Case study on A patient with Intestinal bowel Obstruction

1. CASE STUDY
INTESTINAL BOWEL
OBSTRUCTION
PRESENTED TO :- Dr. KENZHEBEK
PRESENTED BY :- ASIF AHMED

2.  Case :Thai male, 73 years old  CC : Lower abdominal pain ,
abdominal distension 10 hrs. PTA Nausea, vomiting with gastric content 4 times
CASE

3. Present illness
 2 days PTA
o Lower abdominal pain
o sharp pain, no referred pain, severe pain alternate with mild pain
o pain was not related with position
o pain had slightly increase and happened all time

4. Duration of heavy pain is 5-10 minutes per time
o Interval of pain is 1 hr. pain score 8/10
o Nausea, no vomiting ,anorexia
o Medication : antipyretic and analgesic
Patient defecated 2 times in 2 days
first time, it look like bullet, no
mucus and blood
second time, it is watery diarrhea flatus

5. Past history
10 months PTA (12/9/56) He went to Kazakhstan hospital
o suspected gut obstruction
o explore laparotomy with decompression o no obvious cause of obstruction
o Final Diagnosis bowel ileus
Underlying disease: COPD poor control, diagnosed at "Nhong seur" hospital
 no allergy of food and drug
 no alcoholic
 History of nipa palm 10-20 rolls/day 20 years now quit 1 month
no malignancy

6. Physical examination
• V/S : BP 113/68 BT 36.5 PR 128 RR 20
• GA : a Thai elderly male, good consciousness, not pale , no jaundice, no cyanosis
• HEENT : no pale conjunctiva, anicteric sclera, no dry lip, no dry tongue, no lymphad
• CVS : normal S1S2 ,no murmurs
 RS :increase AP diameter, poor air entry, no tachypnea, normal breath
sound, no adventitious sound

7. • Abdominal : hypoactive bowel sound, abdominal distension,
generalized tenderness, no guarding, no rebound
tenderness, hypertympanic on percussion, no sign of
chronic liver disease
Surgical scar
 extremities : cap refill < 2sec, no pitting edema
 PR : no feces,no mass, no rectal shelf, normal sphincter tone

8. Lab investigation
 Complete blood count Hemoglobin 14.6 g/dL Hematocrit 42.7%
White blood cell 12.29 x103
/mm3
Neutrophil 81.2%
Lymphocyte 10.2% Platelet 407x103
/mm3
 Electrolyte Sodium
Chloride Potassium Bicarbonate
140 mmol/L
90 mmol/L 5.27 mmol/L 28.2 mmol/L
 BUN and Creatinine

9. Differential diagnosis:
 Bowel obstruction
 Bowel ileus
 Volvulus
 Enteritis

10. X-RAY
Hollow organs :
- Dilatation of small bowel
- Air-fluid level : different height
in the same loop pattern

11. CT WHOLE ABDOMEN

12. Conclusion:
o abdominal pain and abdominal distension with history of laparotomy
o Film acute abdomen series
o Sign of small bowel obstruction
o CT
o Transition point was seen at small bowel

13. Final diagnosis

14. Small bowel obstruction

15. Treatment:
 Conservative treatment
 Surgical treatment
o Explore laparotomy to lysis adhesion with decompression of small
bowel

16. Primary Treatment
 Resuscitation
 Monitor : V/S , I/O , CVP , Oxygen saturation
• NPO
 IV fluid , Nutrition
 NG with suction for decompression
 Foley catheter
 Medication(Antibiotics,Analgesics,Antiemetic, U/D Treatment)

17. Surgical Treatment
 Indication
 Dx: Complete small bowel obstruction
 Virgin abdomen
 Worsened of disease after conservative treatment
 Methods
 Explore Laparotomy
 Laparoscopic surgery

18. • Complication
 Bowel Strangulation
 Perforation
 Intra-abdominal abscess
• Prevention (Adhesion barrier)
 Sodium hyluronate and
Carboxymethylcellulose (Seprafilm®)
 Oxidized cellulose (Interceed®)