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Zorluk: OrtaGastroenterology and Hepatology

A 67-year-old woman is brought to the emergency department complaining of severe, unremitting abdominal pain and vomiting for the past 8 hours. Her medical history is notable for a total abdominal hysterectomy performed 10 years ago. She describes the pain as initially colicky but now constant and diffusely located across the lower abdomen. Her temperature is 39.1°C (102.4°F), blood pressure is 92/58 mm Hg, and pulse is 114/min. On physical examination, the abdomen is markedly distended and tympanic. There is severe, diffuse tenderness to palpation with involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies reveal a leukocyte count of 19,500/mm³. An upright abdominal radiograph demonstrates multiple dilated small bowel loops with air-fluid levels and a paucity of gas in the colon.

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

  1. A
    Insertion of a gastric decompression tube and intravenous fluid resuscitation
  2. B
    Computed tomography scan of the abdomen and pelvis with intravenous contrast
  3. Urgent surgical explorationCevap
  4. D
    Collection of blood and urine cultures followed by antipyretic administration
  5. E
    Initiation of intravenous broad-spectrum antibiotics and medical observation

Cevap

Urgent surgical exploration is required due to signs of peritonitis and bowel ischemia.
The correct answer is urgent surgical exploration. This patient presents with a small bowel obstruction (SBO) complicated by clinical signs of strangulation (ischemia). Hallmarks of complicated SBO include fever, tachycardia, marked leukocytosis, and peritoneal signs (involuntary guarding, rebound tenderness). While uncomplicated SBO is initially managed conservatively with bowel rest and gastric decompression, the development of peritonitis or hemodynamic instability mandates immediate operative intervention to prevent or resect necrotic bowel. Delaying surgery for further diagnostic imaging or medical management significantly increases mortality.

Adım Adım Çözüm

1
Analyze the patient's history and presenting symptoms.
The patient has a history of abdominal surgery (hysterectomy), which is a major risk factor for adhesions. She presents with symptoms of obstruction (vomiting, colicky pain progressing to constant pain).
Prior abdominal surgeries are the most common cause of small bowel obstruction.
2
Evaluate vital signs and physical examination findings.
Fever, tachycardia, borderline hypotension, absent bowel sounds, and peritoneal signs (guarding, rebound tenderness) are present.
These findings differentiate a simple obstruction from a complicated one, indicating severe inflammation, ischemia, or perforation (strangulation).
3
Determine the appropriate management based on the clinical presentation.
Immediate surgical intervention is indicated.
While uncomplicated small bowel obstructions can be managed conservatively with decompression and fluids, the presence of peritonitis and systemic toxicity (strangulation) is a surgical emergency.

Anahtar Kavram

Complicated Small Bowel Obstruction (Strangulation)
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Konular

Gastroenterology and Hepatology

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