Gastrointestinal and Abdominal Surgery

A 48-year-old woman comes to the emergency department due to a 24-hour history of severe, colicky abdominal pain, nausea, and bilious vomiting. She has not passed flatus or stool since the pain began. Her medical history is notable for a laparoscopic appendectomy 10 years ago. She takes no daily medications. Her temperature is 37.3°C (99.1°F), blood pressure is 114/76 mm Hg, pulse is 106/min, and respirations are 18/min. Physical examination reveals an asymmetrically distended abdomen. It is highly tympanitic to percussion and moderately tender diffusely, but there is no guarding or rebound tenderness. Bowel sounds are high-pitched and hyperactive. A plain radiograph of the abdomen demonstrates a markedly dilated, comma-shaped loop of bowel originating in the right lower quadrant and projecting toward the left upper quadrant. There is a single air-fluid level within the loop and a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

Match each post-bariatric surgery clinical presentation with its most appropriate diagnostic or therapeutic next step.

A 48-year-old male is evaluated in the emergency department after experiencing an abrupt onset of agonizing, diffuse abdominal pain that started two hours ago. He reports that the discomfort is continuous and severely worsens with any physical movement. His medical history is significant for chronic osteoarthritis, which is managed with high-dose daily naproxen, and he is a current tobacco user. He recently noted a gnawing upper abdominal ache that would temporarily improve after meals. Currently, he is lying motionless on the examination table and taking shallow breaths. Vital signs indicate a temperature of 37.9°C (100.2°F), a pulse of 118/min, and a blood pressure of 105/65 mm Hg. Abdominal assessment is notable for board-like rigidity, generalized rebound tenderness, and absent bowel sounds. An upright chest radiograph reveals a distinct crescent of free air below the right hemidiaphragm. Following initial fluid resuscitation, which of the following is the most appropriate next step in management?

A 45-year-old man comes to the emergency department due to intermittent, crampy abdominal pain and nausea for the past 24 hours. He has vomited twice and has not passed flatus since yesterday. His surgical history is significant for an open appendectomy for a perforated appendix 10 years ago.

Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse of $88/\text{min}$, respirations of $14/\text{min}$, and blood pressure of $130/82\text{ mm Hg}$. The abdomen is moderately distended and tympanitic to percussion. High-pitched, hyperactive bowel sounds are auscultated. There is mild, diffuse abdominal tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness is present.

Laboratory studies show a leukocyte count of $8,200/\text{mm}^3$ and a normal basic metabolic panel. A CT scan of the abdomen and pelvis with intravenous contrast reveals dilated loops of small bowel up to $4\text{ cm}$ in diameter, a transition point in the distal ileum, and a collapsed colon. The bowel wall enhances normally, and there is no evidence of pneumatosis intestinalis, free intraperitoneal air, or free fluid.

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

Match each patient's clinical presentation with the most appropriate procedural or operative intervention.

Match each patient's clinical presentation with the most appropriate next step in diagnosis or surgical management. Assume initial standard resuscitation (e.g., intravenous access, basic labs) has been initiated for all patients.

Match the following classic patterns of abdominal pain to the most likely acute intra-abdominal diagnosis.

A 58-year-old female patient is evaluated in the emergency room due to a $2$-day history of severe right upper quadrant abdominal pain, shaking chills, and progressively worsening yellowing of her skin. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $98/60$ mm Hg, pulse is $112$/min, and respirations are $20$/min. Physical examination reveals marked scleral icterus and significant right upper quadrant tenderness, but no rebound or guarding.

Laboratory studies show:
Leukocyte count: $18,500/\text{mm}^3$
Total bilirubin: $6.4 \text{ mg/dL}$
Alkaline phosphatase: $480 \text{ U/L}$
Aspartate aminotransferase (AST): $150 \text{ U/L}$
Alanine aminotransferase (ALT): $165 \text{ U/L}$
Amylase: $85 \text{ U/L}$

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient's condition.

A healthy 41-year-old female arrives at the surgical assessment unit complaining of steady pain under her right rib cage that began shortly after eating a heavy meal. Examination reveals localized tenderness and inspiratory arrest upon deep palpation in the right upper quadrant. Her temperature is 38.2°C (100.8°F) and vital signs are otherwise stable. Arrange the following interventions in the most appropriate chronological sequence for her standard evaluation and definitive care.

A 52-year-old male patient is transported to the emergency department by ambulance following the sudden onset of unrelenting abdominal pain 6 hours ago. He has had multiple episodes of bilious vomiting and is now unable to tolerate oral intake. His medical history is significant for a laparoscopic Roux-en-Y gastric bypass performed 4 years ago, which was complicated by a marginal ulcer that was successfully treated with proton pump inhibitors. His temperature is 38.6°C (101.5°F), pulse is 128/min, respirations are 24/min, and blood pressure is 82/50 mm Hg. Physical examination reveals an ill-appearing, diaphoretic man lying completely still on the stretcher. His abdomen is distended, rigid, and exhibits diffuse rebound tenderness and guarding. Bowel sounds are absent. Intravenous fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 62-year-old woman is evaluated during morning rounds on the surgical ward. She was admitted 48 hours ago for management of a small bowel obstruction secondary to adhesions from a prior total abdominal hysterectomy. Initial management included bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression. Over the last few hours, she reports that her previously intermittent, crampy abdominal pain has become unremitting, constant, and more severe. She has not had any bowel movements or passed flatus since admission. Her temperature is 38.3°C (100.9°F), blood pressure is 112/74 mmHg, pulse is 116/min, and respirations are 20/min. Physical examination reveals a distended abdomen with hypoactive bowel sounds. There is focal, severe tenderness with involuntary muscle spasm in the periumbilical region. Laboratory studies show a leukocyte count of 15,400/mm³ and a serum bicarbonate level of 16 mEq/L. Which of the following is the most appropriate next step in management?

A $58$-year-old man presents to the emergency department with a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and decreased appetite. He has no prior history of similar episodes. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, and pulse is $98\text{/min}$. Physical examination demonstrates marked focal tenderness and voluntary guarding in the left lower quadrant, but no generalized rigidity. Laboratory evaluation reveals a leukocyte count of $16,500\text{/mm}^3$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated.

Assume the patient's clinical course progresses appropriately through standard management. Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and long-term management of this patient.

Match each classic radiographic finding with its most likely surgical gastrointestinal diagnosis.

A $54$-year-old woman is brought to the emergency department due to severe, generalized abdominal pain and persistent bilious vomiting for the past $12$ hours. She has not passed flatus or stool since yesterday. Her surgical history is significant for a total abdominal hysterectomy $5$ years ago. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, and pulse is $122/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse guarding, severe rebound tenderness, and absent bowel sounds. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate of $5.1\text{ mmol/L}$. An upright abdominal radiograph shows multiple dilated loops of small bowel with air-fluid levels and no free air under the diaphragm. Which of the following is the most appropriate next step in management?

An ambulance brings a 60-year-old female to the emergency department due to severe, unrelenting abdominal pain and repeated bilious vomiting that started 24 hours ago. Her past medical history is notable for an open appendectomy performed 15 years prior. She reports that the pain was initially colicky, but over the last 3 hours, it has become constant and generalized. Her temperature is 38.7°C (101.7°F), pulse is 125/min, respirations are 22/min, and blood pressure is 85/50 mm Hg. Physical evaluation reveals a distended and rigid abdomen with marked diffuse tenderness, involuntary guarding, and rebound tenderness. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of 19,500/mm³ and a serum lactate of 5.1 mmol/L. A plain upright abdominal radiograph displays multiple distended small bowel loops with air-fluid levels and no free intraperitoneal gas. Which of the following is the most appropriate next step in the care of this patient?

A 45-year-old individual is evaluated in the emergency department for severe, progressive abdominal pain and persistent vomiting of greenish fluid over the past 24 hours. The patient reports an inability to pass flatus since the symptoms began. Past medical history is notable for a Roux-en-Y gastric bypass performed three years ago for severe obesity. Vital signs are temperature $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure $88/58\text{ mmHg}$, heart rate $122\text{ /min}$, and respiratory rate $22\text{ /min}$. The patient appears acutely ill and diaphoretic. Abdominal examination reveals significant distension, diffuse tenderness to palpation, and involuntary guarding. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of $19,000/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Upright abdominal radiography shows multiple dilated loops of small bowel with prominent air-fluid levels and no gas in the rectum. Which of the following is the most appropriate next step in management?

For each of the following acute gastrointestinal scenarios evaluated in the emergency department, identify the most appropriate next step in diagnosis or management.

An inpatient surgical consult is requested for a 62-year-old male on the medical ward who was admitted two days ago for a small bowel obstruction. He has a history of an open appendectomy in childhood. Initially, his symptoms improved with bowel rest and nasogastric decompression. Over the past 4 hours, however, his clinical status has rapidly declined. Current vital signs show a temperature of 38.6°C (101.5°F), heart rate of 118/min, and blood pressure of 98/60 mm Hg. Physical examination reveals a distended abdomen with marked tenderness, guarding, and rebound in the right lower quadrant. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ and a serum lactate of 4.2 mmol/L. Intravenous fluid resuscitation is immediately initiated. Which of the following is the most appropriate next step in management?

Evaluate the following patients presenting to the emergency department with severe abdominal symptoms. Match each patient's clinical presentation with the most appropriate initial operative or non-operative management strategy.

Emergency medical services bring a 72-year-old female resident of a skilled nursing facility to the acute care clinic due to progressive abdominal swelling, intractable vomiting, and profound weakness over the past day. Her past medical history includes an open total abdominal hysterectomy five years ago. On initial assessment, her temperature is 39.1°C (102.4°F), pulse is 128/min, respirations are 26/min, and blood pressure is 78/45 mm Hg. The patient is poorly responsive. The abdominal examination demonstrates severe distension, generalized rigidity, and diffuse rebound tenderness with absent bowel sounds. Initial laboratory analysis shows a white blood cell count of 22,000/mm³ and a serum lactate concentration of 6.2 mmol/L. Which of the following is the most appropriate next step in management?