Surgery

31 year old female presenting with nausea and vomiting

Nicole Nevarez on Jan 25, 2017

A 31-year-old female presents to the emergency department with a 2-day history of nausea and vomiting.

Her past medical history includes a 5-year history of Crohn's disease. It is currently well controlled on infliximab (Remicade). Her past surgical history includes an appendectomy when she was 18. She has no allergies. 

She does not smoke, but drinks 4-5 glasses of wine per week at dinner. She does do any drugs. She is currently sexually active. She does not use barrier contraception.  

What is included on the differential diagnosis?

Select all that apply
Expand all answers
Viral gastroenteritis
Yes. The history does not mention any sick contacts but viral gastroenteritis is a common cause of nausea and vomiting especially of acute onset such as in this case.


Small bowel obstruction
Yes. She has multiple risk factors for a small bowel obstruction. The most common cause is adhesions. They usually develop due to previous surgery or a chronic inflammatory condition, both of which this patient has a history of.


Pregnancy
Yes. She is currently sexually active and does not use barrier contraception or hormonal contraception (that we know of), making pregnancy a possibility.


Appendicitis
Try again. She had an appendectomy when she was 18.


  • Temp  99 C
  • HR  104
  • BP  115/72
  • RR  13
  • O2  99% on Room Air

Physical Exam: 

She is an uncomfortable female lying in bed. She is tachycardic but has a normal S1/S2 without murmurs. Her lungs are clear to ascultation bilaterally without rales or wheezing. Her abdomen has old, well-healed incisions from her laparoscopic appendectomy and is mildly tender and mildly distended with high-pitched bowel sounds.

If you were this patient's emergency medicine provider, what would be your first step in her management?

Expand all answers
Order labs: CBC, BMP, lactate, and pregnancy test.
No. Eventually these needs to be done but not first.


Zofran 4 mg PO
No. There is a more urgent step in management that must be done first.


1L bolus of 0.9% NaCl
Yes, her vital signs are not within normal limits likely due to dehydration. She needs a fluid bolus.


Abdominal xray
No. There's something else that should be done first. Hint: think ABCs.


After receiving her 1L bolus of 0.9% saline, her vitals signs improve.

  • Temp  99 C
  • HR  85
  • BP  114/76
  • RR  13
  • O2  99% on Room Air

Now that her vital signs are within normal limits, you continue your workup by ordering labs and giving her Zofran. You also obtain an abdominal xray shown below. She is also made NPO. Her pregnancy test is negative.

BMP
134
3.7
93
8
1.2
35
86
CBC
6.4
13
38
212

  • Abdominal radiograph - supine

What does this patient have?

Expand all answers
Pregnancy
Incorrect.


Viral gastroenteritis
Incorrect.


Small bowel obstruction
Correct. There are findings on her abdominal xray of multiple dilated loops of small bowel and air-fluid levels indicating obstruction.


What is the most common cause of the problem this patient has?

Expand all answers
Adhesions
Correct. According to Catena et al, the most common cause of small bowel obstruction is adhesions. These occur in patients who have had previous surgery or have a history of a chronic inflammatory condition such as Crohn's or ulcerative colitis.


Perforation
Incorrect.


Cancer
Incorrect.


Trauma
Incorrect.


The patient's nurse comes to you and tells you that the patient is now complaining of severe abdominal pain. When you go to examine the patient again, she is now severely distended. When you palpate her abdomen, she has guarding especially when in the epigastric area.

  • Temp  101 C
  • HR  100
  • BP  109/71
  • RR  13
  • O2  99% on Room Air

If you were the resident taking care of this patient, what form of management would you include in your plan?

Expand all answers
Medical management
Try again. This patient is now in severe pain, has a concerning exam, and unstable vital signs.


Surgical management
Correct. This patient now has evidence of strangulation. Her exam demonstrates severe distention and guarding. In addition, she is now febrile and tachycardic.


The emergency department resident consulted surgery, who immediately took her to the OR. She was found to have a small bowel obstruction that had progressed to strangulation in the second part of her duodenum.

  1. Catena F, Di Saverio S, Coccolini F, Ansaloni L, De Simone B, Sartelli M, Van Goor H. Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention. World J Gastrointest Surg. 2016; 8(3): 222-231.
  2. Azagury D, Liu RC, Morgan A, Spain DA. Small bowel obstruction: A practice step-by-step evidence-based approach to evaluation, decision making, and management. J Trauma Acute Care Surg. 2015; 79(4):661-8.
  3. Bauer J, Keeley B, Krieger B, Deliz J, Wallace K, Kruse D, Dallas K, Bornstein J, Chessin D, Gorfine S. Adhesive small bowel obstruction: early operative versus observational management. Am Surg. 2015; 81(6):614-20.
  4. O'Leary EA, Desale SY, Yi WS, Fujita KA, Hynes CF, Chandra SK, Sava JA. Letting the sun set on small bowel obstruction: can a simple risk score tell us when nonoperative care is inappropriate? Am Surg. 2014; 80(6):572-9.
  5. Teixeira PG, Karamanos E, Talving P, Inaba K, Lam L, Demetriades D. Early operation is associated with a survival benefit for patients with small bowel obstruction. Ann Surg. 2013; 258(3):459-65.
  6. Maung AA1, Johnson DC, Piper GL, Barbosa RR, Rowell SE, Bokhari F, Collins JN, Gordon JR, Ra JH, Kerwin AJ; Eastern Association for the Surgery of Trauma. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 Suppl 4):S362-9.
  7. Leung AM, Vu H. Factors predicting need for and delay in surgery in small bowel obstruction. Am Surg. 2012; 78(4):403-7.

A 31-year-old female presents to the emergency department with a 2-day history of nausea and vomiting.

Her past medical history includes a 5-year history of Crohn's disease. It is currently well controlled on infliximab (Remicade). Her past surgical history includes an appendectomy when she was 18. She has no allergies. 

She does not smoke, but drinks 4-5 glasses of wine per week at dinner. She does do any drugs. She is currently sexually active. She does not use barrier contraception.  

What is included on the differential diagnosis?

Select all that apply
Expand all answers
Viral gastroenteritis
Yes. The history does not mention any sick contacts but viral gastroenteritis is a common cause of nausea and vomiting especially of acute onset such as in this case.


Small bowel obstruction
Yes. She has multiple risk factors for a small bowel obstruction. The most common cause is adhesions. They usually develop due to previous surgery or a chronic inflammatory condition, both of which this patient has a history of.


Pregnancy
Yes. She is currently sexually active and does not use barrier contraception or hormonal contraception (that we know of), making pregnancy a possibility.


Appendicitis
Try again. She had an appendectomy when she was 18.


  • Temp  99 C
  • HR  104
  • BP  115/72
  • RR  13
  • O2  99% on Room Air

Physical Exam: 

She is an uncomfortable female lying in bed. She is tachycardic but has a normal S1/S2 without murmurs. Her lungs are clear to ascultation bilaterally without rales or wheezing. Her abdomen has old, well-healed incisions from her laparoscopic appendectomy and is mildly tender and mildly distended with high-pitched bowel sounds.

If you were this patient's emergency medicine provider, what would be your first step in her management?

Expand all answers
Order labs: CBC, BMP, lactate, and pregnancy test.
No. Eventually these needs to be done but not first.


Zofran 4 mg PO
No. There is a more urgent step in management that must be done first.


1L bolus of 0.9% NaCl
Yes, her vital signs are not within normal limits likely due to dehydration. She needs a fluid bolus.


Abdominal xray
No. There's something else that should be done first. Hint: think ABCs.


After receiving her 1L bolus of 0.9% saline, her vitals signs improve.

  • Temp  99 C
  • HR  85
  • BP  114/76
  • RR  13
  • O2  99% on Room Air

Now that her vital signs are within normal limits, you continue your workup by ordering labs and giving her Zofran. You also obtain an abdominal xray shown below. She is also made NPO. Her pregnancy test is negative.

BMP
134
3.7
93
8
1.2
35
86
CBC
6.4
13
38
212

  • Abdominal radiograph - supine

What does this patient have?

Expand all answers
Pregnancy
Incorrect.


Viral gastroenteritis
Incorrect.


Small bowel obstruction
Correct. There are findings on her abdominal xray of multiple dilated loops of small bowel and air-fluid levels indicating obstruction.


What is the most common cause of the problem this patient has?

Expand all answers
Adhesions
Correct. According to Catena et al, the most common cause of small bowel obstruction is adhesions. These occur in patients who have had previous surgery or have a history of a chronic inflammatory condition such as Crohn's or ulcerative colitis.


Perforation
Incorrect.


Cancer
Incorrect.


Trauma
Incorrect.


The patient's nurse comes to you and tells you that the patient is now complaining of severe abdominal pain. When you go to examine the patient again, she is now severely distended. When you palpate her abdomen, she has guarding especially when in the epigastric area.

  • Temp  101 C
  • HR  100
  • BP  109/71
  • RR  13
  • O2  99% on Room Air

If you were the resident taking care of this patient, what form of management would you include in your plan?

Expand all answers
Medical management
Try again. This patient is now in severe pain, has a concerning exam, and unstable vital signs.


Surgical management
Correct. This patient now has evidence of strangulation. Her exam demonstrates severe distention and guarding. In addition, she is now febrile and tachycardic.


The emergency department resident consulted surgery, who immediately took her to the OR. She was found to have a small bowel obstruction that had progressed to strangulation in the second part of her duodenum.

  1. Catena F, Di Saverio S, Coccolini F, Ansaloni L, De Simone B, Sartelli M, Van Goor H. Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention. World J Gastrointest Surg. 2016; 8(3): 222-231.
  2. Azagury D, Liu RC, Morgan A, Spain DA. Small bowel obstruction: A practice step-by-step evidence-based approach to evaluation, decision making, and management. J Trauma Acute Care Surg. 2015; 79(4):661-8.
  3. Bauer J, Keeley B, Krieger B, Deliz J, Wallace K, Kruse D, Dallas K, Bornstein J, Chessin D, Gorfine S. Adhesive small bowel obstruction: early operative versus observational management. Am Surg. 2015; 81(6):614-20.
  4. O'Leary EA, Desale SY, Yi WS, Fujita KA, Hynes CF, Chandra SK, Sava JA. Letting the sun set on small bowel obstruction: can a simple risk score tell us when nonoperative care is inappropriate? Am Surg. 2014; 80(6):572-9.
  5. Teixeira PG, Karamanos E, Talving P, Inaba K, Lam L, Demetriades D. Early operation is associated with a survival benefit for patients with small bowel obstruction. Ann Surg. 2013; 258(3):459-65.
  6. Maung AA1, Johnson DC, Piper GL, Barbosa RR, Rowell SE, Bokhari F, Collins JN, Gordon JR, Ra JH, Kerwin AJ; Eastern Association for the Surgery of Trauma. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 Suppl 4):S362-9.
  7. Leung AM, Vu H. Factors predicting need for and delay in surgery in small bowel obstruction. Am Surg. 2012; 78(4):403-7.

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