Acute Intestinal Obstruction (Recurrence)

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Recurrent Acute Intestinal Obstruction : 

Recurrent Acute Intestinal Obstruction Dr Prabal Dutta MBBS

Case : 

Case 22 yrs old male Admitted on 22 Feb 09 with c/o: Sudden onset colicky central abdominal pain Abdominal distension Vomiting on 1st day Constipation

Known case of Acute Intestinal Obstruction (Optd) : 

Known case of Acute Intestinal Obstruction (Optd) Initial onset : 22 Dec 07 Operated on 28 Dec 07 Exploratory laparotomy done for Acute Intestinal Obstruction 30 cms of gangrenous proximal ileum resected with side-to-side anastomosis done LMC P3(T-24) – P2(T-24) – P2(Perm)

O/E on 22 Feb 09 : 

O/E on 22 Feb 09 Vitals maintained Afebrile P 72 /min R 20 /min BP 120 /80 mm of Hg P/A Distended No tenderness Well healed central scar seen in mid-line Bowel sounds - sluggish

Mgmt from 22 Feb 09 – 26 Feb 09 (1st to 5th day) : 

Mgmt from 22 Feb 09 – 26 Feb 09 (1st to 5th day) NPO + Ryle’s tube aspiration IV fluids DNS 500 ml over 04 h 5% Dextrose 2500 ml over 20 h 20 mEq of K Cl 10 ml/ 150 mg q 08 h Inj Ciprofloxacin 200 mg IV q 12h Inj Gentamicin 60 mg IV q 8h Inj Metronidazole 500 mg IV q 8h Inj Perinorm 10 mg IV q 12h Inj Spasmoproxyvon 1 amp IV sos Abdominal girth charting q 24h I/O chart q 24h TRR, BP record q 06h

O/E on 23 Feb 09 (2nd day) : 

O/E on 23 Feb 09 (2nd day) Patient better Passed flatus Pain abdomen – less Vitals maintained P/A Soft Abdominal girth – 81 cms I/O 3500 ml/ 1050 ml

Slide 7: 

Plain x-ray abdomen – PA erect view Shows multiple air-fluid levels in bowel loops

Slide 8: 

Plain x-ray abdomen – PA supine view Shows distended bowel loops

O/E on 24 Feb 09 (3rd day) : 

O/E on 24 Feb 09 (3rd day) Comfortable Passed flatus No distension Vitals maintained P/A Soft Abdominal girth – 81 cms (no incr) I/O 3500 ml/ 2250 ml Enema given – No response

O/E on 25 Feb 09 (4th day) : 

O/E on 25 Feb 09 (4th day) 2 episodes of colicky pain abdomen Not passed flatus Vitals maintained Afebrile P 78 /min R 20 /min BP 114/ 70 mm of Hg P/A Soft Abdominal girth – 82.5 cms (incr by 1.5 cms from 1st day)

Slide 11: 

Plain x-ray abdomen – PA erect view Shows multiple air-fluid levels in bowel loops

Slide 12: 

Plain x-ray abdomen – PA supine view

O/E on 26 Feb 09 (5th day) : 

O/E on 26 Feb 09 (5th day) 2 episodes of colicky pain abdomen Not passed flatus Peristaltic movements seen (from left to right side) Vomited twice Vitals maintained Afebrile P 88 /min R 20 /min BP 122/ 80 mm of Hg P/A Soft No guarding /rigidity Abdominal girth – 84.5 cms (incr by 3.5 cms from 1st day)

Slide 14: 

X-ray chest & Abdomen – PA view

Slide 15: 

Plain x-ray abdomen – PA supine view Shows distended bowel loops

Slide 16: 

Plain x-ray abdomen – PA erect view Multiple central fluid levels seen

O/E on 27 Feb 09 (6th day) : 

O/E on 27 Feb 09 (6th day) Not passed flatus Vitals maintained Afebrile P 96 /min R 24 /min BP 124/ 82 mm of Hg P/A Soft Well healed mid-line scar of previous surgery seen No guarding/ rigidity Abdominal girth – 85 cms (incr by 4 cms from 1st day)

Mgmt from 27 Feb 09 (6th day) : 

Mgmt from 27 Feb 09 (6th day) NPO + Ryle’s tube aspiration q 2h IV fluids 5% Dextrose 1500 ml over 12 h Normal saline 1500 ml over 12 h 20 mEq of K Cl 10 ml/ 150 mg q 06 h Inj Ceftazidime (FORTWIN) 200 mg IV q 12h Inj Amikacin 60 mg IV q 8h Inj Metronidazole (FLAGYL) 500 mg IV q 8h Inj Pantoprazole 40 mg IV q 24h Inj M-Vit 1 amp IV q 24h Low glycerin enema stat TRR, BP record q 06h

Lab Inv : 

Lab Inv Hb 14.0 g% TLC 8,600 / CU MM DLC P66 L26 M04 E04 B00 Blood urea 30 mg% S. Creatinine 0.8 mg% Blood sugar (R) 90 mg%

Slide 20: 

Plain x-ray abdomen – PA supine view Shows distended bowel loops

Slide 21: 

Plain x-ray abdomen – PA supine view

Slide 22: 

Plain x-ray abdomen – PA erect view Shows multiple fluid levels with gas above (‘step-ladder’ pattern); ileal obstruction

Slide 23: 

Plain x-ray abdomen – PA erect view

Slide 24: 

X-ray chest – PA view

Surgery on 28 Feb 09 (7th day) : 

Surgery on 28 Feb 09 (7th day) Exploratory Laparotomy and Adhesionolysis Per Op Findings: Band causing extrinsic compression over ileum 2 feet from ileo-caecal junction causing dilatation of proximal ileum Multiple ileo-ileal, ileo-jejunal adhesions causing sub-acute compression of small gut acting in cohesion Functioning patent side-to-side ileo-ileal anastomosis Omentum seen enveloping bowel loops in two layers – superficial and deep through the small bowel loop and inserting with pelvic peritoneal layer – causing a cocoon-like effect

Details of surgery : 

Details of surgery Band causing extrinsic compression of ileo-ileal loop 2 feet proximal to IC junction sharply divided; ileal loop seen knotted around the branch and its branches Multiple strong inter-loop adhesions divided sharply Bowel contents milked proximally and 1.5 L sucked out through Ryle’s tube – bowel decompressed Haemostasis checked Small gut scanned from DJ flexure to IC junction – continuity ascertained (any obstruction ruled out) Haemostasis checked Wound closed in layers after peritoneal toilet over pelvic drain

01 Mar 09 (1st post-op day) : 

01 Mar 09 (1st post-op day) Comfortable Afebrile Hydration – fair Not passed flatus P/A Soft No soakage at optd site BS - sluggish I/O 4750 ml/ 1475 ml Pelvic drain 100 ml (sero-sanguinous) Ryle’s tube aspiration 20 ml

Mgmt ( 1st to 4th Post-Op days in ICU) : 

Mgmt ( 1st to 4th Post-Op days in ICU) NPO + Ryle’s tube aspiration q 2h ( till 3rd post-op days) IV fluids (till 2nd post-op days) 5% Dextrose 1000 ml over 12 h Ringer’s lactate 1000 ml over 12 h 20 mEq of K Cl 10 ml/ 150 mg q 08 h Inj Ceftazidime (FORTWIN) 200 mg IV q 12h x 7 days Inj Amikacin 60 mg IV q 8h x 7 days Inj Metronidazole (FLAGYL) 500 mg IV q 8h x 7 days Inj Pantoprazole 40 mg IV q 24h x 4 days Inj Fortwin 30 mg IV q 8h Inj Voveran 75 mg IV q 12h I/O chart q 2h (1st day) then q 24h Abdominal girth monitoring q 8h (1st day)

02 Mar 09 (2nd post-op day) : 

02 Mar 09 (2nd post-op day) Febrile T 99.6 degree F P 90 /min R 22 /min BP 124/ 80 mm of Hg Comfortable Not passed flatus No soakage at optd site I/O 3600 ml/ 2900 ml Pelvic drain 370 ml (sero-sanguinous) Ryle’s tube aspiration 150 ml

03 Mar 09 (3rd post-op day) : 

03 Mar 09 (3rd post-op day) Vitals maintained Afebrile P 90 /min R 20 /min BP 130/ 80 mm of Hg Passed flatus Feels hungry P/A Dressing in situ – no soakage / swelling I/O 2800 ml/ 2400 ml Pelvic drain 60 ml Ryle’s tube aspiration 120 ml Rx modified Fluid diet 1000 ml PO q 24h Syp K Cl 5 ml (500 mg) PO q 8h 5% dextrose 1000 ml IV Normal saline 500 ml IV

04 Mar 09 (4th post-op day) : 

04 Mar 09 (4th post-op day) Vitals maintained Afebrile P 86 /min R 20 /min BP 130/ 80 mm of Hg P/A Soft Bowel sounds + I/O 1800 ml + 1000 ml oral/ 1850 ml Pelvic drain 130 ml Rx modified Fluid diet IV fluids omitted Syp K Cl omitted

5th Mar 09 – 16 Mar 09 in Ac Surg Wd : 

5th Mar 09 – 16 Mar 09 in Ac Surg Wd Uneventful Reviewed after 4 wks SL on 16 Apr 09 Asymptomatic Placed in LMC P3 (T-24)

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