What is the best course of management for a 57-year-old female presenting with severe epigastric pain, colicky in nature, with a history of bowel movements (Bowel Movement) on 11/1 and last flatus (passing gas) on 11/2, and previous surgery (Before - BTL)?

Immediate Diagnostic Workup for Suspected Small Bowel Obstruction

This 57-year-old woman with severe colicky epigastric pain, no bowel movement since 11/1, and no flatus since 11/2 requires urgent evaluation for small bowel obstruction (SBO) with immediate CT imaging and assessment for signs of strangulation or perforation. 1

Critical Initial Assessment

The clinical presentation is highly concerning for mechanical bowel obstruction based on:

• Colicky abdominal pain - present in the majority of SBO cases and represents the bowel's attempt to overcome the obstruction 1
• Absence of flatus - occurs in 90% of SBO cases 1
• Absence of bowel movements - occurs in 80.6% of cases 1
• History of prior abdominal surgery (BTL) - adhesions are the most common cause of SBO in adults (55-75% of cases), and prior abdominal surgery has 85% sensitivity for adhesive SBO 1, 2

Immediate Red Flags to Assess

You must immediately evaluate for signs of strangulation/ischemia or perforation, which require emergency surgical intervention 3, 1:

• Fever, tachycardia, tachypnea, or confusion 1
• Intense pain unresponsive to analgesics 1
• Diffuse abdominal tenderness, guarding, or rebound tenderness 1
• Absent bowel sounds (vs. hyperactive early in obstruction) 1
• Signs of shock: hypotension, cool extremities, mottled skin, oliguria 1

Diagnostic Algorithm

Step 1: Physical Examination

Perform focused examination looking for:

• Abdominal distension (present in 65.3% of cases, positive likelihood ratio 16.8) 1
• Abdominal tenderness and peritoneal signs 1
• Bowel sounds (hyperactive early, absent with strangulation) 1
• Examine all hernia orifices and previous surgical incision sites 1
• Digital rectal exam to assess for masses or blood 1

Step 2: Laboratory Studies

Order immediately:

• Complete blood count - assess for leukocytosis/neutrophilia suggesting complications 1
• Lactate level - elevated levels suggest intestinal ischemia 1
• Electrolyte panel - identify metabolic derangements 1
• Renal function tests - evaluate dehydration 1
• Arterial blood gas if severe - low bicarbonate and pH suggest complications 1

Step 3: Imaging

CT scan of the abdomen and pelvis with IV contrast is the diagnostic test of choice with approximately 90% accuracy 1, 2. This should be obtained urgently, not after plain films, given the high clinical suspicion 4, 5.

Plain abdominal radiographs have limited value (sensitivity only 50-60%) and cannot exclude the diagnosis 1, 2.

Initial Management While Awaiting Imaging

Begin resuscitation immediately 2, 4:

• NPO status (nothing by mouth) 5
• IV fluid resuscitation with crystalloids to correct dehydration and electrolyte abnormalities 2, 5
• Nasogastric tube placement if significant distension or vomiting present - this removes contents proximal to obstruction and provides symptomatic relief 2, 5
• Analgesia - provide appropriate pain control, as this does not impair diagnostic accuracy 6
• Immediate surgical consultation 2

Decision Points Based on CT Findings

If Complete Obstruction with Signs of Strangulation:

Emergency surgical intervention is required 3, 1, 2. Signs include:

• Bowel wall thickening, pneumatosis, or portal venous gas
• Mesenteric edema or free fluid
• Closed-loop obstruction
• Lack of contrast passage

If Partial Obstruction without Strangulation:

Consider trial of nonoperative management with:

• Continued bowel rest and NG decompression 5
• Water-soluble contrast (Gastrografin) administration can help predict need for surgery and may expedite resolution 4
• Close monitoring for clinical deterioration 2
• Surgical intervention if no improvement within 24-48 hours or if patient deteriorates 2, 4

Critical Pitfalls to Avoid

• Do not mistake incomplete obstruction with watery diarrhea for gastroenteritis - this can lead to dangerous delays 1
• Do not delay imaging with plain films when clinical suspicion is high 1, 4
• Do not withhold analgesia pending diagnosis - this is safe and humane 6
• In elderly patients, pain may be less prominent - maintain high index of suspicion 1
• Complete obstruction with signs of strangulation is a surgical emergency requiring intervention within hours, not days 3, 1

Disposition

All patients with confirmed SBO require surgical service evaluation and hospital admission 2. The decision for operative vs. nonoperative management depends on presence of strangulation, complete vs. partial obstruction, and response to initial conservative therapy 2, 4, 5.