Patient Case
A 47-year-old white male is admitted to the emergency room with a 36-hour history of
lower abdominal pain, nausea, and vomiting. The patient describes the pain as crampy
in nature and notes that his abdomen has become distended over the last 12 hours. His
last bowel movement was three days prior to presentation. His past medical history
reveals an appendectomy for acute appendicitis eight months ago. He is otherwise
healthy and takes no medications.
Physical exam reveals a temperature of 100F. His abdomen is distended and tympanic.
Mild tenderness is present periumbilically but no guarding or rebound. High-pitched
bowel sounds are present and rectal exam reveals no stool in the ampulla.
Admitting laboratory data include a hemoglobin of 16, hematocrit 48, white blood cell
count 12,200 with 74 polys and 5 bands. Serum electrolytes are normal, BUN is 28, and
creatinine is 1.2. An abdominal series reveals multiple dilated loops of small bowel with
numerous air fluid levels. No gas or stool is visible in the colon. The patient is admitted
to the hospital.
Discussion Questions
1. What is the most likely diagnosis? Do you think his condition can be treated without
an operation? What is the initial management plan?
2. If you choose conservative management in this case, how would you follow his
progress? What form of gastrointestinal decompression would you use in this patient?
3. What are the indications for early operative intervention in postoperative acute small
bowel obstruction?
4.In order of frequency, list the causes of small bowel obstruction in the adult and in the
child.
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