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Zorluk: KolayGastrointestinal and Abdominal Surgery

A 58-year-old man is brought to the emergency department via ambulance due to severe, generalized abdominal pain and persistent bilious vomiting for the past 24 hours. He reports no bowel movements or passage of flatus during this time. His surgical history is significant for an open appendectomy performed 20 years ago. Current vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 88/58 mmHg, heart rate of 124/min, and respiratory rate of 22/min. Physical examination demonstrates a markedly distended abdomen. Palpation reveals diffuse rigidity, severe rebound tenderness, and involuntary guarding. Bowel sounds are absent. Laboratory testing indicates a leukocyte count of 19,000/mm³ with a left shift and a serum lactate of 4.5 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels. Which of the following is the most appropriate next step in management?

  1. Emergent exploratory laparotomyCevap
  2. B
    Placement of a nasogastric tube and intravenous fluids
  3. C
    Computed tomography scan of the abdomen with intravenous contrast
  4. D
    Intravenous broad-spectrum antibiotics and close observation
  5. E
    Diagnostic laparoscopy

Cevap

Emergent exploratory laparotomy
The correct answer is emergent exploratory laparotomy. This patient presents with classic features of a small bowel obstruction (SBO), likely secondary to adhesions from his prior appendectomy. Crucially, he demonstrates clear signs of a complicated obstruction with bowel ischemia and perforation, characterized by fever, tachycardia, hypotension, marked leukocytosis, lactic acidosis, and diffuse peritonitis (rigidity, rebound tenderness, guarding). In any patient with an SBO who develops signs of peritonitis or hemodynamic instability, the standard of care is immediate fluid resuscitation and emergent exploratory laparotomy. Delaying surgery for further imaging or attempting conservative management greatly increases the risk of mortality from ischemic necrosis and overwhelming sepsis.

Adım Adım Çözüm

1
Identify the primary diagnosis based on the clinical presentation and radiographic findings.
The patient has prior abdominal surgery, obstipation, vomiting, and dilated loops of small bowel with air-fluid levels on X-ray, diagnosing a small bowel obstruction (SBO).
Recognizing the core pathology is the first step in determining management.
2
Evaluate the patient for signs of complicated SBO (strangulation, ischemia, or perforation).
The patient has fever, hypotension, tachycardia, leukocytosis, elevated lactate, and diffuse peritonitis (rigidity, rebound tenderness).
Differentiating between uncomplicated and complicated SBO dictates whether management is conservative or surgical.
3
Select the appropriate intervention for a complicated SBO with peritonitis and hemodynamic instability.
The patient requires immediate surgical intervention (exploratory laparotomy) for source control and resection of ischemic bowel.
Delaying surgery in the presence of an acute surgical abdomen leads to bowel necrosis, severe sepsis, and high mortality.

Anahtar Kavram

Patients with a small bowel obstruction who exhibit signs of clinical deterioration, peritonitis, or bowel ischemia (fever, hemodynamic instability, severe localized pain, metabolic acidosis) require emergent exploratory laparotomy.
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Konular

Gastrointestinal and Abdominal Surgery

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