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70 year old with intestinal obstruction
General Surgery

70 year old with intestinal obstruction

We present a 70 year old woman with colicky abdominal pains, vomiting, fever and failure to pass stools in 48 hours.
Patient is a known hypertensive on her usual medications and was apparently well until the aforementioned complaints.
This was the first episode in her presentation. Prior to that she has had no changes in bowel habits.
Examination
Febrile, anicteric, hydration fair, generally stable.
Vital signs :Temp 37.5 , BP 150/90, SPO2 99, RBS 6.7mmol/l
Chest clear,  heart sounds normal
Abdomen was tender without guarding, bowel sounds were present but reduced
Hernia orifices were intact. Lower midline incisional scar present and healthy.
DRE empty rectal ampulla , no masses found
Diagnosis : small bowel obstruction 2 adhesions
Patient was resuscitated with iv fluids. Iv antibiotics were given. She was counselled for laparotomy and she consented
Operative details
Findings: 1.small bowel obstruction caused by volvulous over adhesive band
2.Ischaemic terminal ileum

Ischaemic terminal ileal volvulus

 
Appearance of the terminal ileum after 72 hours


 
Anaesthesia: SAB
Supine position,  abdomen prepared routinely and draped.
Extended lower midline incision used to access peritoneum. Bowel detorsed and adhesive band divided. Bowel warmed with abdominal towel. Peristalsis noted to be present.
Bowel returned to abdomen . Closure of abdomen by apposition of skin only.
Decision taken to do second loook laboratory in 72hrs to asesss viability of bowel
Patient returned to ward to continue iv fluids antibiotics.
Second look laparotomy:unders spinal anaesthesia,  supine position,  abdomen opened. Bowel found to viable and well perfused. Bowel returned to abdomen . Layered closure of abdomen done.
Post operative period

Patient made satisfactory recovery.  Bowel sounds normal. She was able to feed and pass stools normally.
She was discharged on 5th day
Discussion: The small bowel has a robust blood supply and so ischemic pathologies of the small bowel can be managed conservatively instead of resection.  The presence of peristalsis can be a good sign of recovery from tne ischaemic injury. It’s obvious to most surgeons to choose resection on seeing this bowel however picture showing the recovered bowel gives hope to conservative management with second look laparotomy.
Dr Ametih
St Benito Menni Hospital
Adansi Dompoase
 

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