From the Guidelines
The most appropriate investigation for this patient is a CT scan of the chest and abdomen, as it can help identify potential causes of the patient's symptoms, including recurrence or metastasis, and guide further management. Given the patient's history of cecal cancer and presentation with abdominal pain, vomiting, and distension, there is a concern for potential complications such as bowel obstruction or recurrence. According to the study by 1, CT scan of the chest and abdomen every 6 months for 3 years can be considered in patients who are at higher risk for recurrence. The patient's symptoms, such as abdominal pain and vomiting, are consistent with small bowel obstruction, as described in the study by 1. However, the study by 1 focuses on small bowel obstruction in a virgin abdomen, whereas this patient has a history of abdominal surgery. Considering the patient's history and symptoms, a CT scan would be a more appropriate initial investigation than colonoscopy, small bowel series, or barium enema, as it can provide more comprehensive information about the abdomen and chest. Laparotomy is not recommended as an initial investigation, as it is too invasive and should be reserved for cases where less invasive investigations have failed or when there are signs of complete obstruction or peritonitis. Key points to consider in this patient's management include:
- The patient's history of cecal cancer and potential for recurrence or metastasis
- The symptoms of abdominal pain, vomiting, and distension, which are consistent with small bowel obstruction
- The need for a comprehensive initial investigation, such as a CT scan, to guide further management.
From the Research
Diagnostic Approach
To determine the appropriate investigation for the 65-year-old male patient who underwent right hemicolectomy for Caecal cancer one year ago and presented with abdominal pain and vomiting, we need to consider the possible causes of his symptoms. Given his history of abdominal surgery, small bowel obstruction (SBO) is a potential cause of his symptoms.
Investigation Options
The following investigation options are available:
- Small bowel series
- Barium enema
- Colonoscopy
- Laparotomy
Recommended Investigation
Based on the evidence, computed tomography (CT) is a powerful tool for the assessment of patients with suspected small bowel obstruction 2, 3, 4. CT can provide important information about the cause and site of obstruction and the presence of a closed-loop obstruction or ischemia. Therefore, a CT scan with oral and intravenous contrast is the most appropriate initial investigation for this patient.
Rationale
The use of CT scan is supported by several studies, including a study published in the Radiologic clinics of North America, which reviews the appropriate CT technique for assessment of SBO, common causes for obstruction, imaging findings in SBO, and the significance of those findings for determining whether a patient is likely to require surgical management for SBO 2. Another study published in Current opinion in gastroenterology highlights the importance of CT and magnetic resonance (MR) enterography in diagnosing partial small bowel obstruction 5. A study published in Clinics in colon and rectal surgery also recommends CT as the most appropriate and accurate diagnostic imaging modality for most suspected bowel obstructions 3. A systematic review published in Current gastroenterology reports emphasizes the importance of early diagnosis using abdominal CT and aggressive medical therapy, with surgery reserved for failed medical therapy 4.
Key Points
- CT scan with oral and intravenous contrast is the most appropriate initial investigation for suspected small bowel obstruction.
- CT can provide important information about the cause and site of obstruction and the presence of a closed-loop obstruction or ischemia.
- Early diagnosis and aggressive medical therapy are crucial in managing small bowel obstruction, with surgery reserved for failed medical therapy 2, 5, 3, 4.