What is the likely diagnosis for a patient with recurrent episodes of severe abdominal pain, distension, chills, and tachycardia, with a history of exploratory abdominal surgery, that typically resolves with intravenous (IV) fluid resuscitation?

Recurrent Adhesive Small Bowel Obstruction

This patient is experiencing recurrent episodes of adhesive small bowel obstruction (SBO), a common complication following abdominal surgery that typically responds to conservative management with IV fluid resuscitation.

Clinical Presentation Analysis

The constellation of symptoms strongly indicates adhesive SBO:

• Severe abdominal pain and distension are classic findings in SBO, representing fluid and gas accumulation proximal to the obstruction 1
• Tachycardia and systemic symptoms (chills) reflect hypovolemia from third-space fluid losses into the obstructed bowel 2
• Resolution with 2 bags of IV fluids indicates partial rather than complete obstruction, as complete obstructions typically require surgical intervention 3
• Recurrent episodes twice yearly is consistent with adhesive disease, which accounts for 70% of all SBO cases in patients with prior abdominal surgery 1
• History of exploratory surgery without strictures makes adhesions the most likely etiology, as adhesions are the predominant cause of SBO in adults with surgical history 2

Diagnostic Approach for Future Episodes

CT abdomen and pelvis without oral contrast is the diagnostic test of choice, with diagnostic accuracy exceeding 90% 1:

• Oral contrast is contraindicated in suspected high-grade SBO as it delays diagnosis, increases aspiration risk, and can mask bowel wall enhancement abnormalities 1
• CT can distinguish partial from complete obstruction and identify complications requiring surgery (ischemia, closed-loop obstruction, volvulus) 1
• Signs of bowel ischemia on CT include abnormal bowel wall enhancement, bowel wall thickening, mesenteric edema, ascites, and pneumatosis 1

Management Algorithm

Initial Conservative Management (Appropriate for Partial SBO)

Immediate fluid resuscitation is the cornerstone of treatment 1:

• Administer crystalloid boluses (20 mL/kg initially) to restore intravascular volume and enhance visceral perfusion 1
• Target urine output >0.5 mL/kg/hour as a marker of adequate resuscitation 4
• Correct electrolyte abnormalities, particularly hyperkalemia and metabolic acidosis that can accompany bowel obstruction 1

Nasogastric tube decompression should be initiated for patients with significant distension and vomiting 1, 2:

• Removes contents proximal to obstruction and reduces aspiration risk 2
• Improves patient comfort and may facilitate resolution 3

Water-Soluble Contrast Challenge

Consider administering 100 mL of water-soluble contrast (Gastrografin) via NG tube with follow-up radiographs at 4,8,12, and 24 hours 1, 3:

• If contrast reaches the colon within 24 hours, surgery is rarely required 1
• Patients passing contrast within 5 hours have a 90% rate of obstruction resolution 3
• This protocol has both diagnostic and therapeutic value without increasing morbidity 3

Indications for Surgical Intervention

Proceed immediately to surgery if any of the following are present 1, 2:

• Signs of peritonitis on physical examination
• CT findings suggesting bowel ischemia or perforation
• Complete obstruction with contrast not reaching colon by 24 hours 3
• Failure of conservative management after 24-48 hours
• Hemodynamic instability despite adequate resuscitation

Critical Pitfalls to Avoid

Do not delay imaging or surgical consultation when ischemia is suspected, as mortality can reach 25% with bowel ischemia 1:

• Physical examination and laboratory tests are neither sensitive nor specific for detecting strangulation 1
• Fever, hypotension, diffuse abdominal pain, and peritonitis suggest complicated obstruction requiring urgent surgery 2

Avoid excessive fluid administration that can worsen bowel edema and impair perfusion 5:

• While aggressive resuscitation is necessary initially, monitor for signs of fluid overload
• High-volume resuscitation can lead to intestinal edema and subsequent dysfunction 5

Long-Term Considerations

This patient should be counseled that recurrent adhesive SBO is a chronic condition with episodes likely to continue:

• Each episode should be managed conservatively initially unless complications develop
• Patient education about early recognition of symptoms and prompt presentation is crucial
• Surgical adhesiolysis is generally not recommended for recurrent partial SBO without complications, as surgery itself creates new adhesions