A 44-year-old-woman comes to the emergency department due to worsening abdominal pain. Two weeks ago, the patient underwent a laparoscopic hysterectomy and bilateral salpingo-oophorectomy for adenomyosis. Her postoperative course was unremarkable, and the patient went home the day after the procedure. She was eating normally until 2 days ago, when she began experiencing increasing nausea and abdominal cramping after meals. Now, the patient has abdominal cramping every few minutes and has vomited her pain medication. Her last bowel movement was 3 days ago, and she has not passed flatus today. Vital signs are within normal limits. BMI is 34 kg/m². The abdomen is distended and tympanic on percussion. There is abdominal tenderness to palpation, but no rebound or guarding. The skin is intact over all the abdominal incisions, but the right-sided incision has an underlying tender, palpable mass. Bowel sounds are hyperactive. Abdominal x-ray reveals multiple air-fluid levels within the small bowel and no air in the rectum. A nasogastric tube is placed. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

11ec25c8_d8d2_e7a7_bc81_0764bf67ea18_MD0003_00 This patient with abdominal pain, vomiting, and obstipation (ie, no bowel movements or flatus) likely has a small bowel obstruction (SBO). In the setting of recent surgery and a tender, palpable mass at the level of the incision, her obstruction is likely caused by an incisional hernia. Incisional hernias can develop at the site of any abdominal incision and reflect a breakdown in fascial closure. Obesity appears to be an important risk factor. Although most cases present as an asymptomatic abdominal mass, obstruction can occur, particularly with smaller hernias, because bowel can remain trapped within the small fascial defect. SBO typically causes vomiting and abdominal distension due to backup of gastric secretions and intestinal gas. Colicky pain after meals is also common due to unproductive bowel peristalsis against the obstruction, with hyperactive bowel sounds in the early stages. SBO treatment depends on disease severity. Partial SBO, in which the bowel lumen is narrowed but not completely obstructed, typically improves with conservative management (ie, bowel rest, nasogastric tube insertion for bowel decompression, serial abdominal examinations). In contrast, those with a complete SBO (no flatus, no air in the rectum on x-ray), such as this patient, are at increased risk of life-threatening complications (eg, bowel ischemia, perforation) that will not resolve with conservative management (Choice C). Therefore, in addition to nasogastric tube insertion for gastric decompression, these patients require emergency laparotomy to relieve the obstruction and resolve any underlying etiology (eg, incisional hernia, intraabdominal adhesions). (Choices A and F) Further imaging studies (eg, abdominal ultrasound, small bowel follow-through) are not needed in patients with complete SBO diagnosed on abdominal x-ray (eg, no rectal gas). This patient requires emergency surgery; additional testing delays treatment and increases the risk of complications. (Choices B and D) Barium enemas and digital fecal disimpaction are used to treat constipation, a large bowel disorder that appears on abdominal x-ray as impacted stool in the rectum. Neither intervention affects the small bowel. Educational objective: Patients with a complete small bowel obstruction (eg, obstipation, no air in the rectum on abdominal x-ray) require nasogastric tube insertion for gastric decompression plus emergency laparotomy due to the high risk of life-threatening complications (eg, bowel ischemia, perforation). References: Emergency medicine evaluation and management of small bowel obstruction: evidence-based recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/30527563) Adhesion-related small bowel obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/17824969) A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/28439845)

A 44-Year-Old-Woman Comes to the Emergency Department Due to Worsening