Master the board step 3

Surgery
Obstruction
Suspect obstruction in patients with the following symptoms:
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Severe colicky pain
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Absence of flatus or feces
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High-pitched bowel sounds
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Nausea and vomiting in patients with these risk factors:
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Prior surgery (think adhesions)
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Elderly patient with weight loss and anemia or melanotic stools (think
tumor)
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History of recurrent lower abdominal pain (think diverticulitis)
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History of hernia (incarcerated hernia)
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Sudden abdominal pain in elderly patient (don’t forget about volvulus)
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Constant movement, as the patient tries to find a position of comfort
Diagnostic Testing
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CBC and lactate level (elevated)
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Supine and erect abdominal x-ray: Look for dilated loops of bowel, absence
of gas in rectum, bird’s beak sign for volvulus.
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CT scan of the abdomen and pelvis with contrast is the most accurate test,
and can at times show a transition point. The transition point is the location
at which the obstruction has occurred.
In a patient with a hernia,
immediate surgery is the
answer if the case describes
fever, leukocytosis,
constant pain, and signs of
peritoneal irritation (think
strangulated obstruction).
Treatment
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NPO, nasogastric (NG) suction, and IV fluid hydration
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Consider gastrografin contrast study (until perforation has been ruled out).
Basic Science Correlate
Gastrografin is water soluble, unlike barium, which is caustic if it
extravasates.
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Volvulus: Perform proctosigmoidoscopy with rigid instrument. Leave the
rectal tube in place. Perform sigmoid resection for recurrent cases.
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Abdominal hernias: Perform elective repair for all abdominal hernias,
except umbilical hernia in patients < 2 years old and esophageal sliding
hiatal hernia.
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All other obstructions: Perform emergency surgery.
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