Examkin

Question

Difficulty: EasyGastrointestinal and Abdominal Surgery

A 62-year-old female is evaluated in the emergency department for severe, diffuse abdominal pain that worsened abruptly over the last four hours. Her medical history is notable for a total abdominal hysterectomy ten years ago. She has not had a bowel movement or passed flatus in two days. On physical examination, the patient appears diaphoretic and in severe distress. Temperature is 39.2°C (102.6°F), pulse is 130/min, respirations are 24/min, and blood pressure is 80/50 mm Hg. Abdominal examination reveals a rigid, board-like abdomen with severe diffuse guarding and rebound tenderness. Laboratory studies show a leukocyte count of 22,000/mm³ and an elevated serum lactate. Which of the following is the most appropriate next step in the management of this patient?

  1. Emergency open abdominal explorationAnswer
  2. B
    Insertion of a nasogastric tube and serial abdominal examinations
  3. C
    Cross-sectional imaging of the abdomen and pelvis
  4. D
    Administration of broad-spectrum antibiotics and admission to the intensive care unit
  5. E
    Fluoroscopic water-soluble contrast enema

Answer

Emergency open abdominal exploration
The correct answer is emergency open abdominal exploration. This patient exhibits classic manifestations of a complicated, likely strangulated small bowel obstruction or perforated viscus. Key indicators include her history of prior abdominal surgery (adhesions), obstipation, and abrupt clinical deterioration. The presence of hemodynamic instability (hypotension, tachycardia), systemic inflammatory response (high fever, severe leukocytosis, elevated lactate), and generalized peritonitis (rigid abdomen, diffuse rebound tenderness) leaves no doubt that she requires emergent source control. The definitive and life-saving intervention for an unstable acute surgical abdomen is an immediate laparotomy.

Step-by-Step Solution

1
Identify the primary clinical presentation.
The patient has a history of abdominal surgery and presents with obstipation, severe diffuse pain, and systemic toxicity (fever, marked leukocytosis, lactic acidosis).
Recognizing the constellation of symptoms points toward a complicated small bowel obstruction, likely strangulated or perforated.
2
Assess the patient's hemodynamic status and physical examination findings.
The patient is hypotensive (80/50 mm Hg) and tachycardic (130/min) with a rigid abdomen demonstrating generalized rebound tenderness and guarding.
These findings confirm peritonitis in the setting of shock, classifying this as a surgical emergency.
3
Determine the most appropriate management based on the assessment.
The immediate requirement is operative intervention (laparotomy) to address the catastrophic intra-abdominal process.
Any delay for imaging or attempts at conservative management in a hemodynamically unstable patient with an acute surgical abdomen dramatically increases mortality.

Key Concept

Management of complicated small bowel obstruction and acute peritonitis
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic