A 47-year-old female presented to the emergency department (ED) with a 2-day history of cramping abdominal pain in the left upper and lower quadrants. The pain had been
intermittent until 3 am that morning, when it became constant and increased in severity, which she rated as 10 on the 10-point pain scale. The patient also complained of nausea but reported no eructation, diarrhea, constipation, bleeding from the rectum, fevers, or chills. Her weight had been stable. There had been no change in her bladder or bowel habits. Her last bowel movement, which she reported as normal, had occurred 2 days prior to presentation. She denied any previous episodes of abdominal pain and had not experienced any recent trauma. She was not taking any OTC medications, including laxatives.
Review of systems The patient had no significant medical history. Surgical history included laparoscopy for egg harvesting at age 40 years. She did not smoke, consume alcohol, or use recreational drugs, and she was not allergic to any medications. Her family history was noncontributory. She denied chest pain and dyspnea.
Assessment Because of the severity of her pain, the patient was assisted onto the stretcher for evaluation. On initial examination, she was alert and oriented to person, place, and time. Her appearance was consistent with her stated age. She was visibly in pain, tearful, and uncomfortable but in no acute distress. Vital signs were as follows: BP, 150/78 mm Hg; pulse, 53 beats per minute; respirations, 18 breaths per minute; temperature, 98°F. Oxygen saturation was 99% on room air. A focused physical examination revealed a soft, nondistended abdomen. Low-pitched bowel sounds were heard in all four quadrants. Palpation detected tenderness in the left upper and lower quadrants and mild guarding. The patient had no organomegaly, rebound tenderness, or peritoneal signs. Rectal examination found no palpable masses; stool in the vault was minimal and guaiac-negative.
Laboratory studies CBC results included WBC count, 11.5 × 103/µL; hematocrit, 42%; and platelets, 221 × 103/µL. Electrolyte results were normal. Other laboratory results included alkaline phosphatase, 52 U/L; ALT, 30 U/L; AST, 20 U/L; beta-human chorionic gonadotropin, less than 2.4 mIU/mL; lipase, 168 U/L; and total bilirubin, 1.2 mg/dL. A troponin assay was negative. Blood gas determinations were pH 7.33; PCO2, 38 mm Hg; PO2, 29 mm Hg; oxygen 21%; bicarbonate, 20 mEq/L. Base deficit was 5.4 mEq/L.
Imaging studies CT of the abdomen and pelvis with IV contrast revealed multiple loops of dilated small bowel within the left upper quadrant. Thickened bowel walls with adjacent inflammatory changes and free fluid were consistent with a high-grade small-bowel obstruction (SBO), and there were signs suggestive of developing ischemia (Figure 1).
Surgical procedure Following review of the abdominal/pelvic CT scan and surgical consultation, a nasogastric tube and Foley catheter were placed and the patient was admitted to the surgery service. The patient's status was NPO, and IV fluids were initiated to maintain intravascular volume, balance electrolytes, and ensure adequate urinary output. After the risks and benefits of emergent exploratory laparotomy were explained, informed consent was obtained. The patient was taken to the OR under general anesthesia.
The surgical approach was through the abdominal cavity via a midline incision. When the bowel was inspected intraoperatively, several loops of necrotic small bowel were noted in the left upper quadrant; there was no evidence of perforation. The patient was partially eviscerated until a congenital adhesive band was found. The band was causing an internal hernia through which several loops of bowel were passing. The band was lysed, and approximately 2 feet of strangulated necrotic small bowel were resected with a primary anastomosis. The small bowel was measured from the ligament of Treitz to the ileocecal valve; approximately 315 cm of small bowel remained intact. The bowel was returned to its normal anatomic position in the abdominal cavity.