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Zorluk: KolayGastrointestinal and Abdominal Surgery

An ambulance brings a 60-year-old female to the emergency department due to severe, unrelenting abdominal pain and repeated bilious vomiting that started 24 hours ago. Her past medical history is notable for an open appendectomy performed 15 years prior. She reports that the pain was initially colicky, but over the last 3 hours, it has become constant and generalized. Her temperature is 38.7°C (101.7°F), pulse is 125/min, respirations are 22/min, and blood pressure is 85/50 mm Hg. Physical evaluation reveals a distended and rigid abdomen with marked diffuse tenderness, involuntary guarding, and rebound tenderness. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of 19,500/mm³ and a serum lactate of 5.1 mmol/L. A plain upright abdominal radiograph displays multiple distended small bowel loops with air-fluid levels and no free intraperitoneal gas. Which of the following is the most appropriate next step in the care of this patient?

  1. Prompt open surgical exploration of the abdomenCevap
  2. B
    Placement of a nasogastric tube and serial clinical reassessments
  3. C
    Computed axial tomography imaging of the abdomen with intravenous contrast
  4. D
    Initiation of broad-spectrum intravenous antimicrobials and admission to the intensive care unit
  5. E
    Diagnostic laparoscopy to evaluate for possible pelvic pathology

Cevap

Prompt open surgical exploration of the abdomen
The patient presents with a classic clinical picture of a complicated small bowel obstruction (SBO) with impending or actual bowel strangulation. The transition from colicky to constant severe pain, accompanied by fever, hemodynamic instability (hypotension, tachycardia), peritonitis (abdominal rigidity, rebound tenderness), marked leukocytosis, and lactic acidosis all point toward bowel ischemia and necrosis. In the setting of an acute surgical abdomen with hemodynamic instability and generalized peritonitis, the standard of care is immediate fluid resuscitation combined with prompt open surgical exploration (laparotomy). Delaying surgery for further diagnostic imaging or attempting purely conservative measures will increase mortality.

Adım Adım Çözüm

1
Identify the primary diagnosis based on the clinical presentation and radiographic findings.
The patient has a small bowel obstruction (SBO), likely secondary to adhesions from her prior appendectomy.
Bilious vomiting, distention, and air-fluid levels on radiography are classic signs of SBO.
2
Assess the patient for signs of complications such as bowel strangulation or ischemia.
The patient has 'red flag' findings: transition to constant pain, fever, hemodynamic instability (hypotension, tachycardia), peritonitis (rigidity, rebound), leukocytosis, and lactic acidosis.
These findings indicate that the obstruction is no longer simple and bowel necrosis is actively occurring.
3
Determine the definitive management for a complicated, unstable SBO.
Immediate open exploratory laparotomy is required.
When signs of strangulation or generalized peritonitis are present, delaying for conservative management or further imaging significantly increases mortality.

Anahtar Kavram

Patients with a small bowel obstruction who develop signs of strangulation, ischemia (lactic acidosis, continuous pain), generalized peritonitis, or hemodynamic instability require immediate surgical exploration.
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Gastrointestinal and Abdominal Surgery

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