A 38-year-old woman comes to the physician with the complaint of severe abdominal pain for 8 hours. The pain is crampy and periumbilical and occurs every 4 to 5 minutes. It is not improved with positional changes, and there is no radiation to the back. She has vomited 3 times since the pain began. Her last bowel movement was 18 hours ago. She denies any reflux symptoms, hematemesis, melena, or hematochezia. The patient's medical problems include depression, fibromyalgia, and hypothyroidism. Her surgical history includes appendectomy for a ruptured appendix 20 years ago, tonsillectomy, and breast lumpectomy. She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 37.3 C (99.1 F), blood pressure is 110/80 mm Hg, pulse is 92/min, and respirations are 16/min. The abdomen is tender in the periumbilical area. There is no significant abdominal distension, rebound tenderness, or rigidity. Rectal examination shows an empty rectal vault, and test for occult blood is negative.
Laboratory results are as follows:
Urine pregnancy test is negative.
Which of the following is the most appropriate next step in this patient's management?

Question

A 38-year-old woman comes to the physician with the complaint of severe abdominal pain for 8 hours.  The pain is crampy and periumbilical and occurs every 4 to 5 minutes.  It is not improved with positional changes, and there is no radiation to the back.  She has vomited 3 times since the pain began.  Her last bowel movement was 18 hours ago.  She denies any reflux symptoms, hematemesis, melena, or hematochezia.  The patient's medical problems include depression, fibromyalgia, and hypothyroidism.  Her surgical history includes appendectomy for a ruptured appendix 20 years ago, tonsillectomy, and breast lumpectomy.  She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 37.3 C (99.1 F), blood pressure is 110/80 mm Hg, pulse is 92/min, and respirations are 16/min.  The abdomen is tender in the periumbilical area.  There is no significant abdominal distension, rebound tenderness, or rigidity.  Rectal examination shows an empty rectal vault, and test for occult blood is negative.
Laboratory results are as follows:
 Urine pregnancy test is negative.
Which of the following is the most appropriate next step in this patient's management?

Quizplus · Accepted Answer

This patient presents with crampy periumbilical abdominal pain associated with vomiting. There is no radiation of the pain to the back. The likely diagnosis given the history of abdominal surgery is proximal small-bowel obstruction (SBO). Patients with proximal obstruction present with vomiting and less abdominal distention. Obstipation and inability to pass flatus are characteristic for complete bowel obstruction; however, patients may not complain of these as emptying of the colon requires 12-24 hours after the onset of obstruction. This patient's lipase is only mildly elevated. Common non-pancreatic causes of lipase elevation include renal insufficiency, diabetic ketoacidosis, and intestinal obstruction or ileus. Conversion of crampy into persistent pain and presence of fever, lactic acidosis, and worsening leukocytosis indicate likely severe obstruction leading to strangulation with necrosis. Plain upright chest x-ray and upright and supine abdominal films are preferred to diagnose SBO, and most patients do not need further imaging. Abdominal films usually show multiple air-fluid levels with distended small-bowel loops. Air seen in the colorectal area usually rules out complete obstruction. Abdominal CT with oral and IV contrast is the preferred next step if plain films are not diagnostic of SBO (Choice A). Small-bowel series are inferior to CT scan in detecting SBO etiology, ischemia, or closed-loop obstructions. As a result, a small-bowel series is done only if CT is nondiagnostic (Choice E). Nonoperative SBO management includes NPO, fluid resuscitation, electrolyte repletion, serial abdominal examinations, and strict monitoring of urine and NG output (Choice B). Decreased abdominal distension, passage of flatus and/or stool, and decreased NG tube output indicate likely SBO resolution. Water-soluble (Gastrografin) contrast study used with CT scan can assess for strangulation and be used for therapy. Gastrografin is hypertonic and draws water into the intestinal lumen to decrease wall edema, stimulate intestinal peristalsis, and lead to improved bowel function with faster symptom resolution. The presence of contrast in the colon 4-24 hours after administration is a good predictor of SBO resolution; its absence may indicate the need for surgery. About 25% of SBO patients require surgery for worsening clinical symptoms, complete obstruction, strangulation, or necrosis. (Choice C) Pain management consult would not be appropriate without further workup given the laboratory abnormalities. Educational objective: Patients with proximal small-bowel obstruction present with vomiting and less abdominal distention. Common non-pancreatic causes of lipase elevation include renal insufficiency, diabetic ketoacidosis, and intestinal obstruction or ileus. __________ References: Bowel obstruction and hernia. (http://www.ncbi.nlm.nih.gov/pubmed/21515182)

A 38-Year-Old Woman Comes to the Physician with the Complaint