Vomiting and distension in a 74-year-old woman
An aimag hospital has one surgeon, no CT after 20:00, and a portable ultrasound. A 74-year-old woman presents with 3 days of vomiting, colicky abdominal pain and no flatus or stool for 36 hours. She had an open cholecystectomy 8 years ago. She is drowsy, tongue dry, BP 96/60, pulse 118, temperature 37.8°C, respiratory rate 24. Abdomen is distended and tympanic, with mild diffuse tenderness but no guarding; an incisional hernia is reducible. Ultrasound shows dilated fluid-filled small-bowel loops with sluggish peristalsis and no free fluid. WBC 14,000, creatinine 150 micromol/L, sodium 132, potassium 3.1. The surgeon must decide between resuscitation and observation, urgent laparotomy, or transfer to the capital 10 hours away. There is no ICU bed locally.
1. How would you classify and assess this patient, and what immediate resuscitation would you start?
Read the worked answer
The picture is most consistent with adhesive small-bowel obstruction after prior abdominal surgery, complicated by hypovolemia and hypokalemia. I would assess for strangulation rather than focus only on the obstruction: constant rather than colicky pain, fever, tachycardia, localized tenderness, guarding, rising leukocytosis, acidosis, or an irreducible hernia would raise concern. The ultrasound supports dilated loops but cannot exclude ischemia. Immediate measures are NPO, nasogastric decompression, IV balanced crystalloid or normal saline, potassium replacement after urine output is confirmed, a urinary catheter, strict fluid balance, analgesia and antiemetic therapy. I would not give oral contrast. Serial abdominal examinations and vital signs are essential because a normal initial examination does not exclude strangulation. The patient is elderly with renal impairment, so fluid and drug doses need adjustment.
2. Would you operate, observe, or transfer? Explain the decision and the criteria for changing plan.
Read the worked answer
I would resuscitate first for several hours while reassessing. If she remains stable, has no peritonitis or strangulation signs, and the obstruction is partial or improving, nasogastric decompression and transfer to a facility with CT, surgery and ICU support is reasonable. Transfer of an unstable patient over 10 hours is dangerous, however. If she develops peritonitis, worsening pain, fever, tachycardia, rising WBC, acidosis, or clinical deterioration, I would operate locally after rapid resuscitation even without an ICU, because delay risks bowel necrosis and perforation. The single surgeon and limited resources increase risk, so the decision must be documented and the receiving hospital contacted early. Antibiotic prophylaxis for laparotomy should cover bowel flora. The key is repeated examination and clear triggers for surgery rather than a single decision at admission.