A 55-year-old woman is evaluated on the surgical ward for nausea, bilious vomiting, and di… — USMLE Step 2 CK

A $55$ -year-old woman is evaluated on the surgical ward for nausea, bilious vomiting, and diffuse abdominal cramping. She is currently on postoperative day $6$ following an open abdominal hysterectomy for uterine fibroids. The patient reports she has not passed flatus or stool since the operation. Her temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $128/78\text{ mmHg}$ , pulse is $86/\text{min}$ , and respiratory rate is $14/\text{min}$ . Physical examination reveals a significantly distended and tympanic abdomen. Auscultation demonstrates high-pitched, hyperactive bowel sounds. There is mild diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. The surgical incision is healing well with no erythema or discharge. Laboratory results show a leukocyte count of $7,500/\text{mm}^3$ and normal serum lactate levels. Upright abdominal radiography reveals multiple dilated loops of small bowel with prominent air-fluid levels and no free intraperitoneal air. Which of the following is the most appropriate next step in management?

A
Administration of oral metoclopramide to stimulate bowel motility
B
Immediate preparation for an exploratory laparotomy
Insertion of a nasogastric tube and administration of intravenous fluidsCevap
D
Initiation of broad-spectrum intravenous antibiotics
E
Pelvic ultrasonography to evaluate for an infected postoperative fluid collection

Cevap

Insertion of a nasogastric tube and administration of intravenous fluids

The correct answer involves conservative management with a nasogastric tube and intravenous fluids. This patient presents with classic signs of a mechanical small bowel obstruction (SBO), including bilious vomiting, abdominal distension, tympany, high-pitched (hyperactive) bowel sounds, and obstipation. The upright abdominal X-ray confirms the diagnosis with multiple dilated loops of small bowel and air-fluid levels. Because her vital signs are stable, her abdomen lacks peritonitic signs (e.g., rebound tenderness, rigidity), and her lab values (WBC, lactate) are normal, there is no evidence of bowel ischemia or strangulation. Therefore, the first-line treatment is supportive care and bowel decompression.

Adım Adım Çözüm

Analyze the patient's presentation and physical examination findings.

The patient has nausea, bilious vomiting, failure to pass flatus, a distended/tympanic abdomen, and high-pitched bowel sounds on postoperative day 6.

Identifying these classic symptoms helps differentiate mechanical small bowel obstruction (high-pitched sounds) from paralytic ileus (absent or severely decreased bowel sounds).

Evaluate vital signs and laboratory/imaging results for complications.

The patient is afebrile with normal hemodynamics, no peritoneal signs (rigidity/rebound tenderness), normal leukocyte count, normal lactate, and no free air on imaging.

Checking for signs of ischemia, strangulation, or perforation is critical, as these dictate whether the patient needs immediate surgery versus conservative management.

Select the appropriate initial management for an uncomplicated small bowel obstruction.

Conservative management with a nasogastric tube for decompression, intravenous fluids for resuscitation, and strict bowel rest is indicated.

In the absence of complications, conservative management is the standard first-line approach for postoperative small bowel obstructions.

Anahtar Kavram

Initial management of uncomplicated mechanical small bowel obstruction

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

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