Examkin

Soru

Zorluk: KolayGastrointestinal and Abdominal Surgery

A 48-year-old woman is admitted to the medical ward for the management of a partial small bowel obstruction. She initially presented with diffuse, colicky abdominal pain and bilious vomiting. Her surgical history is notable for a total abdominal hysterectomy 5 years ago. Upon admission, she was hemodynamically stable and managed with intravenous fluid resuscitation and nasogastric tube decompression.

Fourteen hours later, the nursing staff requests an urgent physician evaluation because the patient reports a sudden, drastic worsening of her abdominal pain, which has become severe and unremitting.

Vital signs are now:
Temperature: 38.8°C (101.8°F)
Pulse: 124/min
Blood pressure: 86/54 mm Hg

Physical examination reveals a markedly distended abdomen that is rigidly firm. There is severe, diffuse rebound tenderness and involuntary guarding present. Laboratory testing reveals a leukocyte count of 21,000/mm³ and a serum lactate of 4.8 mmol/L.

Which of the following is the most appropriate next step in management?

  1. Emergency surgical explorationCevap
  2. B
    Continuation of current conservative therapy
  3. C
    Administration of an oral water-soluble contrast agent
  4. D
    Computed tomography scan of the abdomen and pelvis
  5. E
    Addition of broad-spectrum antibiotics and reassessment in 6 hours

Cevap

Emergency surgical exploration
The correct answer is emergency surgical exploration. This patient initially presented with an uncomplicated small bowel obstruction (SBO) and was appropriately managed with conservative therapy (bowel rest, nasogastric decompression, IV fluids). However, the subsequent development of fever, marked tachycardia, hypotension, severe unremitting pain, and definitive peritoneal signs (rigidity, rebound tenderness) indicates that the obstruction has complicated into bowel ischemia, strangulation, or perforation. The presence of an elevated lactate and significant leukocytosis further supports this critical diagnosis. In the presence of a generalized acute surgical abdomen and hemodynamic instability, conservative management has failed and must be abandoned. Immediate laparotomy is required to resect any necrotic bowel, clear abdominal contamination, and address the underlying source of the peritonitis.

Adım Adım Çözüm

1
Analyze the patient's clinical deterioration.
The patient transitioned from a stable partial small bowel obstruction to demonstrating fever, tachycardia, hypotension, and a rigid abdomen with lactic acidosis.
Tracking vital signs and abdominal exam findings differentiates uncomplicated bowel obstruction from complicated obstruction.
2
Interpret the new clinical signs.
Fever, leukocytosis, elevated lactate, and diffuse peritonitis indicate bowel ischemia, strangulation, or gross perforation.
Closed-loop obstructions or compromised vascular supply rapidly lead to transmural bowel necrosis and systemic toxicity.
3
Determine the required intervention based on the diagnosis.
Immediate surgical intervention is required.
Hemodynamic instability and a surgical acute abdomen (peritonitis) are absolute indications for emergency laparotomy; conservative management must be abandoned.

Anahtar Kavram

Indications for immediate surgical intervention in small bowel obstruction
Bu soruyu puanla

Konular

Gastrointestinal and Abdominal Surgery

Bu konudan daha fazla soru