case presentation - srinakharinwirot...

Case Presentation

004 Yanisa Jarusyingdumrong

014 Intouch Sopchokchai

021 Kompiya Thongakaraniroj

041 Kritrath Panittaveekul

058 Todsapon Praphanuwat

063 Tanaporn Sangsuwan

132 Supitchaya Phirom

152 Apiphan Theeraphattana

Case• HN: 020546-44

• Age: 67 years old

• Sex: Female

• Ward: 13/2

• Religion: Buddhist

• Martial status: married

• Occupation: Homemaker

• Domicile: Nakhon Nayok Province, Thailand

• Medical eligibility: Social security

The following history is obtained from the

patient and her medical record and is reliable.

• Chief Complaint:

Tight squeezing abdominal pain 2 weeks prior

to admission

History of present Illness

• 2 weeks prior to admission

– Tight, squeezing pain at right and left lower

quadrants of the abdomen (Pain score = 5)

–Occurs in 30 minute durations with 30

minute intervals

–No radiation

–Nausea without vomiting

–Normal bowel habits; normal flatulence

History of present Illness

• 2 days prior to admission

–Pain and nausea continued in the same

manner but vomited after waking up

–Went to HRH Maha Chakri Sirindhorn

Medical Centre for treatment and received a

certain analgesic

–Pain subsided but recurred when the patient

returned home

History of present Illness

• 1 day prior to admission

–Tight, squeezing pain continues

–Vomited 2-3 times at random points during

the day, despite not eating

– Ingested a certain over-the-counter laxative,

subsequently resulting in 5 bowel

movements. All were watery; no mucous, no

fresh blood

Past History

• 1 year prior to admission

–Gut obstruction; treated by NG tube

insertion for decompression

–Gallstones; treated with laparoscopic

cholecystectomy at the MSMC

• Cervical cancer continuously receiving

treatment by brachytherapy and external beam

radiation therapy for 3 years at Maha

Vajiralongkorn Thanyaburi Hospital

• Underlying diseases:

–Diabetes mellitus

–Hypertension

–Dyslipidaemia

–Chronic kidney

disease

• Current medications:

–Omeprazole

–Dimenhydrinate

–Domperidone

–Alumina magnesia

–Simethicone

–Folic Acid

–Glipizide

• Allergies: None

• Accidents: None

• Blood transfusions: None

• Social History: No tobacco/alcohol

–Occupation : Homemaker

• Family History:

–Mother and younger sister has lung cancer

–2 younger brothers: both have DM and HT,

one has liver cancer

Physical Examination

• Vital sign : BP 103/70 mmHg , BT 36.5 C,

RR 20 /min, PR 95/min

• General appearance : A Thai woman, good

consciousness, co-operative, not pale, no

jaundice, no cyanosis

• Skin : no abnormal pigmentation, no rash, no

ecchymosis, no petechiae

• HEENT

–Head: normocephalic shape, no evidence of head

trauma, no mass, no lesion, no scar

–Eyes: no pale conjunctivae, anicteric sclerae, no

ptosis, no exophthalmos, no lid lag, no lid

retraction

–Ears: no deformity, no discharge, no hearing loss

–Nose: normal shape, no septal deviation, no

nasal swelling, no discharge

–Throat: no oral ulcer, pharynx and tonsils are not

injected, no tracheal shift, no cervical

lymphadenopathy

• CVS : normal s1s2, no murmur, PMI at 5th

intercostal space at midclavicular line, no

heaving, no thrill

• RS : clear both lungs, symmetrical chest wall,

no abnormal breath sounds, no adventitious

sounds

• Abdomen : hyperactive bowel sound, soft,

abdominal distension, tenderness at right and

left lower quadrants, no rebound tenderness,

no guarding, no palpable mass

Problem list

1. Colicky pain at right and left lower quadrants

2 weeks PTA

2. Nausea and vomiting 1 day PTA

3. Abnormal physical examination

- Abdominal distention

- Tenderness at right and left lower quadrants

Problem list

4. Underlying disease :

• Diabetes mellitus

• Hypertension

• Dyslipidemia

• Chronic kidney disease

• Post radiotherapy cervical cancer 3 years PTA

Differential diagnosis

1. Small bowel obstruction

2. Large bowel obstruction

Provisional diagnosis

• Partial small bowel obstruction

Lab Investigation

1. Complete Blood Count

Hb 10.1 g/dL

Hct 30.0 %

WBC count 9,250 / mm3

neutrophil 79.5%

lymphocyte 12.9%

monocyte 6.5%

eosinophil 0.9%

basophil 0.2%

Platelet 480,000 /mm3

Lab Investigation

2. Electrolyte

Na 134 mmol/L

K 3.86 mmol/L

Cl 91.4 mmol/L

HCO3- 23.2 mmol/L

Anion gap 23.28

Lab Investigation

3. DTX blood sugar = 155 mg/dL

Plain film

Treatment

Primary Management

• Resuscitation and rehydration : IV fluid and

electrolyte therapy

• NPO

• Retain nasogastric tube : decompression

• Foley catheter : monitor hourly urine

Specific Treatment

• Conservative treatment

• Surgical treatment

Conservative Treatment

• Intravenous fluid

• Nasogastric tube with suction

• Serial physical examination

• Serial film acute abdomen series

Surgical Treatment

• Indication

– complete small bowel obstruction

–during conservative treatment

• worsening abdominal pain

• peritoneal sign or sign of strangulation

• symptom not improved within 48 hrs.

Algorithm

ABDOMINAL DISTENSION

ileus mechanical obstruction

observation

IV fluid, NG suction, serial evaluation

improved not improved progressed

off NG tube,

start oral diet

continue observation fever, colic,

abdominal sign,

leukocytosis

discharge laparotomy

Knowledge

• Role of ultrasonography

– Limitation of plain film in proximal GI obstruction

– Bedside procedure

– No radiation -> safe in repeated scanning

– Real-time -> bowel movement

– Detect cause & site of obstruction

– Doppler -> Bowel wall perfusion

– Evaluate status for resuscitation

– High specificity

Typical SBO findings

1. Dilated bowel loops

2. Increased intraluminal fluid

3. Characteristic alternating peristalsis

4. Valvulae conniventes in jejunum “keyboard sign”

5. Circumscribed free fluid “Tanga sign”

*Surgical case?

1. Intraperitoneal free fluid

2. Bowel wall thickness of more than 4 mm

3. Decreased or absent peristalsis in previously

documented mechanically obstructed bowel

Take Home Message

Di

Dis

Dif

String

Step

Thank you