A 42-year-old woman is evaluated in the surgical step-down unit due to an acute exacerbati… — USMLE Step 2 CK

A $42$ -year-old woman is evaluated in the surgical step-down unit due to an acute exacerbation of abdominal pain. She was admitted yesterday for a bowel obstruction attributed to adhesions from a previous pelvic surgery. Initial treatment consisted of intravenous hydration, fasting, and placement of a nasogastric tube. Over the past two hours, her symptoms have shifted from colicky and intermittent discomfort to severe, unyielding pain. Vital signs show a temperature of $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), blood pressure of $110/68\text{ mmHg}$ , heart rate of $122/\text{min}$ , and respiratory rate of $24/\text{min}$ . Abdominal examination demonstrates marked rigidity, involuntary guarding, and focal rebound tenderness. Blood tests reveal a white blood cell count of $19,500/\text{mm}^3$ with $85\%$ neutrophils and a serum lactate level of $4.5\text{ mmol/L}$ . Which of the following is the most appropriate next step in the management of this patient?

Immediate open abdominal explorationCevap
B
Computed tomography of the abdomen with intravenous contrast
C
Administration of oral water-soluble contrast medium
D
Initiation of piperacillin-tazobactam and continued observation
E
Placement of a percutaneous abdominal drain

Cevap

Immediate open abdominal exploration is the most appropriate next step for a patient presenting with signs of a strangulated small bowel obstruction.

The patient is presenting with a small bowel obstruction that has progressed to strangulation, evidenced by the transition to severe and constant pain, fever, tachycardia, marked leukocytosis, lactic acidosis, and frank peritonitis (rigidity, guarding, rebound). The definitive management for a strangulated bowel obstruction or any bowel obstruction with signs of peritonitis is immediate surgical intervention to resect necrotic bowel and relieve the obstruction.

Adım Adım Çözüm

Evaluate the patient's history and change in symptom character.

The patient has a known mechanical bowel obstruction and her pain has suddenly transitioned from colicky (typical of uncomplicated obstruction) to severe and constant.

A change in pain character is a hallmark clinical sign that an obstruction may be progressing to ischemia or strangulation.

Analyze the vital signs and physical examination findings.

The patient exhibits fever, tachycardia, rigidity, involuntary guarding, and rebound tenderness.

These findings strongly indicate systemic toxicity and localized peritonitis, implying that the bowel wall has become ischemic or has perforated.

Interpret the laboratory results.

Significant leukocytosis with a left shift and an elevated serum lactate (

4.5\text{ mmol/L}

) are present.

Lactic acidosis and marked leukocytosis corroborate the clinical suspicion of bowel ischemia and necrosis.

Determine the optimal management strategy.

Immediate surgical intervention is required.

When clinical, physical, and laboratory signs of strangulation or peritonitis are present, conservative management must be abandoned in favor of emergent surgery to resect nonviable tissue.

Anahtar Kavram

Surgical management of strangulated bowel obstruction

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