Case Presentation

Case PresentationDr.Mohammad Amin K MirzaSaudi Board of Surgery

Holy Makkah, KSA2008History & Clinical Data34 y.o Saudi, female Pt, Married Came to ER c\o:Lt sided abdominal pain, colicky in nature 1wk Vomiting of gastric content 1 day No flatus 3daysPassed hard stool at the night prior to admissionH\O open appendectomy 1 yr back ( histopath: acute suppurative appendicitis)No DM or HTN

O\E: Conscious, oriented, not toxic, not in destress

V.S: Temp: 37 C , BP: 130/80 mmHg, HR: 96 bpm

Abdomen: Mild distension , soft lax no tenderness Bowel sounds: Audible, hernail orifices intact

CBC: normal Chemistry: K 3.2 Na 127

AXR: Distended small bowel, multiple fluid levels

History & Clinical Data cont..Adheasive intestinal obstruction

ManagemaentNPONGTD5 NS 125 ml/hr Inj KCl 60 meq \24 hr Intake output chart

Patient progressShe showed slow progressAlthough she had no signs of peritonitis, sepsis, or any systemic response , there was no improvement regarding bowel movement , & she didnt pass stool or fleatusCorrection of electrolytes was achieved on 3ed day of admessionLaparoscopic explorationOn 5th laparoscopic exploration was planned as the patient didnt show any improvement although there was no any signs of systemic response

Laparoscopic explorationDilated small bowel down to Rt colonSevere adhesive process at RIF Release of adhesions donePost-operativelyPatient is well & feeling goodWeak mobilizationNo abdominal apinNo fever , tachycardia, or hypotentionSoft lax abdomen , mild destensionNGT 150-200 cc / 24hrAXR decreased gaseous distension

Post-operativelyStill didnt pass stool or flatusNo vomiting , NGT 1050-200 cc greenish K 3.8 Postoperative ileus was considered & decided to start on erythromycin tab 500 mg BDCT scan abdomen was arranged for next day

4th day post operativelySlow recovery : still no stool or flatusBP: 120/70 ,, HR: 110 , T: 37.4Patient is well generally, not toxic or destressedAbdomen: Soft lax , mild distension, BS +veNa 134 K: 3.8CT abdomen: adhesive process at RIF with obstruction at the ceacum !!!!!!!!!!!!

Needs some tool to reach the diagnosis & exact cause of our problem12

Something is hidden as this boy.13

Need to be bold & go again into the deep looking for diagnosis14Exploratory laparotomy2 fibrous bands at the area of Lig. Of Treitz surrounding a segment of proximal ileum It is 20 cm long segment , 60 cm away from ileoceacal junctionThe segment is thickened adherent to posterior abdominal wall , with small perforation at mesenteric border.Small amount of pus & fibrinous patches in peritoneal cavityResectio anastomosis done using GIA

Post operative courseSmooth recoveryNo feverOral intake started on 4th day post opPassed stool on 5th dayTolerated oral intakeMinimal superficial wound infection Pus C/S no growthDischarged in good condition 9th day post opOPD follow up , clips removedHistopath: acute inflammatory process.Medications ErythromycinCeftazidimeGentamycin MetronidazolePantoprazoleEnoxiparin

23Adhesive Small bowel obstructionCongenital & acquired bandsBackground Peritoneal adhesions can be defined as abnormal fibrous bands between organs or tissues or both in the abdominal cavity that are normally separated.Adhesions may be acquired or congenitalCausesmost common cause of is abdomino-pelvic surgeryinflammatory conditionsIntraperitoneal infectionAbdominal traumaIntraperitoneal foreign bodies, including mesh, glove powder, suture material and spilled gallstones.

93% to 100% of patients who undergo transperitoneal surgery will develop postoperative adhesions.Intraabdominal adhesions are the most common cause of SBO accounting for approximately 65% to 75% of cases

The risk of SBO is 1% to 10% after appendectomy.6.4% after open cholecystectomy, 10% to 25% after intestinal surgery 17% to 25% after restorative proctocolectomy

Unable to accurately identify clear criteria for the success of nonoperative vs. operative treatment of SBO. The management of SBO and timing of surgical intervention continue to be governed by clinical decisions honed by training and experience

35

We need to have an imaging tool for appropriate management plan36

Gastrografin transit time may allow for the selection of appropriate patients for non-operative management. Some studies have shown when the contrast does not reach the colon after a designated time it indicates complete intestinal obstruction that is unlikely to resolve with conservative treatment. When the contrast does reach the large bowel, it indicates partial obstruction and patients are likely to respond to conservative treatment.Although Gastrografin does not cause resolution of small bowel obstruction there is strong evidence that it reduces hospital stay in those not requiring surgery.

1- sensitivity 0.9-1 , specificity 0.67-12-How gastrografin acts & it s safe. It can cause pneumonitis if aspiration occurs

38