The Surgical Abdomen
65
Carlos A. Pelaez and Nanakram Agarwal
Questions and Answers
1. An 89-year-old female patient from the nursing home
with history of hypertension, diabetes, dementia, and constipation is sent to the emergency department for sudden
onset of abdominal pain and distension. Her temperature
is 37.4°C, heart rate is 98, BP 150/88 mmHg. The abdomen is distended, tympanic, and tender to palpation,
mainly over the left lower quadrant without peritoneal
signs. A plain abdominal X-ray reveals a dilated sigmoid
colon with a “coffee bean” appearance. After adequate
fluid resuscitation, the initial management of this condition is:
(a) Stool softener and lactulose
(b) Barium enema
(c) Flexible proctosigmoidoscopy
(d) Blind placement of rectal tube
(e) Sigmoid resection
Answer: c
Sigmoid volvulus is uncommon in the US and other western countries. In the US, the typical patient is an old nursing home resident suffering from constipation. If there is
no evidence of gangrene, following adequate hydration/
resuscitation, endoscopic detorsion should be attempted
by proctosigmoidoscopy, a maneuver successful in 95%
of cases. Blind placement of a rectal tube initially is dangerous as it may cause perforation. A rectal tube is left in
place after proctosigmoidoscopy to prevent recurrence
and allow decompression. Prior to discharge, sigmoid
resection with primary anastomosis is indicated.
2. A 75-year-old male with chronic obstructive lung disease,
hypertension, diabetes, and heart failure presents at emergency department with worsening right groin pain for
48 h. On exam, his heart rate is 105/min, BP 160/90 mmHg,
and oxygen saturation 96% on room air. His abdomen is
soft, nontender without peritoneal signs; examination
demonstrates a reducible nontender mass in the right
groin. After initial assessment, the next best step in management is:
(a)Nasogastric tube placement, hydration, and observation for 24 h
(b) Immediate exploratory laparotomy
(c) Inguinal hernia repair under local anesthesia
(d) Inguinal hernia repair under general anesthesia
(e) Discharge with observation as outpatient
Answer: c
Inguinal herniorrhaphy with mesh placement under local
anesthesia is a safe operation with high success rate in the
elderly. Elective repair of inguinal hernia is advisable soon
after the diagnosis is made as mortality risks are far greater
for emergency repair. Mortality increases 7-fold after emergency operation and 20-fold if bowel resection is undertaken, in contrast to nearly 0% for elective repair. Laparotomy
is indicated when there is evidence of bowel ischemia.
3. A 75-year-old female is hospitalized for evaluation of recent
worsening mental status. She is drowsy, falling asleep during conversation. She is cold and diaphoretic, with a pulse
of 120/min, and BP 105/60 mmHg. Her abdomen is not
distended but is tender to palpation in the epigastrium with
voluntary guarding. Laboratory tests reveal an elevated
white blood cell count, high anion gap acidosis, and elevated
serum creatinine. Of the following, the initial diagnostic
test is:
(a) CT abdomen
(b) Chest X-ray
(c) Gallbladder ultrasound
(d) Liver function tests and amylase
Answer: b
The evaluation of an acutely ill older patient with multiple
comorbidities can be challenging, especially when they
cannot participate in the history and diagnostic process.
Her acute mental status change is best characterized as
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_65, © Springer Science+Business Media, LLC 2012
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delirium, the result of infection, electrolyte or metabolic
factors, or medications. In the presence of abdominal
pain, routine laboratory tests, although essential, are not
diagnostic. An upright chest X-ray is relevant in the initial
evaluation of patients with abdominal pain to rule out free
intraperitoneal air that in most cases, is an indication for
immediate laparotomy; besides the chest X-ray can be
easily performed and will demonstrate pneumonia which
can present as an ileus. Abdominal films, CT, and ultrasound are secondary but also useful in the evaluation of
the patient with abdominal pain if the upright chest X-ray
is noncontributory.
4. A 79-year-old female without any medical or surgical history presents to the emergency department for evaluation
of intermittent episodes of nausea and vomiting over the
last 5 days. On physical exam she appears dehydrated.
Her abdomen is distended with diffuse tenderness without peritoneal signs. Abdominal X-ray series (flat and
upright) demonstrates dilated small bowel loops with air
C.A. Pelaez and N. Agarwal
in the biliary tree (pneumobilia). The most likely reason
for the bowel dilation is:
(a) Obstruction secondary to adhesions
(b) Mesenteric ischemia
(c) Gallstone ileus
(d) Carcinoma of the colon
Answer: c
Gallstone ileus is an uncommon presentation of bowel
obstruction and biliary disease. Although uncommon, the
highest incidence is in older subjects, with an average age
at presentation of 70 years. Typically presentation is initially vague with intermittent symptoms progressing to
subacute obstruction. Only 20% of these patients will
manifest signs consistent with acute cholecystitis. The
major radiographic findings of gallstone ileus include
signs of partial or complete intestinal obstruction, air in the
biliary tree, direct visualization of the stone if it is calcified,
and change in position of a previously located stone.