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Zorluk: KolayGastroenterology and Hepatology

On her sixth day of recovery following an open partial colectomy for recurrent diverticulitis, a 65-year-old woman develops severe, sudden-onset abdominal pain associated with bilious vomiting. Although she had previously tolerated clear liquids and passed flatus on postoperative day 3, she has not passed gas or had a bowel movement in the last 24 hours. Vital signs show a temperature of 38.9°C (102.0°F), blood pressure of 86/54 mm Hg, and heart rate of 122/min. Abdominal examination reveals severe distension, absent bowel sounds, and diffuse rigidity with rebound tenderness. Laboratory evaluation is notable for a leukocyte count of 19,500/mm³ (with 12% band forms) and a serum lactate concentration of 4.8 mmol/L. Upright abdominal radiography displays prominent, dilated loops of small intestine with multiple air-fluid levels. Which of the following is the most appropriate next step in management?

  1. A
    Insertion of a nasogastric tube and intravenous fluid resuscitation
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. Immediate exploratory laparotomyCevap
  4. D
    Blood cultures and initiation of empiric intravenous antifungal therapy
  5. E
    Administration of an intravenous sodium bicarbonate infusion

Cevap

Immediate exploratory laparotomy is the correct management for a patient with signs of a strangulated small bowel obstruction.
The correct answer is immediate exploratory laparotomy. This patient presents with a classic picture of a strangulated small bowel obstruction (SBO), characterized by bowel dilation with air-fluid levels, absence of flatus, and severe clinical deterioration. The presence of fever, tachycardia, hypotension, severe abdominal rigidity (peritonitis), leukocytosis with a left shift, and lactic acidosis all point to ischemic or necrotic bowel. When signs of strangulation or peritonitis are present, or when the patient is hemodynamically unstable, immediate surgical intervention is mandated. Delaying surgery for further imaging or attempting conservative management greatly increases mortality.

Adım Adım Çözüm

1
Identify the primary diagnosis from the clinical presentation and radiographic findings.
The patient has a small bowel obstruction, indicated by vomiting, inability to pass flatus, and dilated small bowel loops with air-fluid levels on X-ray.
Recognizing the underlying pathology is necessary before determining the treatment algorithm.
2
Assess for signs of complications, specifically bowel ischemia or peritonitis.
The patient has fever, hypotension, tachycardia, abdominal rigidity, rebound tenderness, leukocytosis, and elevated lactate.
The presence of these 'red flag' symptoms shifts the management from conservative to emergent surgical intervention.
3
Determine the most appropriate next step in management based on patient stability.
Immediate exploratory laparotomy is selected.
Hemodynamically unstable patients with an acute surgical abdomen require immediate operative intervention without delay for further imaging.

Anahtar Kavram

Management of complicated small bowel obstruction
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Konular

Gastroenterology and Hepatology

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