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Question

Difficulty: MediumGastrointestinal and Abdominal Surgery

A 51-year-old woman is brought to the emergency department complaining of sudden-onset, severe, and unremitting abdominal pain for the past 6 hours. She has vomited bilious material twice since the pain began. Her surgical history is notable for a total abdominal hysterectomy performed five years ago for uterine fibroids. On presentation, her temperature is 38.3°C (100.9°F), heart rate is 118/min, and blood pressure is 105/65 mm Hg. Physical examination shows a significantly distended abdomen with focal rigidity and pronounced rebound tenderness in the left lower quadrant. Bowel sounds are absent. Laboratory results reveal a leukocyte count of 16,500/mm³ and a serum lactate level of 3.2 mmol/L. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates a transition point in the distal jejunum, poor enhancement of the bowel wall distal to the transition point, a mesenteric "whirl" sign, and moderate free pelvic fluid. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Placement of a nasogastric tube and serial abdominal examinations
  3. C
    Administration of oral water-soluble contrast
  4. D
    CT angiography of the mesenteric vessels
  5. E
    Intravenous antibiotics and image-guided percutaneous drainage

Answer

Immediate exploratory laparotomy
This patient presents with classic signs and symptoms of a small bowel obstruction (SBO) complicated by strangulation and bowel ischemia. The presence of focal peritonitis (rigidity, rebound tenderness), systemic toxicity (fever, tachycardia, leukocytosis), and lactic acidosis strongly suggest compromised intestinal blood flow. The CT scan confirms this by showing poor bowel wall enhancement and a mesenteric 'whirl' sign (highly indicative of a volvulus or closed-loop obstruction). When clinical or radiographic signs of ischemia, necrosis, or perforation are present in the setting of an SBO, the definitive and required treatment is immediate surgical exploration to relieve the obstruction and resect any nonviable bowel.

Step-by-Step Solution

1
Identify the primary diagnosis from the clinical and imaging findings
Small bowel obstruction (SBO) complicated by strangulation
The patient has a history of abdominal surgery (causing adhesions), bilious vomiting, and a CT scan showing a transition point with a 'whirl' sign and poor mural enhancement.
2
Assess for signs of clinical deterioration and peritonitis
The patient has fever, tachycardia, focal rigidity, rebound tenderness, and lactic acidosis
These findings indicate compromised intestinal perfusion, leading to transmural ischemia and impending or actual bowel perforation.
3
Determine the definitive intervention
Emergent surgical exploration
A strangulated closed-loop obstruction is a surgical emergency. Delaying surgery for conservative management or further imaging drastically increases mortality.

Key Concept

Signs of strangulation in a small bowel obstruction (such as fever, tachycardia, peritonitis, lactic acidosis, and poor bowel enhancement on CT) mandate immediate surgical exploration.
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Topics

Gastrointestinal and Abdominal Surgery

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