Soru

An 82-year-old woman is brought to the emergency department from a skilled nursing facility due to a 3-day history of worsening, colicky abdominal pain and intractable vomiting. The nursing staff notes that she has not had a bowel movement or passed flatus for 48 hours. Her medical history is significant for type 2 diabetes mellitus, hypertension, severe chronic obstructive pulmonary disease, and recurrent episodes of right upper quadrant abdominal pain that she has managed conservatively for several years. Her temperature is 37.9°C (100.2°F), pulse is 112/min, blood pressure is 108/64 mm Hg, and respirations are 20/min. Physical examination reveals dry mucous membranes and decreased skin turgor. The abdomen is markedly distended and tympanitic. Auscultation demonstrates high-pitched, tinkling bowel sounds. There is mild, diffuse abdominal tenderness without rebound guarding or rigidity. Laboratory studies show a leukocyte count of 14,200/mm³, blood urea nitrogen of 42 mg/dL, and serum creatinine of 1.6 mg/dL. An upright plain radiograph of the abdomen reveals dilated loops of small bowel with multiple air-fluid levels and branching radiolucencies overlying the central hepatic shadow. Which of the following is the most appropriate definitive management for this patient?