Question 18#
A 45 year old man presented to the emergency department with colicky abdominal pain, vomiting, and a painful groin lump. On examination he had a pulse of 110 beats/min and temperature of 37.8°C. There was marked abdominal distension, high pitched bowel sounds, and an erythematous, tender mass in the left groin above and medial to the pubic tubercle. A plain abdominal radiograph was taken in the emergency department (figure below).
Plain abdominal radiograph showing evidence of small bowel obstruction.
What is the next step in management?
A. Apply local pressure to the swelling to reduce itB. Discharge with analgesia
C. Elective surgery
D. Nil by mouth, nasogastric tube, and intravenous drip
E. Reassurance and book an outpatient department appointment
Correct Answer is D
Comment:
Nil by mouth, nasogastric tube, and intravenous drip. The history is consistent with small bowel obstruction secondary to an irreducible inguinal hernia—above and medial to the pubic tubercle. Figure above shows a loop of small bowel leading towards the position of an inguinal hernia. The concern here is that the bowel is ischaemic and is at risk of perforation, which would put the patient at risk. Initial management should aim to prepare the patient for emergency operation.