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Difficulty: MediumGastrointestinal and Abdominal Surgery

An emergency medical team is evaluating a 58-year-old male who developed excruciating, unremitting abdominal pain 6 hours ago. He reports no bowel movements or flatus for the past 48 hours. Ten years ago, he underwent an open appendectomy. His temperature is 38.6°C (101.5°F), blood pressure is 94/60 mmHg, pulse is 118/min, and respiratory rate is 22/min. On physical examination, the abdomen is markedly distended and tympanitic. Palpation elicits diffuse tenderness, which is most prominent in the periumbilical region, accompanied by involuntary guarding and rebound tenderness. Auscultation reveals absent bowel sounds. Laboratory analysis demonstrates a leukocyte count of 18,500/mm³ with 15% bands and a serum lactate level of 4.8 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with air-fluid levels, and no free air under the diaphragm. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Placement of a nasogastric tube and intravenous fluid resuscitation
  3. C
    Computed tomography scan of the abdomen and pelvis with intravenous contrast
  4. D
    Intravenous administration of broad-spectrum antibiotics and close observation
  5. E
    Flexible sigmoidoscopy with attempted endoscopic decompression

Answer

Immediate exploratory laparotomy
The correct approach is an immediate exploratory laparotomy. This patient presents with the classic triad of small bowel obstruction (SBO): crampy abdominal pain, vomiting/obstipation, and abdominal distension, confirmed by the presence of air-fluid levels on X-ray. However, the presence of fever, hypotension, marked peritonitis, leukocytosis, and an elevated lactate level indicates that the obstruction is complicated by bowel ischemia or strangulation. In this scenario, conservative management is contraindicated, and the patient must be taken directly to the operating room to resect necrotic bowel and relieve the obstruction.

Step-by-Step Solution

1
Analyze the patient's history and imaging findings.
Prior open appendectomy, absence of flatus/stool, and dilated small bowel loops with air-fluid levels on X-ray confirm a diagnosis of adhesive small bowel obstruction (SBO).
Establishing the baseline diagnosis is necessary before determining the severity and appropriate treatment.
2
Evaluate for 'red flag' symptoms indicating a complicated obstruction.
The patient has fever, tachycardia, hypotension, localized peritonitis (guarding and rebound tenderness), leukocytosis with bandemia, and elevated lactate.
These findings reliably indicate that the SBO has progressed to bowel ischemia, necrosis, or perforation.
3
Determine the management pathway based on clinical stability and complication status.
Because the patient has peritonitis and hemodynamic compromise, non-operative management must be abandoned in favor of immediate surgical exploration.
Ischemic or strangulated bowel is a surgical emergency; delaying for observation or further imaging increases mortality.

Key Concept

Patients with a small bowel obstruction who exhibit signs of strangulation or ischemia (fever, tachycardia, leukocytosis, metabolic acidosis, peritonitis) require immediate surgical exploration.
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Topics

Gastrointestinal and Abdominal Surgery

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