A 61-year-old male is brought to the acute care clinic complaining of severe, unremitting … — USMLE Step 2 CK

A $61$ -year-old male is brought to the acute care clinic complaining of severe, unremitting abdominal pain that began suddenly $5$ hours ago. For the past three days, he had experienced mild, crampy abdominal discomfort and nausea, but the pain abruptly intensified today. His past medical history includes an appendectomy during childhood and a cholecystectomy a decade ago. Vital signs show a temperature of $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), a heart rate of $122\text{ /min}$ , and a blood pressure of $92/58\text{ mmHg}$ . Physical examination reveals a rigid, distended abdomen with profound guarding and generalized rebound tenderness. Complete blood count demonstrates a leukocyte count of $19,000/\text{mm}^3$ . Arterial blood gas analysis reveals a pH of $7.28$ , $\text{pCO}_2$ of $32\text{ mmHg}$ , and $\text{HCO}_3^-$ of $15\text{ mEq/L}$ . Serum lactate is markedly elevated at $5.4\text{ mmol/L}$ . An initial plain radiograph reveals multiple dilated loops of small intestine with prominent air-fluid levels. Intravenous fluids and broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in the management of this patient?

A
Nasogastric tube placement and serial abdominal reassessments
B
Tomographic cross-sectional imaging of the abdomen
Urgent operative abdominal explorationCevap
D
Fluoroscopic study with water-soluble enteral contrast
E
Endoscopic decompression of the affected intestinal segments

Cevap

Urgent operative abdominal exploration

This patient presents with a small bowel obstruction (SBO) that has progressed to strangulation and ischemia. Classic signs of a complicated or strangulated SBO include systemic toxicity (fever, severe tachycardia, hypotension), lactic acidosis, and peritonitis (rigid abdomen, rebound tenderness). While uncomplicated SBO can initially be managed conservatively with nasogastric decompression and intravenous fluids, the presence of peritonitis and hemodynamic instability is an absolute indication for immediate surgical intervention to resect ischemic or necrotic bowel.

Adım Adım Çözüm

Identify the primary diagnosis from the clinical presentation and radiographic findings.

The patient has a small bowel obstruction (SBO) based on a history of abdominal surgeries, crampy pain, obstipation, and a radiograph showing dilated small bowel loops with air-fluid levels.

Establishing the baseline underlying pathology is the first step in determining the appropriate management pathway.

Assess the patient for signs of complications, specifically bowel strangulation or ischemia.

The patient exhibits fever, severe tachycardia, hypotension, leukocytosis, lactic acidosis, and a rigid abdomen with rebound tenderness (peritonitis).

The presence of ischemia, necrosis, or perforation drastically alters the management pathway from a conservative approach to an emergent one.

Determine the most appropriate next step in management based on hemodynamic status and the abdominal examination.

Due to hemodynamic instability and overt peritonitis, immediate surgical exploration is required.

Delaying surgery for further imaging or attempting conservative observation in a patient with a strangulated SBO increases the risk of mortality and extensive bowel necrosis.

Anahtar Kavram

Management of complicated (strangulated) small bowel obstruction

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

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