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 65-year-old male patient with a history of right hemicolectomy for cecal cancer who presents with abdominal pain, vomiting, and abdominal distension is option C, Colonoscopy, as it allows for direct visualization of the colon to identify potential obstructing lesions, anastomotic strictures, or recurrent cancer. This patient's presentation suggests a possible bowel obstruction, which is a common complication following colorectal cancer surgery, as noted in the study by 1. Given his history of colon cancer, there is concern for recurrence or anastomotic stricture at the surgical site.

Key Considerations

• The patient's symptoms, including abdominal pain, vomiting, and abdominal distension, are consistent with a bowel obstruction, as described in the study by 1.
• Colonoscopy is a less invasive and more appropriate initial diagnostic approach compared to laparotomy, as it can provide direct visualization of the colon and potentially identify the cause of the obstruction, as noted in the study by 1.
• Small bowel series would be less helpful as the primary concern is colonic pathology, and barium enema is contraindicated in suspected obstruction as it may worsen the condition.
• The patient should be stabilized with IV fluids and nasogastric decompression before colonoscopy is performed, as recommended in the study by 1.

Diagnostic Approach

• The study by 1 highlights the importance of considering organic obstruction, including adhesions and strictures, in patients with a history of abdominal surgery.
• The study by 1 notes that small bowel obstruction can be classified as partial or complete, and imaging studies such as CT scans can help differentiate between the two.
• The study by 1 emphasizes the importance of evaluating electrolyte imbalances, elevated urea nitrogen, and metabolic alkalosis in patients with suspected bowel obstruction.
• The study by 1 discusses the management of adult patients with severe chronic small intestinal dysmotility, including the use of colonoscopy to diagnose and treat obstructing lesions.

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