A 35-year old man comes to his physician because of a 4-hour history of severe abdominal pain. He says the pain is in the middle of his abdomen; the pain is crampy and comes in spasms lasting several minutes. He rates the pain as 8-9 out of 10 in intensity. He has vomited 4 or 5 times since the pain began, and says that the vomit is mostly undigested food. He says his abdomen appears bigger than usual, and that he has not passed flatus or stool since yesterday. He drinks 1-2 bottles of beer per week. The patient had an exploratory laparotomy 1 year ago for a gunshot wound to the abdomen. Temperature is 37.2°C (99.0°F), pulse is 90/min, respiratory rate is 16/min, and blood pressure is 110/70 mm Hg. Physical examination shows the abdomen is distended and diffusely tender with high-pitched bowel sounds. Rebound tenderness with guarding is elicited. Both supine and erect radiographs show dilated loops of small bowel with air-fluid levels. Laboratory studies show:

WBC count: 5510/mm³
RBC count: 5.91 million/mm³
Hemoglobin: 12.2 g/dL
Hematocrit: 44.0%
Mean corpuscular volume: 82.0 fL
Platelet count: 340,000/mm³
Na⁺: 140 mmol/L
K⁺: 3.1 mmol/L
Cl^–: 92 mmol/L
Ca²⁺: 9.1 mg/dL
HCO₃^–: 31 mEq/L
pH: 7.36
PaCO₂: 38 mm Hg
PaO₂: 89 mm Hg
SaO₂: 95%

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