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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 71-year-old man is brought to the emergency department by his daughter due to a 2-day history of progressively worsening abdominal pain, severe nausea, and multiple episodes of dark green emesis. He has not passed flatus or had a bowel movement since the symptoms began. His medical history is notable for hypertension, benign prostatic hyperplasia, and a myocardial infarction 5 years ago. His temperature is 38.3°C (100.9°F), blood pressure is 105/65 mmHg, pulse is 112/min, and respirations are 20/min. Physical examination reveals a significantly distended abdomen with high-pitched, tinkling bowel sounds. Inspection of the groin reveals a 5-cm, exquisitely tender, firm, and erythematous mass in the right inguinal region that extends into the scrotum. Laboratory studies show a leukocyte count of 16,500/mm³ and a serum lactate of 4.1 mmol/L. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Nasogastric tube decompression and serial abdominal examinations
  3. Urgent operative interventionAnswer
  4. D
    Attempted manual reduction under conscious sedation
  5. E
    Intravenous broad-spectrum antibiotics and clinical observation

Answer

Urgent operative intervention
The correct answer is urgent operative intervention. This patient presents with a small bowel obstruction (SBO) secondary to an incarcerated inguinal hernia. Crucially, he demonstrates multiple signs of strangulation (compromised blood supply to the bowel), including a systemic inflammatory response (fever, tachycardia, leukocytosis), tissue hypoperfusion (elevated lactate), and local signs of ischemia (exquisite tenderness and overlying erythema). When an SBO is complicated by suspected strangulation, bowel ischemia, or perforation, the standard of care is immediate surgical exploration. Delaying surgery significantly increases the risk of bowel necrosis, perforation, sepsis, and mortality. During surgery, the viability of the herniated bowel segment will be assessed, and necrotic segments will be resected before hernia repair.

Step-by-Step Solution

1
Identify the primary clinical syndrome.
The patient presents with symptoms of a complete small bowel obstruction (SBO), including bilious emesis, abdominal distension, high-pitched bowel sounds, and obstipation.
Recognizing the obstructive pattern is the first step in abdominal pain triage.
2
Determine the etiology of the obstruction.
Physical examination reveals a tender, erythematous right inguinal mass, diagnosing an incarcerated right inguinal hernia as the cause of the SBO.
Identifying the mechanical cause guides specific management.
3
Assess for complications, specifically ischemia or strangulation.
The patient exhibits fever, tachycardia, leukocytosis, elevated lactate, and overlying skin erythema, which are all hallmarks of a strangulated hernia with ischemic bowel.
The presence of strangulation fundamentally changes management from conservative to immediate surgical intervention.

Key Concept

Management of strangulated small bowel obstruction
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Topics

Gastrointestinal and Abdominal Surgery

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