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Difficulty: EasyGastrointestinal and Abdominal Surgery

A 61-year-old man presents to the emergency department with severe, unremitting right groin pain and nausea for the past 6 hours. He has vomited dark, foul-smelling fluid three times. He has a history of a right-sided groin bulge that he normally pushes back in, but since the pain started, he has been unable to do so. His temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, heart rate is 115/min, and respiratory rate is 18/min. Physical examination reveals a distended abdomen with high-pitched bowel sounds. Examination of the right groin reveals a 5-cm, firm, exquisitely tender, and erythematous mass above the inguinal ligament. Laboratory studies show a leukocyte count of 16,500/mm³ and a serum lactate level of 3.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Nasogastric tube decompression and serial abdominal examinations
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Manual reduction of the mass under conscious sedation
  4. Immediate surgical explorationAnswer
  5. E
    Abdominal ultrasound to evaluate the groin mass

Answer

Immediate surgical exploration
The correct answer is immediate surgical exploration. This patient presents with a small bowel obstruction caused by an incarcerated inguinal hernia, as evidenced by his vomiting, abdominal distension, and irreducible groin mass. Furthermore, he has clear signs of strangulation and bowel ischemia, including fever, tachycardia, leukocytosis, elevated serum lactate, and overlying skin erythema on the mass. When an obstruction is complicated by ischemia or strangulation, emergent surgical exploration is required to resect necrotic bowel and relieve the obstruction; conservative management is contraindicated.

Step-by-Step Solution

1
Analyze the patient's clinical presentation.
The patient has a mechanical small bowel obstruction (feculent vomiting, distension, high-pitched bowel sounds) secondary to an incarcerated inguinal hernia (irreducible groin mass).
Identifying the etiology of the obstruction is the first step in guiding management.
2
Assess for complications such as ischemia or strangulation.
The patient exhibits fever, tachycardia, leukocytosis, elevated lactate, and an erythematous, exquisitely tender groin mass, which all indicate strangulation and bowel ischemia.
Differentiating uncomplicated obstruction from complicated obstruction determines whether conservative or surgical management is required.
3
Determine the most appropriate next step.
The presence of a strangulated hernia with bowel ischemia mandates immediate surgical exploration.
Conservative management or diagnostic delays increase the risk of bowel perforation, severe sepsis, and mortality.

Key Concept

Management of complicated small bowel obstruction with signs of ischemia or strangulation
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Topics

Gastrointestinal and Abdominal Surgery

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