A 67-year-old male with severe chronic obstructive pulmonary disease requiring continuous … — USMLE Step 2 CK

A 67-year-old male with severe chronic obstructive pulmonary disease requiring continuous home oxygen is evaluated for acute-onset, generalized abdominal cramping and bilious emesis over the past 24 hours. His surgical history is notable for an appendectomy and a partial colectomy for diverticulitis. Vital signs are temperature $37.8^\circ\text{C}$ ( $100.0^\circ\text{F}$ ), pulse $102/\text{min}$ , respirations $22/\text{min}$ , and blood pressure $118/76 \text{ mmHg}$ . Physical examination reveals a distended abdomen with focal, severe tenderness and involuntary guarding in the right lower quadrant. Laboratory testing shows a leukocyte count of $14,500/\text{mm}^3$ and a serum lactate level of $3.4 \text{ mmol/L}$ . Cross-sectional imaging with intravenous contrast demonstrates a transition point in the distal ileum, a twisting of the mesenteric vessels, and a focal segment of small intestine exhibiting reduced wall enhancement. Which of the following is the most appropriate next step in management?

Urgent surgical exploration of the abdomenCevap
B
Continuous nasogastric decompression and serial physical examinations
C
Enteral administration of a water-soluble radiopaque contrast agent
D
Initiation of broad-spectrum antimicrobial therapy and intensive care observation
E
Endoscopic decompression of the gastrointestinal tract

Cevap

Urgent surgical exploration of the abdomen

Urgent surgical exploration is the definitive and life-saving intervention for a closed-loop small bowel obstruction with signs of strangulation. The patient's focal right lower quadrant peritonitis, elevated serum lactate, and characteristic computed tomography findings (mesenteric twist with reduced wall enhancement) strongly indicate impending or established bowel ischemia. Delaying surgery in favor of conservative measures in this clinical context leads to transmural necrosis, perforation, and catastrophic septic shock. This requirement for emergent source control supersedes the baseline perioperative risks associated with his severe chronic obstructive pulmonary disease.

Adım Adım Çözüm

Analyze the patient's presentation and surgical history.

The patient has a history of prior abdominal surgeries and presents with classic symptoms of a small bowel obstruction (cramping pain, bilious emesis).

Prior abdominal surgery is the most common risk factor for adhesive small bowel obstruction.

Evaluate for complications or indications for immediate surgery.

The patient demonstrates focal right lower quadrant guarding, an elevated serum lactate of 3.4 mmol/L, and CT findings of a mesenteric twist (whirl sign) with reduced bowel wall enhancement.

These findings collectively confirm a closed-loop obstruction complicated by early bowel ischemia and strangulation.

Determine the optimal management strategy based on the severity of the obstruction.

Despite the patient's high surgical risk due to severe COPD, the presence of ischemic bowel mandates urgent surgical exploration to resect non-viable tissue and relieve the obstruction.

Delaying surgery for conservative management in the setting of strangulation universally leads to transmural necrosis, perforation, septic shock, and death.

Anahtar Kavram

Signs of a strangulated small bowel obstruction (focal peritonitis, elevated lactate, reduced bowel wall enhancement) mandate immediate surgical exploration, regardless of the patient's baseline surgical risk.

Soru

Cevap

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