From the Guidelines
The most appropriate initial investigation for this patient is a CT scan of the abdomen, but given the options provided, the best choice is not listed, however, among the options, Colonoscopy (option C) is the most suitable investigation for this 65-year-old male patient with a history of right hemicolectomy for cecal cancer who presents with abdominal pain, vomiting, and abdominal distension. This patient's presentation suggests a possible bowel obstruction, which is a common complication following colorectal cancer surgery. Given his history of colon cancer, there is concern for anastomotic stricture or cancer recurrence causing the obstruction.
Key Considerations:
- The patient's symptoms of abdominal pain, vomiting, and distension are indicative of a possible bowel obstruction, which requires prompt evaluation to prevent complications such as ischemia or perforation 1.
- The patient's history of colon cancer and previous surgery increases the risk of anastomotic stricture or recurrence, making Colonoscopy a valuable diagnostic tool to directly visualize the colon and identify any obstructive lesions 1.
- While a CT scan of the abdomen is typically the initial imaging modality of choice for suspected bowel obstruction, as it can help evaluate the severity of the obstruction, identify the etiology and site of the obstruction, and detect complications such as ischemia or perforation 1, it is not among the provided options.
- Small bowel series (option A) may not be as helpful in this case, as the primary concern is in the colon given the patient's surgical history.
- Barium enema (option B) is contraindicated in suspected obstruction, as it may worsen the condition.
- Laparotomy (option D) is too invasive as an initial diagnostic approach and should be reserved for cases where less invasive options have been tried and failed, or in cases of suspected ischemia or perforation requiring emergency surgery 1.
Diagnostic Approach:
- The diagnostic approach should prioritize identifying the cause of the obstruction and assessing for any complications.
- Colonoscopy allows for direct visualization of the colon and can be therapeutic in some cases, making it a suitable choice among the provided options.
- Laboratory tests, such as a complete blood count, renal function, and electrolytes, should also be performed to evaluate for signs of ischemia or other complications 1.
From the Research
Appropriate Investigation for Abdominal Pain and Vomiting
The patient's symptoms of abdominal pain, vomiting, and distended but soft abdomen suggest a possible small bowel obstruction. Considering the patient's history of right hemicolectomy for Caecal cancer, it is essential to investigate the cause of these symptoms.
Diagnostic Options
- Small bowel series: This investigation can help diagnose small bowel obstruction, but it may not be the most appropriate initial test 2.
- Barium enema: This test is not typically used to investigate small bowel obstruction, especially in a patient with a history of Caecal cancer 2.
- Colonoscopy: While colonoscopy can help diagnose large bowel obstruction, it may not be the best initial test for small bowel obstruction 3.
- Laparotomy: This is a surgical procedure and should only be considered if other diagnostic tests confirm the need for surgery 4.
Recommended Diagnostic Approach
Given the patient's symptoms and history, a small bowel series or computed tomography (CT) scan would be a more appropriate initial investigation 3, 5. CT scans are usually the most accurate diagnostic imaging modality for suspected bowel obstructions 3. Additionally, cross-sectional imaging and capsule endoscopy may be considered to evaluate for small intestinal strictures 6.
Initial Steps
The patient's symptoms and history suggest the need for further investigation to rule out small bowel obstruction or other complications. A systematic approach to imaging interpretation is crucial to ensure diagnostic accuracy 3, 5.