. B
    Nasogastric tube insertion and serial abdominal examinations
  3. C
    Computed tomography of the abdomen and pelvis with oral and intravenous contrast
  4. D
    Administration of intravenous broad-spectrum antibiotics and admission to the intensive care unit
  5. E
    Flexible pouchoscopy

Answer

Exploratory laparotomy
This patient presents with a small bowel obstruction (SBO) complicated by strangulation and bowel ischemia. A standard uncomplicated SBO presents with colicky abdominal pain, vomiting, and obstipation. However, this patient's clinical picture has evolved. The transition to constant and severe pain, combined with fever, hemodynamic instability (tachycardia, hypotension), marked leukocytosis, elevated serum lactate, and diffuse peritoneal signs (involuntary guarding, rebound tenderness), indicates that the affected bowel segment has become severely ischemic or necrotic. In any patient with an SBO who develops peritonitis or clinical deterioration suggesting strangulation, the standard of care is immediate exploratory laparotomy to resect the necrotic bowel and relieve the obstruction. Conservative management is strictly contraindicated in this setting.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and imaging.
The crampy abdominal pain, vomiting, obstipation, prior abdominal surgery, and radiograph showing dilated loops with air-fluid levels confirm a diagnosis of small bowel obstruction (SBO).
Establishing the primary clinical syndrome is the first step in formulating a management plan.
2
Evaluate for 'red flag' clinical signs indicating complications.
The patient has transitioned to constant severe pain, is hemodynamically unstable (tachycardic, hypotensive, febrile), has marked leukocytosis and elevated lactate, and exhibits peritonitis (guarding and rebound tenderness).
These findings differentiate a simple, uncomplicated SBO from a strangulated SBO with impending or actual bowel infarction.
3
Determine the definitive therapeutic intervention based on the clinical status.
The presence of peritonitis and signs of systemic toxicity in the setting of an SBO mandates immediate surgical exploration.
Conservative management or delaying for further imaging would result in bowel perforation, overwhelming sepsis, and death.

Key Concept

Management of complicated small bowel obstruction (SBO) with signs of strangulation or ischemia
Estimated Time:1m 0s
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Topics

Gastrointestinal and Abdominal Surgery

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