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Difficulty: EasyGastrointestinal and Abdominal Surgery

A 45-year-old woman is brought to the emergency department due to progressively worsening abdominal pain. Two days ago, she developed diffuse, crampy abdominal pain associated with nausea and bilious vomiting. Over the past 4 hours, the pain has become severe and constant. She has not passed flatus or stool for 24 hours. Her past medical history is notable for an open abdominal hysterectomy performed four years ago. Her temperature is 38.9°C (102°F), blood pressure is 85/50 mmHg, pulse is 125/min, and respirations are 22/min. Physical examination reveals a distended abdomen that is rigid, with diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Nasogastric tube insertion and intravenous fluid hydration
  3. C
    Computed tomography scan of the abdomen and pelvis
  4. D
    Intravenous administration of broad-spectrum antibiotics and observation
  5. E
    Intravenous sodium bicarbonate infusion

Answer

Immediate exploratory laparotomy is the correct next step in management.
The correct action is immediate exploratory laparotomy. This patient's initial presentation (crampy pain, bilious vomiting, obstipation, prior abdominal surgery) is classic for a small bowel obstruction (SBO) caused by postoperative adhesions. However, her clinical status has deteriorated, marked by a transition to severe, constant pain. The presence of fever, hemodynamic instability (hypotension, tachycardia), rigid abdomen with rebound tenderness (peritonitis), pronounced leukocytosis, and lactic acidosis strongly indicates that the SBO has become complicated by bowel ischemia, strangulation, or full perforation. In any patient presenting with an acute abdomen characterized by peritonitis and shock, emergent surgical exploration is the standard of care to resect nonviable tissue and control contamination.

Step-by-Step Solution

1
Identify the underlying primary diagnosis.
The patient has a small bowel obstruction, likely secondary to adhesions from her previous open hysterectomy.
Crampy abdominal pain, bilious vomiting, obstipation, and a history of abdominal surgery are classic presenting symptoms of a mechanical small bowel obstruction.
2
Evaluate the clinical presentation for signs of complications.
The patient exhibits severe, constant pain, fever, hypotension, tachycardia, peritoneal signs (rigidity, rebound tenderness), leukocytosis, and lactic acidosis.
These specific clinical and laboratory markers indicate that the obstruction has progressed to bowel ischemia, strangulation, or perforation.
3
Determine the most appropriate management based on the patient's stability and exam.
The patient requires urgent surgical exploration.
Hemodynamically unstable patients with an acute surgical abdomen (peritonitis) must undergo immediate laparotomy without delaying for further imaging or attempting conservative measures.

Key Concept

Management of complicated small bowel obstruction
Estimated Time:1m 0s
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Topics

Gastrointestinal and Abdominal Surgery

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