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Chapter 23. The Acute Abdomen

A 50-year-old white woman presents to the emergency department with a 24-hour history of right upper quadrant abdominal pain, fever, and a white blood cell count of 14,000/µL. What is the initial imaging study of choice?

A. 99m-Tc hepatobiliary scintigraphy (hepatic iminodiacetic acid [HIDA]) scan

B. Computed tomography (CT) scan of the abdomen

C. Kidney, ureter, and bladder radiograph

D. Abdominal ultrasound

E. Magnetic resonance cholangiopancreatography

The correct answer is D. Abdominal ultrasound. Ultrasound is the best test for detecting most gallbladder disease, including acute cholecystitis. Classic findings for cholecystitis include presence of gallstones, gallbladder wall thickening, and pericholecystic fluid. Ultrasound also allows for assessment for choledocholithiasis and the common bile duct can be visualized and the diameter measured. A dilated common bile duct (CBD) along with a direct hyperbilirubinemia is highly concerning for choledocholithiasis. Normal CBD diameter is up to 4 mm in patients through their 40s. Thereafter, every decade, normal CBD diameter increases by 1 mm maximum. Thus, a patient in their 50s may have a normal CBD up to 5 mm in diameter, and a patient in their 70s may have a normal CBD up to 7 mm in diameter.

A 75-year-old man has a right hemicolectomy performed for cecal polyps. The patient has return of bowel function. On postoperative day 10, the patient complains of worsening abdominal pain and a low-grade fever. A CT scan is performed that shows evidence of a high-grade small bowel obstruction. A nasogastric (NG) tube is placed. The patient is observed over the next 2 days, and he has no return of bowel function. The next step in management is to

A. Start Reglan and encourage ambulation

B. Diagnostic laparoscopy

C. Exploratory laparotomy

D. NG tube decompression and continued observation

E. Repeat CT scan

The correct answer is D. NG tube decompression and continued observation. The most common cause of a small bowel obstruction is due to adhesive disease, and the majority of these cases can be treated with nonoperative therapy. This includes NG tube decompression, bowel rest, electrolyte replacement, and ambulation. After 48 hours, there should be signs of a resolving obstruction. If this fails, surgery may be required to find the point of obstruction and release it. Early postoperative patients are managed differently in that the observational period is extended to 2 to 3 weeks before consideration of surgery, providing there are no signs ...

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