A 72-year-old man with no previous abdominal surgery presents with acute small bowel obstruction. CT abdomen confirms a closed-loop obstruction of the distal ileum with a transition point at the right iliac fossa. The bowel wall shows pneumatosis intestinalis and portal venous gas. The most appropriate next step is:
- A Urgent laparotomy — pneumatosis intestinalis and portal venous gas indicate bowel ischemia/necrosis ✓
- B NG tube decompression and IV fluids; reassess in 24 hours
- C CT-guided drainage of any associated fluid collection
- D Water-soluble contrast follow-through to assess level of obstruction
Explanation
Pneumatosis intestinalis (gas within the bowel wall) and portal venous gas are radiological signs of advanced bowel ischemia/necrosis and are indications for emergency surgery. Closed-loop obstruction has a much higher risk of strangulation than simple SBO and requires urgent intervention even without these signs. The combination of closed-loop obstruction + pneumatosis intestinalis + portal venous gas = transmural ischemia with high likelihood of full-thickness necrosis. Non-operative management is contraindicated. Resection of necrotic bowel with primary anastomosis or stoma (depending on intraoperative contamination) is the appropriate treatment.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.