What are the recommended ER diagnostics for a 72-year-old male with abdominal distention and worsening pain after recent hernia surgery?

Emergency Diagnostics for Post-Hernia Surgery Abdominal Distention and Pain

A CT scan with intravenous contrast is the most appropriate initial diagnostic test for a 72-year-old male presenting with abdominal distention and worsening pain following recent hernia surgery. 1

Initial Evaluation

When evaluating a post-hernia surgery patient with abdominal distention and worsening pain, consider these critical diagnostic steps:

1. Laboratory tests:

   • Complete blood count (CBC) to assess for leukocytosis
   • Serum electrolytes to evaluate fluid/electrolyte imbalances
   • C-reactive protein (CRP) and procalcitonin as inflammatory markers
   • Serum lactate levels to evaluate for intestinal ischemia
   • Renal and liver function tests
   • Blood gas analysis 1

2. Imaging studies:

   • CT scan with IV contrast (primary recommendation)
   • No oral contrast is needed in suspected high-grade obstruction 1

CT Scan Protocol and Findings to Look For

The CT scan should include:

• IV contrast administration
• Arterial and venous phases to assess mesenteric vessels
• Multi-planar reconstructions 1

Key findings to evaluate:

• Internal hernia through surgical defect
• Small bowel obstruction
• Mesenteric swirling (suggestive of internal hernia or volvulus)
• Signs of bowel ischemia:
  • Abnormal bowel wall enhancement
  • Bowel wall thickening
  • Mesenteric edema
  • Pneumatosis intestinalis
  • Portal venous gas 1

Rationale for CT as First-Line Imaging

CT is recommended as the first-line imaging modality because:

1. High diagnostic accuracy (>90%) for small bowel obstruction 1
2. Can identify the cause of obstruction (adhesions, internal hernia, volvulus) 1
3. Can detect complications like ischemia that require immediate intervention 1
4. Provides critical anatomical information for surgical planning 1

Common Post-Hernia Repair Complications to Consider

Several complications may present with abdominal distention and pain after hernia surgery:

1. Internal hernia - Particularly common after certain types of hernia repairs 1, 2
2. Small bowel obstruction - Due to adhesions or technical issues with the repair 1
3. Volvulus - Rotation of bowel around a fixed point 2
4. Strangulation - Compromised blood supply to herniated bowel 3
5. Recurrent hernia - Failure of the initial repair 1

Warning Signs Requiring Urgent Intervention

The following findings on CT warrant immediate surgical consultation:

• Evidence of bowel ischemia
• Closed-loop obstruction
• Complete obstruction
• Internal hernia with compromised bowel 1

Pitfalls to Avoid

1. Delaying imaging - Prompt CT is essential to prevent morbidity and mortality
2. Administering oral contrast - May delay diagnosis and increase risk of aspiration in high-grade obstruction 1
3. Overlooking subtle signs of ischemia - Even with normal laboratory values
4. Misinterpreting normal postoperative changes - Differentiate from pathologic findings 1

In this patient's case, the recent hernia surgery, abdominal distention, and worsening pain strongly suggest a potential complication requiring immediate evaluation with CT imaging to guide appropriate management.