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Difficulty: EasyGastrointestinal and Abdominal Surgery

A 52-year-old woman is admitted to the hospital with a 2-day history of progressively worsening crampy abdominal pain, abdominal distension, and bilious vomiting. She has not passed flatus or stool for the past 24 hours. Her surgical history is significant for a total abdominal hysterectomy performed 5 years ago for uterine fibroids. Vital signs show a temperature of 37.1°C (98.8°F), pulse of 86/min, and blood pressure of 126/82 mm Hg. Physical examination reveals a distended and tympanic abdomen. There is diffuse mild tenderness to palpation, but no rebound tenderness, guarding, or rigidity. Laboratory studies show a normal leukocyte count and a serum potassium of 3.8 mEq/L. Computed tomography (CT) of the abdomen reveals multiple dilated loops of small bowel with air-fluid levels and a discrete transition point in the mid-ileum. There is no evidence of bowel wall thickening, pneumatosis intestinalis, or free intraperitoneal air. What is the most appropriate next step in the management of this patient?

  1. A
    Immediate exploratory laparotomy
  2. B
    Administration of broad-spectrum intravenous antibiotics
  3. Placement of a nasogastric tube and administration of intravenous fluidsAnswer
  4. D
    Barium contrast enema
  5. E
    Administration of an oral prokinetic agent

Answer

Placement of a nasogastric tube and administration of intravenous fluids
The patient presents with classic signs and symptoms of a small bowel obstruction (SBO), likely secondary to post-surgical adhesions from her previous hysterectomy. The clinical evaluation and CT scan reveal no signs of bowel ischemia, necrosis, or perforation (such as fever, tachycardia, localized peritonitis, leukocytosis, or pneumatosis intestinalis). Therefore, the standard of care is a trial of nonoperative, conservative management. This involves gastrointestinal decompression via a nasogastric tube to alleviate distension and vomiting, aggressive intravenous fluid resuscitation to correct volume depletion, and bowel rest.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and surgical history.
The patient has symptoms of bowel obstruction (vomiting, distension, obstipation) and a history of abdominal surgery (hysterectomy), which is the most common cause of adhesive small bowel obstruction (SBO).
Identifying the etiology helps guide standard management protocols.
2
Evaluate the patient's vital signs, physical examination, and diagnostic imaging for complications.
The patient is hemodynamically stable, afebrile, and lacks peritoneal signs. The CT scan confirms a mechanical SBO but shows no evidence of bowel ischemia, necrosis, or perforation (e.g., no pneumatosis intestinalis or free air).
Differentiating between uncomplicated and complicated (strangulated) SBO dictates whether management should be conservative or surgical.
3
Select the appropriate treatment pathway based on the absence of complications.
Since the obstruction is uncomplicated, an initial trial of conservative management is indicated.
Uncomplicated adhesive SBO often resolves with nonoperative management, avoiding the morbidity of unnecessary surgery.

Key Concept

Initial management of uncomplicated adhesive small bowel obstruction
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Topics

Gastrointestinal and Abdominal Surgery

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