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 diagnose a possible bowel obstruction, which is a common complication following abdominal surgery, especially in patients with a history of colon cancer 1. Given the patient's history of right hemicolectomy for cecal cancer and presentation with abdominal pain, vomiting, and abdominal distension, there is a high suspicion for bowel obstruction. The patient's symptoms, such as abdominal distension and vomiting, are consistent with a possible bowel obstruction, which can be caused by adhesions or other complications from the previous surgery. Some key points to consider in this patient's presentation include:

• The patient's history of abdominal surgery, which increases the risk of bowel obstruction due to adhesions or other complications 1
• The patient's symptoms, such as abdominal pain, vomiting, and abdominal distension, which are consistent with a possible bowel obstruction 1
• The importance of imaging studies, such as small bowel series or CT scans, in diagnosing bowel obstruction and identifying the location and cause of the obstruction 1
• The potential risks and benefits of different diagnostic approaches, including the risk of worsening an obstruction with contrast studies and the invasiveness of laparotomy 1 In terms of the most appropriate investigation, a small bowel series is a reasonable initial choice because it can help diagnose a possible bowel obstruction and identify the location and cause of the obstruction. While colonoscopy may also be useful in some cases, it may not be the best initial choice for this patient given the suspicion of small bowel obstruction. Laparotomy is too invasive as a first-line diagnostic approach and should be reserved for cases where less invasive methods have failed or when there are signs of peritonitis or perforation, which this patient does not exhibit.

From the Research

Diagnostic Approach

The patient's symptoms of abdominal pain, vomiting, and distended but soft abdomen suggest a possible small bowel obstruction (SBO). The appropriate investigation for this condition is crucial for determining the cause and site of obstruction, as well as the presence of any complications such as ischemia.

Imaging Modalities

• Computed Tomography (CT) is a powerful tool for assessing patients with SBO, as it can provide important information about the cause and site of obstruction, as well as the presence of a closed-loop obstruction or ischemia 2, 3, 4.
• Barium studies, such as a barium meal, can also be used to diagnose SBO, especially in cases where the diagnosis is unclear or equivocal 5.
• Other imaging modalities, such as plain radiographs, contrast imaging/fluoroscopy, ultrasonography, and magnetic resonance imaging, may also be used to evaluate SBO, but CT is usually the most appropriate and accurate diagnostic modality 3.

Specific Investigations

• A small bowel series, which involves swallowing a barium solution to visualize the small intestine, may be useful in diagnosing SBO, but it is not the most appropriate initial investigation in this case.
• A barium enema is not typically used to diagnose SBO, as it is more commonly used to visualize the colon and rectum.
• Colonoscopy is not relevant in this case, as the patient's symptoms suggest a small bowel obstruction rather than a colonic obstruction.
• Laparotomy, or surgical exploration of the abdomen, may be necessary in some cases of SBO, but it is not an initial diagnostic investigation.

Recommended Investigation

Based on the patient's symptoms and the available evidence, the most appropriate initial investigation for suspected SBO is a CT scan of the abdomen 2, 3, 4. This will provide valuable information about the cause and site of obstruction, as well as the presence of any complications, and will help guide further management.