Case Presentation Dr.MohammadAmin K Mirza Saudi Board of Surgery Holy Makkah, KSA 2008
History & Clinical Data • 34 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 – 3days • Passed hard stool – at the night prior to admission • H\O open appendectomy 1 yr back ( histopath: acute suppurative appendicitis) • No DM or HTN
History & Clinical Data cont.. • 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
Managemaent • NPO • NGT • D5 ¼ NS 125 ml/hr • Inj KCl 60 meq \24 hr • Intake output chart
Patient progress • She showed slow progress • Although she had no signs of peritonitis, sepsis, or any systemic response , there was no improvement regarding bowel movement , & she didn’t pass stool or fleatus • Correction of electrolytes was achieved on 3ed day of admession
Laparoscopic exploration • On 5th laparoscopic exploration was planned as the patient didn’t show any improvement although there was no any signs of systemic response
Laparoscopic exploration • Dilated small bowel down to Rt colon • Severe adhesive process at RIF • Release of adhesions done
Post-operatively • Patient is well & feeling good • Weak mobilization • No abdominal apin • No fever , tachycardia, or hypotention • Soft lax abdomen , mild destension • NGT 150-200 cc / 24hr • AXR – decreased gaseous distension
Post-operatively • Still didn’t pass stool or flatus • No vomiting , • NGT – 1050-200 cc greenish • K 3.8 • Postoperative ileus was considered & decided to start on erythromycin tab 500 mg BD • CT scan abdomen was arranged for next day
4th day post operatively • Slow recovery : still no stool or flatus • BP: 120/70 ,, HR: 110 , T: 37.4 • Patient is well generally, not toxic or destressed • Abdomen: Soft lax , mild distension, BS +ve • Na 134 K: 3.8 • CT abdomen: adhesive process at RIF with obstruction at the ceacum !!!!!!!!!!!!
Exploratory laparotomy • 2 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 junction • The segment is thickened adherent to posterior abdominal wall , with small perforation at mesenteric border. • Small amount of pus & fibrinous patches in peritoneal cavity • Resectio anastomosis done using GIA
Post operative course • Smooth recovery • No fever • Oral intake started on 4th day post op • Passed stool on 5th day • Tolerated oral intake • Minimal superficial wound infection • Pus C/S no growth • Discharged in good condition 9th day post op • OPD follow up , clips removed • Histopath: acute inflammatory process.
Medications • Erythromycin • Ceftazidime • Gentamycin • Metronidazole • Pantoprazole • Enoxiparin
Adhesive Small bowel obstruction Congenital & acquired bands
Background • 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 congenital
Causes • most common cause of is abdomino-pelvic surgery • inflammatory conditions • Intraperitoneal infection • Abdominal trauma • Intraperitoneal 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
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.