A 68-year-old woman with colorectal cancer presents with acute abdominal pain, distension, and vomiting. Plain abdominal X-ray shows dilated small bowel loops with an air-fluid level and free air in the peritoneal cavity. Contrast-enhanced CT confirms a perforated small bowel loop proximal to a large obstructing mass in the sigmoid colon. Her vital signs are stable (BP 110/70 mmHg, HR 95/min, RR 20/min, Temperature 37.5°C). What is the most appropriate next step in management?

Explanation

## Clinical Scenario Analysis This is a **perforated small bowel secondary to large bowel obstruction** — a surgical emergency with a complicating factor: the patient is **haemodynamically stable**. The presence of both perforation and obstruction mandates operative intervention, but the stable status allows a brief window for optimization. ## Why Resuscitation + Urgent Surgical Consultation is Correct **Key Point:** Even in stable patients with confirmed perforation, the priority is **resuscitation and operative readiness**, not further investigation or endoscopic intervention. **High-Yield:** Management of perforated viscus follows a standardized sequence regardless of haemodynamic status: | Step | Rationale | |------|----------| | NG tube | Decompress stomach; reduce aspiration risk; improve surgical access | | IV fluids | Correct dehydration from obstruction and third-spacing | | Broad-spectrum antibiotics | Cover gram-negative, gram-positive, anaerobes; prevent sepsis progression | | Surgical consultation | Discuss operative approach (single-stage vs. staged resection, colostomy considerations) | | Urgent OR | Proceed once resuscitation optimized (usually within 1–2 hours) | **Clinical Pearl:** Stability does not mean safety. Even a stable patient with perforation can decompensate rapidly if resuscitation is delayed. The goal is to optimize within 1–2 hours, then proceed to OR. ## Why NOT the Other Options - **Immediate laparotomy (Option A):** Premature — the patient needs NG decompression and fluid resuscitation first to reduce perioperative risk. - **Percutaneous drainage (Option C):** Inappropriate. Drainage alone does not address the perforation or obstruction; it delays definitive surgery and risks infection spread. - **Endoscopic stent (Option D):** Contraindicated. Endoscopy in a patient with confirmed perforation risks further contamination and sepsis. Stenting the sigmoid mass does not address the small bowel perforation. [cite:Harrison 21e Ch 287; Sabiston Textbook of Surgery 21e Ch 48]