A 62 year-old Caucasian man is brought to the emergency department (ED) with complaints of nausea, vomiting, crampy lower abdominal pain and distension over the past two days. His last bowel movement was four days ago. His wife tells you that he has been unable to eat anything for the past 24 hours due to repeated episodes of vomiting. His past medical history includes hypertension, hyperlipidemia, and peptic ulcer disease. His current medications include thiazide diuretics, atorvastatin, and pantoprazole. He had an appendectomy at the age of 36 years, and surgical repair of a perforated peptic ulcer 8 years ago. His temperature is 36.7C (98F), blood pressure is 124/62 mmHg, respiratory rate is 22/min and heart rate is 96/min. His mucous membranes are dry. Abdominal examination reveals a distended abdomen with increased bowel sounds, a tympanic note throughout the abdomen, and tenderness on deep palpation over the lower abdomen. The rest of the examination is unremarkable. His initial blood work reveals marked electrolyte abnormalities. An obstruction series done in the ED reveals multiple air fluid levels in the small intestine consistent with a diagnosis of small bowel obstruction. There is some air seen in the distal colon. What is the most appropriate next step in the management of this patient?

Question

A 62 year-old Caucasian man is brought to the emergency department (ED) with complaints of nausea, vomiting, crampy lower abdominal pain and distension over the past two days.  His last bowel movement was four days ago.  His wife tells you that he has been unable to eat anything for the past 24 hours due to repeated episodes of vomiting.  His past medical history includes hypertension, hyperlipidemia, and peptic ulcer disease.  His current medications include thiazide diuretics, atorvastatin, and pantoprazole.  He had an appendectomy at the age of 36 years, and surgical repair of a perforated peptic ulcer 8 years ago.  His temperature is 36.7C (98F), blood pressure is 124/62 mmHg, respiratory rate is 22/min and heart rate is 96/min.  His mucous membranes are dry.  Abdominal examination reveals a distended abdomen with increased bowel sounds, a tympanic note throughout the abdomen, and tenderness on deep palpation over the lower abdomen.  The rest of the examination is unremarkable.  His initial blood work reveals marked electrolyte abnormalities.  An obstruction series done in the ED reveals multiple air fluid levels in the small intestine consistent with a diagnosis of small bowel obstruction.  There is some air seen in the distal colon. What is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The patient in the vignette has a clinical presentation consistent with a partial small bowel obstruction. The presence of air in the distal colon makes the diagnosis of complete obstruction less likely. Partial small bowel obstruction should be initially managed with observation and supportive treatment. If the patient fails to improve in the next 12 to 24 hours, early surgical intervention is recommended. (Choices A and E) Patients with partial small bowel obstruction should be managed by conservative therapy initially before proceeding to invasive interventions; however, patients with signs of impending strangulation (incarcerated hernias) or mesenteric ischemia should undergo urgent surgical intervention to prevent further deterioration of the clinical status. (Choice B) Colonoscopy has no role in the management of patients with small bowel obstruction. (Choice D)A rectal tube is not indicated in patients with small bowel obstruction. Educational Objective: All patients with partial small bowel obstruction should be admitted and managed initially with conservative therapy (e.g., intravenous hydration, nasogastric suctioning and correction of electrolyte abnormalities).

A 62 Year-Old Caucasian Man Is Brought to the Emergency