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Therapy with levofloxacin and metronidazole
0%
0/10
Immediate laparotomy and surgical management
60%
6/10
Continue IV fluid hydration, nasogastric suction, NPO
30%
3/10
Pneumatic enema
10%
1/10
Sigmoidoscopy, attempted derotation and rectal tube placement
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This patient with an extensive surgical history presents with a small bowel obstruction and likely small bowel ischemia. After worsening on conservative therapy, immediate surgical management is required, with laparotomy being the approach of choice. Small bowel obstructions account for around 15% of all surgical admissions in the United States. Adhesive disease, typically secondary to previous surgery, accounts for around 75% of all small bowel obstructions, with malignancy and hernias accounting for another 16% combined. Conservative management with nasogastric suction, IV fluid hydration, and bowel rest is an appropriate first strategy for patients who present without evidence of peritonitis and who are hemodynamically stable. Patients who fail conservative management or who present with more advanced disease require immediate surgical management. Jackson et al. discuss the diagnosis and management of intestinal obstructions in adults. They conclude that in the hemodynamically stable patient, IV fluid hydration, nasogastric intestinal decompression, and bowel rest is an appropriate first strategy to attempt to resolve the obstruction. However, hemodynamically unstable patients, patients with perforations or ischemic gut, and patients who fail conservative management require surgical intervention. O'Connor et al. discuss the growing role of laparoscopic surgical approaches for acute small bowel obstruction. They conclude that with the limited literature available, laparoscopic lysis of adhesions is an appropriate approach for the treatment of adhesive small bowel disease. In this study, ~30% of laparoscopic approaches were converted to midline laparotomies. Laparoscopy was associated with reduced morbidity and length of hospital stay. Further studies that randomize patients to open vs. laparoscopic surgical approaches are required to further elucidate the outcomes of these two approaches. Figure A shows a partially upright abdominal radiograph with dilated loops of small bowel and air fluid levels, consistent with a small bowel obstruction. Figure B shows an axial reconstruction of an abdominal CT scan, showing dilated loops of small bowel. Red arrow is pointing at an air fluid level. Illustration A shows an abdominal radiograph with significantly dilated sigmoid colon, with a characteristic coffee bean sign highly suggestive of sigmoid volvulus and obstruction. Incorrect Answers Answer 1: Broad spectrum antibiotics is not an appropriate strategy for management of small bowel obstruction. Answer 3: Continuing conservative management with IV fluid hydration, NG suction, and NPO is appropriate in hemodynamically stable patients, but this patient presents with worsening shock. Answer 4: Pneumatic enema is the procedure of choice for patients with intussusception, as it is both diagnostic and therapeutic. It has no role in the management of adhesive small bowel obstructions. Answer 5: Sigmoidoscopy with attempted derotation is a reasonable approach to patients presenting with sigmoid volvulus. These patients can present similarly to those with a small bowl obstruction; however, this patient's radiograph is suggested of a small bowel source. See Illustration A
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