What is the immediate treatment for a patient with severe abdominal bloating, severe pain, and abdominal distension, considering potential life-threatening conditions such as bowel obstruction, perforation, or severe inflammatory processes?

Immediate Management of Severe Abdominal Bloating with Severe Pain and Distension

Patients presenting with severe abdominal bloating, severe pain, and abdominal distension require immediate assessment for life-threatening conditions—if hemodynamically unstable, showing signs of peritonitis, or having free perforation, proceed directly to emergency surgical exploration; if hemodynamically stable, obtain CT angiography urgently while initiating aggressive resuscitation. 1

Initial Stabilization and Assessment

Immediate Resuscitation

• Begin aggressive intravenous fluid resuscitation with electrolyte correction immediately, including potassium supplementation of at least 60 mmol/day to prevent toxic dilatation and correct hypokalemia. 2, 3
• Administer low-molecular-weight heparin for thromboprophylaxis as soon as possible, even in the presence of rectal bleeding, due to markedly elevated thromboembolism risk in acute abdominal emergencies. 2, 3
• Insert nasogastric tube for decompression in patients with signs of obstruction or severe distension. 1
• Correct anemia and electrolyte abnormalities promptly. 3

Critical Red Flags Requiring Immediate Surgery

Proceed directly to emergency laparotomy without delay if any of the following are present:

• Hemodynamic instability (shock, persistent hypotension despite resuscitation) 1
• Signs of peritonitis on physical examination 1
• Free perforation (pneumoperitoneum on imaging) 1
• Massive bleeding with persistent hemodynamic instability 1
• Clinical deterioration with signs of septic shock 1

Diagnostic Workup for Stable Patients

Imaging Priority

• Obtain CT angiography (CTA) as soon as possible for any patient with severe abdominal pain and distension to identify acute mesenteric ischemia, bowel obstruction, perforation, or other surgical emergencies. 1
• Severe abdominal pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia until disproven, which requires immediate CTA. 1
• Plain radiographs have limited diagnostic value but may show free air indicating perforation. 1

Laboratory Assessment

• No laboratory studies are sufficiently accurate to identify ischemic or necrotic bowel, although elevated lactate and D-dimer may assist in suspecting acute mesenteric ischemia. 1
• Obtain complete blood count, comprehensive metabolic panel, lactate, and coagulation studies. 1

Medical Management for Stable Patients

Antibiotic Therapy

• Administer broad-spectrum antibiotics immediately covering Gram-negative aerobic/facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli. 1, 3
• Continue antibiotics based on clinical and biochemical response (serum CRP levels). 3

Anticoagulation

• Unless contraindicated, anticoagulate with intravenous unfractionated heparin immediately after diagnosis of vascular compromise or mesenteric ischemia. 1

Specific Considerations for Inflammatory Bowel Disease

If the patient has known IBD or findings suggest acute severe colitis:

• Administer intravenous corticosteroids (methylprednisolone 60 mg/24h or hydrocortisone 100 mg four times daily) for hemodynamically stable patients. 2, 3
• Assess response by day 3; maximum corticosteroid duration is 7-10 days without escalation to rescue therapy or surgery. 3
• Perform unprepared flexible sigmoidoscopy with biopsy to confirm diagnosis and exclude cytomegalovirus infection. 2

Surgical Indications and Timing

Absolute Indications for Immediate Surgery

Do not delay surgery in the following scenarios:

• Overt peritonitis 1
• Toxic megacolon with perforation, massive bleeding, or clinical deterioration after 24-48 hours of medical treatment 1
• Bowel obstruction with signs of strangulation or ischemia 1
• Radiological signs of pneumoperitoneum with free fluid in acutely unwell patients 1

Surgical Approach

• For hemodynamically unstable patients with perforation, generalized peritonitis, or toxic megacolon, use an open approach. 1
• Apply damage control surgery principles with planned re-laparotomy for patients requiring intestinal resection to reassess bowel viability. 1
• Subtotal colectomy with ileostomy is the procedure of choice for acute severe ulcerative colitis with massive hemorrhage or medical treatment failure. 1, 3

Critical Pitfalls to Avoid

• Never delay surgery in critically ill patients with toxic megacolon—mortality increases significantly with perforation. 3
• Never extend IV corticosteroids beyond 7-10 days in IBD patients without escalating to rescue therapy or surgery. 3
• Do not withhold analgesia while establishing diagnosis—judicious analgesia does not impair diagnostic accuracy and reduces patient suffering. 4
• Recognize that acute mesenteric ischemia is a true surgical emergency—high index of suspicion with prompt imaging and surgical exploration is essential to prevent mortality. 1
• In patients with no improvement after 48-72 hours of medical treatment, second-line therapy or surgery must be considered without further delay. 1, 2