During morning rounds in the surgical intensive care unit, a physician evaluates a 53-year… — USMLE Step 2 CK

During morning rounds in the surgical intensive care unit, a physician evaluates a $53$ -year-old man. The patient underwent an open sigmoid colectomy for complicated diverticulitis $5$ days ago. Over the past $24$ hours, he has not passed flatus or stool and has developed worsening abdominal bloating. Overnight, his clinical status declined significantly, and he now reports severe, unremitting, generalized abdominal pain. His temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), blood pressure is $82/50 \text{ mm Hg}$ , pulse is $128 \text{ beats/min}$ , and respirations are $24 \text{ breaths/min}$ . Physical examination of the abdomen demonstrates marked distension, diffuse rigidity, and involuntary guarding. A nasogastric tube placed previously is draining dark, foul-smelling material. Laboratory evaluation is significant for a leukocyte count of $19,500/\text{mm}^3$ and a serum lactate level of $6.2 \text{ mmol/L}$ . Bedside plain abdominal radiography shows multiple dilated small bowel loops with prominent air-fluid levels and no pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?

A
Computed tomography of the abdomen and pelvis with intravenous contrast
B
Intravenous administration of broad-spectrum antibiotics and serial abdominal examinations
C
Continuation of nasogastric decompression and intravenous fluid resuscitation
Preparation for an emergent laparotomyCevap
E
Collection of blood cultures, urinalysis, and portable chest radiography

Cevap

Preparation for an emergent laparotomy

The correct answer is preparation for an emergent laparotomy. This patient is presenting with a postoperative small bowel obstruction that has rapidly progressed to strangulation and ischemia. While uncomplicated small bowel obstructions and postoperative ileus are initially managed conservatively with bowel rest, nasogastric decompression, and fluid resuscitation, this patient exhibits classic signs of intestinal ischemia and systemic toxicity. These cardinal signs include high fever, severe hemodynamic instability (shock), marked leukocytosis, elevated serum lactate, and diffuse peritonitis with a rigid abdomen. In the setting of an acute, unstable surgical abdomen, immediate exploratory laparotomy is the standard of care to resect necrotic bowel, achieve source control, and prevent catastrophic septic shock.

Adım Adım Çözüm

Identify the primary clinical syndrome from the presentation.

The patient has clinical and radiographic signs of a mechanical small bowel obstruction (SBO), including obstipation, feculent nasogastric drainage, and dilated bowel loops with air-fluid levels.

Establishing the baseline diagnosis is necessary before determining if the obstruction is uncomplicated or complicated.

Assess for signs of clinical deterioration, ischemia, or strangulation.

The patient demonstrates severe hemodynamic instability (hypotension, tachycardia), high fever, marked leukocytosis, severe lactic acidosis, and diffuse peritonitis (rigidity, guarding).

These are cardinal signs of intestinal ischemia, necrosis, or perforation, distinguishing a strangulated SBO from an uncomplicated postoperative SBO or ileus.

Determine the definitive management pathway based on hemodynamic and physical findings.

Due to the presence of strangulation and hypoperfusion, conservative management is contraindicated, and immediate surgical exploration is required.

Ischemic bowel can rapidly progress to profound sepsis and death; emergent surgical source control (laparotomy) is the only appropriate life-saving intervention.

Anahtar Kavram

Patients presenting with a mechanical small bowel obstruction who develop systemic toxicity, hemodynamic instability, lactic acidosis, or peritonitis require immediate surgical exploration (laparotomy) rather than conservative management or further diagnostic imaging.

Soru

Cevap

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