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Discussion Starter · #1 ·
A 40-year-old man with a recent history of exploratory laparotomy for a stabbing injury presents to the emergency department with diffuse cramping abdominal pain for 1 day, accompanied by nausea, multiple episodes of brown colored vomitus, and lack of stool, but he reports some flatulence. He denies any fever. On physical examination, the patient has stable vital signs, and there is diffuse distention in the abdomen with guarding and tenderness but no rebound, as well as high-pitched bowel sounds.
Rectal examination reveals no fecal impaction in the rectal vault, and the stool was guaiac negative.
Complete blood cell count reveals no significant abnormalities and serum chemistry shows a mild metabolic alkalosis. CT demonstrates a noticeable difference in the diameter of proximal and distal small bowel. Which of the following is the most appropriate management?

a) Colonoscopy
b) Exploratory laparotomy with lysis of adhesions
c) Give the patient nothing by mouth, insert a nasogastric tube, and perform intravenous correction of electrolyte abnormalities
d) serial abdominal examination
 

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Questiofs that i hate :scared:

Usmle tought me to refrain from surgery

Give the patient nothing by mouth, insert
a nasogastric tube, and perform intravenous
correction of electrolyte

And i know im wrong :D
 

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d)serial abdominal examination

yeah that is the type of question where u have to answer WTF am i supposed to answer
 

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I personally would go with B to lyse the adhesion.
High pitched BS s/p Ex Lap and the xray finding point to obstruction. If it's ileus, you can probably do serial abd film, but obstruction with some sort of peritoneal sign makes me want to go with surgery...
Anyone else?? What's the answer anyway?
 

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I personally would go with B to lyse the adhesion.
High pitched BS s/p Ex Lap and the xray finding point to obstruction. If it's ileus, you can probably do serial abd film, but obstruction with some sort of peritoneal sign makes me want to go with surgery...
Anyone else?? What's the answer anyway?
I thought of the same option.
 

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I personally would go with B to lyse the adhesion.
High pitched BS s/p Ex Lap and the xray finding point to obstruction. If it's ileus, you can probably do serial abd film, but obstruction with some sort of peritoneal sign makes me want to go with surgery...
Anyone else?? What's the answer anyway?
Just couple of points in q why i don't think surgery: "reports some flatulence", no rebound, guy has vomited a lot dehydrated, npo and iv could be simply initial action before surgery. Anyway if you have correct answer dont torture us
 

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Just couple of points in q why i don't think surgery: "reports some flatulence", no rebound, guy has vomited a lot dehydrated, npo and iv could be simply initial action before surgery. Anyway if you have correct answer dont torture us
Now I would agree with you if the question asked for "what is the most appropriate next step?" You would probably want to stablize the pt before sending him to OR...
But the question asked "what is the most appropriate management?" I doubt NPO would do anything to obstruction. Faltulence simply means the pt does not have "complete" obstruction. High pitched BS + change in Caliber of small bowel still points to obstruction...
Just my $0.02
Keep on the good discussion!!
 

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High pitched bowel sounds, diffuse distention of abd, lack of stool, H/o recent exploratory laparotomy could be bowel obstruction. They are asking "most appropriate" and not "next appropriate management", so is it b) as most common cause of bowel obstruction is adhesions. It could be wrong, whats the answer?
 

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This is subacute intestinal obstruction (passing flatus) . Its managed by npo, ng decompression and iv fluid and electrolyte correction. But this is CK so yeah if you have the correct answer do let us know:D
 

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i guess recent laparatomy indicates insufficient time for adhesion formation (but it should be included in DDx)
and before proceeding to laparatomy and lysis of adhesions there must be some convincing evidence
can u plz post the whole explanation for this Question
 

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Discussion Starter · #15 ·
the answer is c..
but while i was doing the q i went with surgery for the lysis of adhesions..cz the symptoms provided are directly pointing to small bowel obstruction and how can bowel rest and fluids cure his adhesions..
this was in the explanation..
Patients with partial
small bowel obstruction may complain of
crampy abdominal pain, with or without passage
of feces or flatus. Those with malignancies,
hernias, or previous intra-abdominal surgeries
may be prone to bowel obstructions.
Presentation may include fever, tachycardia,
hypotension, dry mucous membranes, high
pitched or hypoactive bowel sounds, and abdominal
tenderness or distention.
For a partial
small bowel obstruction, supportive care may
be enough under close supervision. Nasogastric
suction should be used for decompression,
and the patient should be maintained on nothing
by mouth with intravenous hydration and
correction of electrolyte abnormalities.
 

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Discussion Starter · #16 ·
for surgery this was the explanation
Complete small bowel
obstruction will present with vomiting and
crampy abdominal pain with or without passage
of feces or flatus, since 12–24 hours are
usually required before the colon has become
vacant.
Surgery is appropriate for complete
small bowel obstruction, small bowel obstruction
with vascular compromise such as necrotic
bowel, or symptoms lasting at least 3 days without
resolution
 

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Discussion Starter · #17 ·
so acc to the explanation..passage of flatus can be a feature of both complete as well as partial bowel obstruction so how do u diffrentiate between the two?:eek:
 

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lol where is the question from?
Yeah source seems not familiar, not a good question at all, but usually when they give you couple of unneeded clues, that its obstuction but with some flatulence, abdomen tender but not rebound.. This is cause they point toward incomplete obstruction, although caliber is different and obstruction is obvious.. As i remember this is only 24 hrs also. Whatever .. Ihave seen lot of adult and pediatric even reboundly tender acute abdomens with obstruction resolving with npo, iv fluids. Postoperative adhesions especially.
Wheh a week ago operated patient for any cause comes back to you you never start with knife ;)
 
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