Case 321 Medical history A 20 year-old male patient with non-specified neuropsychomotor development retardation is admitted to the emergency department with respiratory distress, abdominal distension and a 4 week constipation history that did not resolve with home laxative measures. Interrupted flatus passage in the last 24 hours. Digital rectal examination identified a large fecaloma. After being submitted to complementary exams, the patient developed tachydyspnea (40 ripm), tachycardia (140 bpm), confusion and respiratory failure (SpO2 82% while breathing ambient air). Image 1: Chest radiograph, AP view, patient in dorsal decubitus. Image 2: Plain abdominal radiograph, AP view, patient in dorsal decubitus. Image 3: Non contrast-enhanced adbominal and pelvic computed tomography (CT) scan, coronal reconstruction at the level of the coxofemoral articulations. Question:After careful consideration of the clinical scenario and imaging exams, what is the most appropriate management option for this patient? A) Non-invasive ventilation followed by per os administration of 120 mL of lactulose solution or 500 mL of 80g polyethylene glycol solution. B) Face mask or nasal cannula oxygen therapy and immediate 12% glycerol enema followed by cathartic measures. C) General anesthesia with rapid sequence intubation, urgent left colectomy and Hartmann colostomy. D) Orotracheal intubation, manual fecal disimpaction under anesthesia and enema tube placement. Test question (Emergency Hospital of Goiânia – adapted question) In a clinical scenario of acute obstructive abdomen, which of the following should be the first imaging exam ordered? a) Plain abdominal radiographs b) Abdominal CT scan c) Abdominal ultrasound d) Barium enema Time is Up! Time's up
