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Zorluk: ZorGastrointestinal and Abdominal Surgery

An 8282-year-old male is evaluated in the surgical ward on postoperative day 88 following an open sigmoid colectomy for recurrent diverticulitis. Over the past 2424 hours, he has developed worsening, severe abdominal pain and multiple episodes of bilious emesis. He has not passed flatus or stool for two days. His temperature is 38.8∘C38.8^\circ\text{C} (101.8∘F101.8^\circ\text{F}), blood pressure is 82/50 mm Hg82/50\text{ mm Hg}, pulse is 132/min132/\text{min}, and respiratory rate is 26/min26/\text{min}. The patient is lethargic and diaphoretic. Abdominal examination reveals a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. The surgical incision is clean with no surrounding erythema or purulent drainage.

Laboratory studies show:
Leukocyte count: 24,000/mm324,000/\text{mm}^3
Serum lactate: 6.2 mmol/L6.2\text{ mmol/L}
Bicarbonate: 12 mEq/L12\text{ mEq/L}

Arterial blood gas (room air):
pH: 7.217.21
pCO 2_2: 29 mm Hg29\text{ mm Hg}
pO 2_2: 80 mm Hg80\text{ mm Hg}

Supine and upright abdominal radiographs display multiple dilated loops of small bowel with air-fluid levels and an absence of colonic gas. Aggressive intravenous fluid resuscitation is initiated.

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

  1. A
    Placement of a nasogastric tube and serial abdominal examinations
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. Immediate exploratory laparotomyCevap
  4. D
    Urinalysis and chest radiography
  5. E
    Administration of sodium bicarbonate and non-invasive positive pressure ventilation

Cevap

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient is presenting with classic signs of a strangulated small bowel obstruction (SBO) or a devastating anastomotic leak leading to secondary peritonitis. The hallmarks of ischemic or strangulated bowel include continuous severe pain, systemic toxicity (fever, leukocytosis), hemodynamic instability (tachycardia, hypotension), peritonitis (rigidity, rebound), and metabolic acidosis (elevated lactate). In the presence of a rigid surgical abdomen and shock, emergent surgical exploration is the definitive standard of care to perform source control and resect necrotic tissue.

Adım Adım Çözüm

1
Analyze vital signs and physical examination.
The patient is in septic shock (blood pressure 82/50 mm Hg82/50\text{ mm Hg}, pulse 132/min132/\text{min}) and has generalized peritonitis (rigid abdomen, diffuse rebound tenderness).
Identifies a hemodynamically unstable patient with an acute surgical abdomen.
2
Interpret laboratory and radiographic data.
Severe lactic acidosis (6.2 mmol/L6.2\text{ mmol/L}) and an acute abdominal series showing a small bowel obstruction.
Confirms the progression of an early postoperative bowel obstruction to bowel ischemia and strangulation.
3
Determine the definitive management.
Immediate surgical exploration is indicated.
Definitive management for a strangulated obstruction and peritonitis is source control via laparotomy; delaying for imaging or conservative measures increases mortality.

Anahtar Kavram

Surgical management of strangulated small bowel obstruction
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Konular

Gastrointestinal and Abdominal Surgery

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