A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?

Strictureplasty of individual strictures

Small bowel resection with ileostomy

Abdominal closure and start palliative care

Small bowel resection and primary anastomosis

A 13-year-old boy is brought to the emergency department by his mother because of vomiting and severe testicular pain for 3 hours. The boy has had 4–5 episodes of vomiting during this period. He has never had a similar episode in the past and takes no medications. His father died of testicular cancer at the age of 50. His immunizations are up-to-date. He appears anxious and uncomfortable. His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 14/min, and blood pressure is 100/60 mm Hg. Cardiopulmonary examination shows no abnormalities The abdomen is soft and nondistended. The left scrotum is firm, erythematous, and swollen. There is severe tenderness on palpation of the scrotum that persists on elevation of the testes. Stroking the inner side of the left thigh fails to elicit elevation of the scrotum. Which of the following is the most appropriate next step in management?

Surgical exploration of the scrotum

Ceftriaxone and doxycycline therapy

CT scan of the abdomen and pelvis

A 27-year-old man is brought to the emergency department by ambulance following a motor vehicle accident 1 hour prior. He appears agitated. His blood pressure is 85/60 mm Hg, the pulse is 110/min, and the respiratory rate is 19/min. Physical examination shows bruising of the left flank and fracture of the left lower thoracic bones. Strict bed rest and monitoring with intravenous fluids is initiated. Urinalysis shows numerous RBCs. A contrast-enhanced CT scan shows normal enhancement of the right kidney. The left renal artery is only visible in the proximal section with a small amount of extravasated blood around the left kidney. The left kidney shows no enhancement. Imaging of the spleen shows no abnormalities. Which of the following is the most appropriate next step in management?

Observation with delayed repair

Renal artery embolization with delayed nephrectomy

Three days after being admitted to the hospital because of a fall from the roof of a two-story building, a 27-year-old man is being monitored in the intensive care unit. On arrival, the patient was somnolent and not oriented to person, place, or time. A CT scan of the head showed an epidural hemorrhage that was 45 cm3 in size and a midline shift of 7 mm. Emergency surgery was performed with craniotomy and hematoma evacuation on the day of admission. Perioperatively, a bleeding vessel was identified and ligated. Postoperatively, the patient was transferred to the intensive care unit and placed on a ventilator. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 117/78 mm Hg. The ventilator is set at a FiO2 of 55%, tidal volume of 520 mL, and positive end-expiratory pressure of 5.0 cm H2O. In addition to intravenous administration of fluids, which of the following is the most appropriate next step in managing this patient's nutrition?

Enteral feeding via nasogastric tube

Enteral feeding using a percutaneous endoscopic gastrostomy (PEG) tube

Necrotizing enterocolitis surgical management

💥 Pathophysiology - Gut Punch Breakdown

Multifactorial insult to the immature gut, primarily in premature infants.
- Intestinal Immaturity: ↓ mucosal barrier function, ↓ motility, altered immunity.
- Ischemia/Hypoxia: Often from perinatal stress or hypotension.
- Enteral Feeding & Dysbiosis: Formula feeding provides substrate for pathogenic bacteria.
This triad leads to bacterial translocation, triggering a massive inflammatory cascade (↑PAF, TNF-α).
Gas-producing organisms invade the bowel wall, causing the hallmark finding of pneumatosis intestinalis.
Progression leads to transmural necrosis, perforation, and peritonitis.

⭐ The terminal ileum and proximal colon are the most frequently involved segments due to their tenuous blood supply and high bacterial load.

Necrotizing Enterocolitis Pathophysiology

🩺 Diagnosis - Spotting the Sickness

Presentation: Suspect in premature infants with feeding intolerance, abdominal distension, and hematochezia (bloody stools).
Labs: Nonspecific but show systemic illness: thrombocytopenia, metabolic acidosis, hyponatremia, leukopenia/leukocytosis.
Imaging (Serial AXRs): Key to staging (Modified Bell's Staging).
- Stage I (Suspected): Normal or mild ileus.
- Stage II (Definite): Pneumatosis intestinalis (pathognomonic) or portal venous gas.
- Stage III (Advanced): Pneumoperitoneum (perforation).

⭐ Pneumoperitoneum on abdominal X-ray is an absolute indication for surgical exploration.

🔪 Management - The Decisive Incision

Surgical intervention is crucial for perforated or gangrenous bowel to prevent overwhelming sepsis. The primary goal is to resect non-viable tissue while preserving maximal bowel length to prevent short gut syndrome.

Absolute Indication for Surgery:
- Pneumoperitoneum on abdominal X-ray (pathognomonic for perforation).
Relative Indications:
- Clinical deterioration despite 48-72 hours of maximal medical therapy.
- Palpable abdominal mass (sentinel loop).
- Portal venous gas (ominous sign).
- Positive paracentesis (stool/bacteria).
- Persistent severe thrombocytopenia or metabolic acidosis.

⭐ Pneumoperitoneum on abdominal X-ray is an absolute indication for immediate surgical exploration in NEC. It signifies bowel perforation.

Abdominal X-ray: Neonate with NEC and pneumoperitoneum

Surgical Options:
- Exploratory Laparotomy: Gold standard. Resect necrotic bowel, create an ostomy.
- Primary Peritoneal Drain (PPD): A temporizing "bailout" for extremely unstable, low-weight (<1000g) infants.

🚧 Complications - Post-Op Perils

Short Bowel Syndrome (SBS):
- Most significant long-term morbidity from extensive resection.
- Results in malabsorption, failure to thrive, and chronic TPN dependence.
Intestinal Strictures:
- Develop in 10-35% of survivors, often at anastomotic sites.
- Cause delayed obstructive symptoms (feeding intolerance, distension).
Other Major Issues:
- Adhesions: Leading to future small bowel obstruction.
- TPN-Associated Cholestasis: Risk with prolonged parenteral nutrition.
- Neurodevelopmental Delay: Multifactorial risk from prematurity and severe illness.
- Recurrent NEC: Can occur in remaining bowel segments.

⭐ Strictures are a common delayed complication, often presenting weeks to months post-op. Suspect in a former NEC infant with new-onset feeding intolerance or obstructive symptoms after a period of recovery.

⚡ Biggest Takeaways

Pneumoperitoneum on abdominal X-ray is the absolute indication for surgery, signifying perforation.

Other indications include clinical deterioration on medical therapy, a fixed dilated loop, or portal venous gas.

The standard procedure is exploratory laparotomy with resection of necrotic bowel and creation of an ostomy.

Primary anastomosis is generally avoided due to high leak risk in critically ill infants.

A peritoneal drain is a less invasive alternative for extremely unstable infants.

Short bowel syndrome is the most feared long-term complication.