OBSTRUCTION & ISCHEMIA • SENIOR RESIDENT / SURGEON

Small Bowel Obstruction

A prior-operation patient with vomiting and obstipation forces the key ACS distinction: simple adhesive obstruction versus threatened bowel.

PROTOTYPE REVIEW REQUIRED

The Call

65-year-old woman with prior hysterectomy

Two days of crampy abdominal pain, bilious vomiting, abdominal distention and obstipation. She is diffusely tender but initially without peritonitis. Nasogastric decompression returns 1.5 liters of bilious fluid.

T 37.6 C • HR 108 • BP 112/68

The first question is not merely whether obstruction exists; it is whether the bowel is threatened and whether nonoperative management is safe.

Read the Image • Clinical DataACS VISUAL

Small-bowel obstruction imaging from the ACS image archive.

Make the Decision • Commit to a Plan

A patient with prior laparotomy has SBO. CT shows a C-shaped closed loop, mesenteric edema and reduced enhancement but no free air. Pain is continuous. Best next step?

Small Bowel Obstruction

65-year-old woman with prior hysterectomy

A patient with prior laparotomy has SBO. CT shows a C-shaped closed loop, mesenteric edema and reduced enhancement but no free air. Pain is continuous. Best next step?

After lysing a single adhesive band, 40 cm of ileum is purple but not frankly necrotic. Doppler signal is equivocal. What is the best principle?

Six hours later lactate rises and vasopressor needs increase after leaving questionable bowel in situ. Best next step?

When you operate, answer two questions: why is it obstructed, and is the bowel viable?

The postoperative course should confirm physiologic recovery.

Surgical Pearls

Pitfalls

Six hours later she develops constant focal pain, tachycardia, guarding and a rising lactate. Repeat CT suggests a closed-loop obstruction with reduced bowel-wall enhancement. What is the next move?