What are the next steps in managing a patient with abdominal pain and urinary retention, with a KUB (Kidney, Ureter, Bladder) result showing an abnormal bowel gas pattern suggestive of Small Bowel Obstruction (SBO) versus ileus, and superimposed constipation, who is about to receive Toradol (Ketorolac)?

From the Guidelines

The patient's management should prioritize addressing the potential small bowel obstruction, and given the current symptoms and KUB results, a CT scan of the abdomen and pelvis with IV contrast is crucial to confirm the diagnosis and determine the cause and location of obstruction. The use of Toradol (ketorolac) in this context may not be ideal due to its potential to mask symptoms and worsen the condition, as suggested by the need for careful management in suspected bowel obstruction cases 1.

Instead, a comprehensive approach should be implemented:

• Nasogastric tube placement for decompression to alleviate abdominal pain and prevent further bowel distension.
• IV fluid resuscitation with normal saline or lactated Ringer's at 125-150 mL/hour to ensure adequate hydration and maintain fluid balance.
• NPO (nothing by mouth) status to rest the bowel and prevent further distension.
• For pain management, consider alternatives to Toradol, such as hydromorphone 0.5-1 mg IV every 4 hours or morphine 2-4 mg IV every 4 hours as needed, under close monitoring to avoid masking symptoms of potential bowel obstruction.
• Prompt surgical consultation is essential as SBO may require operative intervention, especially if there are signs of bowel ischemia or complete obstruction.
• Monitoring of vital signs, abdominal examination findings, and fluid status every 4 hours is critical to assess the patient's response to treatment and detect any complications early.
• Placement of a urinary catheter to address urinary retention and monitor output, ensuring that the patient's urinary system is not compromised.
• Laboratory tests, including complete blood count, comprehensive metabolic panel, and lactate level, should be performed to assess for complications such as infection, electrolyte imbalances, or bowel ischemia.

The CT scan, as emphasized in the World Journal of Emergency Surgery 1, plays a key role in the decision on the management of patients with SBO, not just in confirming the diagnosis but also in identifying the underlying cause of obstruction and predicting the need for emergency surgery. This diagnostic approach aligns with the latest recommendations for managing small bowel obstruction, prioritizing both diagnostic accuracy and timely therapeutic intervention to improve patient outcomes.

From the Research

Patient Management

The patient is experiencing abdominal pain and urinary retention, with a KUB result showing an abnormal bowel gas pattern suggestive of Small Bowel Obstruction (SBO) versus ileus, and superimposed constipation. The patient is about to receive Toradol (Ketorolac) for pain management.

• The use of Toradol in this scenario is supported by studies such as 2, which demonstrated the effectiveness of ketorolac in controlling postoperative pain.
• However, it is essential to consider the potential side effects of Toradol, such as urinary retention, although studies like 2 have shown a lower incidence of urinary retention compared to other analgesics.

Abdominal Pain and Urinary Retention Management

• For the management of abdominal pain, Toradol can be an effective option, as shown in studies like 3 and 4, which demonstrated its analgesic efficacy in acute pain management.
• Regarding urinary retention, studies like 2 and 5 suggest that ketorolac may have a lower incidence of urinary retention compared to other analgesics, which could be beneficial in this patient's case.

Small Bowel Obstruction (SBO) Management

• The management of SBO is crucial in this patient's care, and studies like 6 provide guidance on the use of oral water-soluble contrast to manage adhesive SBO.
• The study 6 suggests that nonoperative management can be effective in a significant proportion of patients with SBO, and that the use of oral contrast can help accelerate the decision-making process for management.

Next Steps

• Continue to monitor the patient's abdominal pain and urinary retention, and adjust the treatment plan as needed.
• Consider the use of oral water-soluble contrast to manage the SBO, as suggested by study 6.
• Be aware of the potential side effects of Toradol, such as urinary retention, and adjust the treatment plan accordingly.