What is the appropriate investigation for a 65-year-old male patient with a history of right hemicolectomy (surgical removal of the right side of the colon) for cecal (part of the large intestine) cancer, presenting with abdominal pain, vomiting, and abdominal distension one year post-operatively?

From the Guidelines

The most appropriate investigation for this patient is option A: Small bowel series, as it can help visualize the site and cause of obstruction, given the patient's history of previous abdominal surgery and current symptoms of obstruction. This patient's presentation suggests a possible small bowel obstruction, which is a common complication following abdominal surgery due to adhesions 1. The symptoms of abdominal pain, vomiting, and abdominal distension are consistent with a small bowel obstruction, and the soft, lax abdomen suggests that the obstruction may be partial rather than complete. Given the patient's history and symptoms, a small bowel series would be the most appropriate initial investigation, as it can help identify areas of narrowing, blockage, or abnormal motility in the small intestine 1. The use of contrast material in a small bowel series can outline the small intestine and provide valuable information about the site and cause of obstruction. In contrast, a barium enema would be less useful, as the symptoms point to small bowel rather than colonic pathology 1. Colonoscopy is not indicated in acute obstruction and could be dangerous, while laparotomy is too invasive as a first-line investigation when non-invasive imaging can provide diagnostic information to guide management 1. Therefore, a small bowel series is the most appropriate initial investigation for this patient, as it can provide valuable information about the site and cause of obstruction, and guide further management. Some key points to consider in this patient's management include:

• The patient's history of previous abdominal surgery, which increases the risk of adhesions and small bowel obstruction
• The symptoms of abdominal pain, vomiting, and abdominal distension, which are consistent with a small bowel obstruction
• The soft, lax abdomen, which suggests that the obstruction may be partial rather than complete
• The need for non-invasive imaging to guide management and avoid unnecessary invasive procedures.

From the Research

Appropriate Investigation for Small Bowel Obstruction

The patient's symptoms of abdominal pain, vomiting, and distended abdomen suggest a possible small bowel obstruction. The appropriate investigation for this condition is:

• Computed Tomography (CT) scan, as it is a powerful tool for assessing patients with small bowel obstruction 2, 3
• CT can provide important information about the cause and site of obstruction, as well as the presence of a closed-loop obstruction or ischemia 2
• CT is considered the preeminent imaging modality for evaluating patients with suspected high-grade small-bowel obstruction 4

Alternative Investigations

Other investigations, such as:

• Barium enema, may play a less significant role in the diagnosis of acute small-bowel obstruction 4
• Small bowel series, may be used in certain cases, but CT is generally preferred 5, 4
• Colonoscopy, is not typically used for diagnosing small bowel obstruction
• Laparotomy, may be necessary in some cases, but it is not typically the first line of investigation

Imaging Findings

Imaging findings, such as:

• Normal to rapid transit time to the point of obstruction
• Homogenous dilution of barium in dilated proximal loops
• Inhomogenous, scattered, and fragmented collections of barium in the distal, collapsed loops, can be indicative of small bowel obstruction 5