Examkin

Question

Difficulty: MediumGastrointestinal and Abdominal Surgery

A 34-year-old man is brought to the emergency department due to the sudden onset of severe, diffuse abdominal pain and bilious vomiting over the past 14 hours. He reports no passage of flatus or stool since the pain began. His past medical history is notable for a perforated appendicitis requiring an open appendectomy 5 years ago. On arrival, his temperature is 38.6°C (101.5°F), blood pressure is 96/60 mmHg, pulse is 126/min, and respirations are 24/min. Physical examination reveals a distended abdomen with marked rigidity, involuntary guarding, and diffuse rebound tenderness. Bowel sounds are completely absent. Laboratory evaluation shows a leukocyte count of 19,000/mm³ and a serum lactate level of 4.5 mmol/L. An upright abdominal radiograph demonstrates multiple dilated loops of small intestine with prominent air-fluid levels, and no free air under the diaphragm. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Nasogastric tube decompression and intravenous fluid resuscitation
  2. B
    CT scan of the abdomen and pelvis with intravenous contrast
  3. Immediate exploratory laparotomyAnswer
  4. D
    Intravenous broad-spectrum antibiotics and intensive care observation
  5. E
    Diagnostic laparoscopy

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. The patient's history of an open appendectomy puts him at high risk for adhesive small bowel obstruction. While uncomplicated small bowel obstructions can be managed conservatively, this patient presents with fever, tachycardia, hypotension, severe abdominal rigidity, rebound tenderness, and lactic acidosis. These findings indicate a complicated obstruction with bowel ischemia or strangulation (strangulated SBO). In this setting, immediate surgical intervention is mandated to relieve the obstruction, resect any necrotic bowel, and control abdominal sepsis.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation and radiographic findings.
The patient has a small bowel obstruction (SBO), supported by a history of abdominal surgery, obstipation, bilious vomiting, and multiple dilated loops of small intestine with air-fluid levels on the radiograph.
Establishing the underlying pathology is the first step before determining if the condition is complicated or uncomplicated.
2
Evaluate the patient for signs of complicated SBO (ischemia, strangulation, or perforation).
The patient displays clear signs of strangulation and clinical deterioration, including peritonitis (rigidity, rebound tenderness), fever, hypotension, marked leukocytosis, and lactic acidosis.
The presence of complications dictates a drastic shift in management from conservative observation to emergency surgery.
3
Select the most appropriate next step in management for a complicated SBO.
Immediate exploratory laparotomy is required to relieve the obstruction, resect any necrotic bowel, and manage the peritonitis.
In an unstable patient with a strangulated SBO, delaying for further imaging or attempting conservative management significantly increases mortality.

Key Concept

Complicated small bowel obstruction (SBO) presenting with signs of ischemia, strangulation (e.g., fever, tachycardia, leukocytosis, lactic acidosis), or peritonitis requires immediate exploratory laparotomy, bypassing conservative management or further diagnostic imaging.
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic