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Image of the Day 10 : Acute Intestinal Obstruction, Small Bowel. Muhamad Na’im B. Ab Razak (MD USM)Disclaimer: The history was modified and no breach of patient’s confidentiality are made inthe publication of this case study. A 70 years old gentleman with Benign Prostate Hypertrophy and history of laparotomy fewyears back presented with abdominal pain, nausea and altered bowel habit for three daysduration. Patient was co-morbidly well but since for the past few days, he was having colickyabdominal pain centering at periumbilical region and radiates to the whole abdomen. The painscore was 5-6/10 and not relieve by medication taken at Klinik Kesihatan. He also complainsof passing out small, hard and black stool once daily since three days ago and not passingflatus on the day of admission. His oral intake was also reduce in view of feeling nauseatedeach time taking meal and only took clear fluids.On examination, he look cachexic, afebrile, normal vital sign and pink conjunctiva. Perabdomen examination, there is a lower midline incision scar and right transverse lowerincision scar. No discoloration of the abdomen noted. On palpation, the abdomen is soft andslightly distended with voluntary guarding around the umbilical area. No mass palpable perabdomen. Auscultation reveals hyperactive bowel sound and percussion note is resonance. Perrectal examination reveals empty rectum and moderately enlarged prostate which is firm,present of median sulcus and normal mucosa. Examination of other systems reveal no
abnormality. Bedside ultrasound shows dilated small bowel with fluid and faecal materialinside the bowel lumen. There is no free fluid collection and no abnormality of other organnoted.Labarotory investigation shows normal FBC, coagulation profile and no acidosis. Thepottasium however is borderline high but other electrolytes are normal.The Abdominal X Rays shows dilated small bowel with intraluminal gas and minimal faecalmaterials. There was no sign of extra luminal gas. A well defined rounded opacity also notedinside the pelvic cavity, ? of bladder stone. A diagnosis of Acute Intestinal Obstruction ofthe Small Bowel secondary to Adhesion Colic was made and managed conservatively with1) 4 hourly vital sign monitoring, 2) Ryle’s tube insertion with free flow and 4 hourlyaspiration, 3) Keep nil by mouth, 4) CBD insertion, 5) Strict monitoring of Input/Outputcharting, 6) Analgesia PRN with IV Fentanyl 50 mcg, 7) IVD fluids with 3 pints of NS and 2pints of D5% over 24 hours, 8) DXT monitoring, 9) IV Omeprazole 40 mg OD, 10) KIV forCVP insertion if patient become unwell 11) Replacement of loss fluid from RT, 12) GroupScreen and Hold (GSH) and 13) KIV for laparotomy if non resolving of obstruction or signsof bowel perforation or gangrene present.
DiscussionIntestinal obstruction is a very common surgical emergency that pose a high morbidity andmortality to the patient with inappropriate management. Being divided into large and smallbowel obstruction, both are caused by mechanical obstruction and non mechanical. 80% ofbowel obstructions involves the small bowel. The mechanical small bower obstruction isfurther divided into the luminal cause (foreign body, impacted fecal material, gallstone,bezoars, parasites and polypoidal tumors), intrinsic (atresia, tumors and inflammatorystructures like TB and Crohn disease) and and extrinsic cause (adhesion, hernias, volvulus,intussuception, band, inflammation and neoplastic mass).Other type of obstruction in small bowel is coined as ‘Paralytic Ileus’ and most commonlyoccurs post operatively (up to 72 hours), pancreatitis and mesenteric infarct. Less commoncause would be Pseudo obstruction (Ogilvie’s syndrome), Opiates, anticholinergics,retroperitoneal hemorrhage and metabolic cause (ketoacidosis, severe hypokalaemia).Although this entry is to discuss about small bowel obstruction, it is vital to differentiatebetween small vs large bowel obstruction as the definitive management is different. The tableillustrated below will give a summary for it. My Version is modified from original table by DrChew Keng Sheng, Emergency Physician of University Science Malaysia. You can refer tohis original table via this link. http://emergencymedic.blogspot.cm/2010/11/bowel-obstruction_15.html Acute Intestinal ObstructionCharacter Small bowel Large bowePain Colicky periumbilical pain. Not predominant, if present then located at lower abdomenVomiting Early in proximal obstruction It is often a late sign due to and late in distal obstruction the incompetency of the ileo- caecal valveAbdominal Distension Little or no in proximal Significant abdominal obstruction and significant in distension. distal obstructionBowel opening Late sign Altered bowel opening. Absolute obstruction when no bowel opening and not passing flatus.
Radiologic features Small bowel features: large bowel features: Valvulae conniventes – folds Haustrations: incomplete that cross the lumen crossing of folds across the completely lumen Normal features of small bowel: - No more than 3 mm wall thickness - Generally no more than 3 air fluid levels - No more than 3 cm diameter3,6,9 rule Maximal normal diameter in small bowel 3 cm Maximal normal diameter in large bowel 6 cm Maximal normal diameter in cecum 9 cmMisscelenous Paralytic ileus usually In colorectal Carcinoma painless. Left sided tumors: generally presented with altered bowel habit, blood or mucus PR, mass PR Right sided tumors: generally presented with weight loss, anemia, less obstructive symptomsOther Physical sign to look - Dehydrationfor - Hyper peristaltic bowel sound. Diminish in paralytic ileus or perforation/ infarction. - Hypovolumic shock in late stage - Abdominal mass - Hernia orifices - Rectal examination – blood, palpable mass.Specific type of mechanical - Strangulatedobstruction - Closed loop - Volvulus - Intussusception.Warning sign - Constant severe pain of sudden onset is omnious sign of bowel strangulation or infarct. - Presence of shock, leukocytosis, peritoneal irritation should rise of suspicion of strangulated obstruction.
Investigation that you should take includes 1) blood investigation (FBC, Coagulation profile,BUSE/Creat, LFT if indicated, Ca2+, Mg2+ and Po4- if indicated, blood culture if patient isseptic), 2) Imaging (Plain radiograph, Ultrasound abdomen, water soluble contrast study ifneeded.As for management, the conservative management as i outlined in the case history is adequateand almost 80% of the cases will resolve with conservative management. Indication forsurgical intervention includes 1) non resolving obstruction after 48 hours of conservativemanagement, 2) present of primary underlying cause like hernia, obstructing tumor, 3) sign ofperitoneal irritation.ReferenceChristian M & Gordon LC, “Acute Abdomen: Intestinal Obstruction”, Emergency Surgery,Surgery 26:3, Elsevier Ltd 2008