A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain. The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement. The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control. He also has hypertension, which is controlled with a thiazide diuretic. He walks 5 miles daily. The patient has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach. His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min. He lies flat and motionless on the bed. His mucous membranes are dry. Abdominal examination shows marked tenderness on superficial palpation. The patient does not allow any further palpation of the abdomen. Electrocardiogram shows sinus tachycardia. The patient was managed operatively, and he recovers well. Three years later, he comes to the emergency department with a 1-day history of nausea, vomiting, upper-abdominal pain, and distension. An abdominal radiograph reveals the presence of multiple air-fluid levels in the small intestine consistent with intestinal obstruction. Which of the following is the most likely mechanism of his intestinal obstruction?

Question

A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain.  The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement.  The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control.  He also has hypertension, which is controlled with a thiazide diuretic.  He walks 5 miles daily.  The patient has been consuming large amounts of milk and other dairy products to relieve "burning" symptoms in his stomach.  His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min.  He lies flat and motionless on the bed.  His mucous membranes are dry.  Abdominal examination shows marked tenderness on superficial palpation.  The patient does not allow any further palpation of the abdomen.  Electrocardiogram shows sinus tachycardia. The patient was managed operatively, and he recovers well.  Three years later, he comes to the emergency department with a 1-day history of nausea, vomiting, upper-abdominal pain, and distension.  An abdominal radiograph reveals the presence of multiple air-fluid levels in the small intestine consistent with intestinal obstruction.  Which of the following is the most likely mechanism of his intestinal obstruction?

Quizplus · Accepted Answer

Explanation: This patient has signs and symptoms of small bowel obstruction. Complete obstruction of the intestinal lumen leads to dilation of the stomach and proximal small intestine. This causes abdominal distension, nausea, vomiting, and intermittent abdominal pain. Postoperative adhesion formation is the most common cause of small bowel obstruction in patients with a history of prior abdominal or pelvic surgery. Some of the less common causes include hernia, neoplasm, volvulus, intussusception, and stricture formation in patients with inflammatory bowel disease (Choice D). (Choice B) Ulcer extension generally does not lead to intestinal obstruction. (Choice C) Intestinal fibrosis can occur with ulcer healing, but this is a less common cause of obstruction than adhesions. (Choice E) Ogilvie's syndrome (also known as acute colonic pseudo-obstruction) is characterized by the dilation of the cecum and right colon in the absence of a mechanical obstruction to the flow of intestinal contents. It tends to involve the right side of the colon and not the small intestine. Educational objective: Postoperative adhesions are the most common cause of small intestinal obstruction in patients with a history of abdominal surgery. References: Adult small bowel obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/23758299)

A 65-Year-Old Man Is Brought to the Emergency Department by His