Case review and discussion of Intestinal Obstruction

in StemSocial3 months ago

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On Friday I was enjoying a day I thought would be absolutely free. Then I got a call from the registrar on my team (general surgery team) that we had a case of Intestinal Obstruction that needed our attention.

I will be telling the story while protecting the identity of the patient by referring to her by her pronoun only.

The first thing that came into my mind was why the General Surgery team on call isn't handling it. But it turned out that this was a patient that our surgery team had once handled and discharged from the hospital 9 months ago.

9 months ago she had presented with a case of intestinal obstruction that required surgical management. Months ago she had not passed feces for a very long time, her abdomen was distended, and she was vomiting. In addition to all that, she was also in painful distress as the content of her bowels no longer moved by peristalsis due to the obstruction.

It is like having a pipe blocked at one end...all that pressure will surmount and in the case of humans it will stretch the tissue and cause pain, it will flow backward and cause vomiting and since the pipe is blocked it won't be able to progress to the anus.

The formal surgical procedure was evident when we got to see her because she had a surgical scar on her abdomen.

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The scar was due to the midline abdominal incision (labeled M in the diagram above). Read about midline incisions here](https://teachmesurgery.com/general/presentations/incisions/) that was done on her abdomen to do a laparotomy.


A laparotomy is the surgical opening of the abdomen done for both investigative and therapeutic purposes.

Investigative in the sense that an acute abdomen (a cause of severe abdominal pain) may warrant a laparotomy simply to check what it is that's going on in the body.

To know more about laparotomies check here.


On getting there we saw that she was an ill-looking young lady and she was in painful distress.

We first tried to get the story behind why she was in the hospital even though we already could tell that it was something related to her intestines based on the referring team's notes they left. But it's good you don't leave these things to chance.

So we asked her informant (Her father) what brought them to the hospital.

He explained that since the last Sunday she had not passed feces and that she had vomited once and was now running a fever. We confirmed all this from her and with a thermometer.

She had a Nasogastric tube draining her gastric content, preventing vomiting, which also was the main conservative method of handling post-operative adhesion band obstructions. The Nasogastric tube was placed by the formal team in an attempt to relieve her abdominal symptoms of pain and slight distention.

She had a urine bag collecting urine through a tube from her urethra

As I earlier stated, she had also had surgery (9 months ago) for intestinal obstructions. All these findings were all peculiar with a particular type of intestinal obstructions caused by adhesion bands.



Adhesion bands are scar tissue forms when tissue that is not supposed to be bound together is bound together...Like the walls of the small intestine could be attached to the walls of the larger intestine or the the the Liver to the walls of the small intestine or the walls of the abdominal cavity to the walls of the bowel. Here is what Web MD said.


They usually come about as a result of operative procedures.

In surgical practice, it is possible to reduce the number of adhesions that come after surgery.

Surgeons usually:

  • Use gloves that have less talc or starch powder. This is because talc or starch powder is a foreign body.

  • Make the surgery as bloodless as possible, maintaining hemostasis. The mechanism through which this happens has not been understood by researchers. Read more here

  • Preventing ischemia and inflammation in the gut by proper handling can also help prevent fibrous tissue formation in the gut.

  • When the surgery is being performed the gut should be properly irrigated with normal saline, and

It has been found that high molecular weight dextran and Heparin and Non-Steroidal Anti Inflammatory Drugs play a role in preventing adhesion band formation

Proper closure of the abdominal cavity can help prevent adhesion formation as discussed in this article.


She was commenced on the conservative management for Post operational Intestinal obstructions due to adhesion bands. This includes the nasogastric tube that was placed in her stomach.

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Diagram showing the position of a nasogastric tube CRUK 340.svg
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CapillaryAction.svg

A nasogastric tube is a tube as the name suggests that goes from the nose all the way to the stomach. It drains by capillary pressure as the content of the stomach rises. it goes to higher levels in the tube because of its small surface area. This is a basic concept that is thought in basic physics.

Intravenous access was created with the use of an Intravenous cannula to take samples for investigations like her blood serum level for Electrolytes (Sodium, Potassium, Bicarbonate, and Chlorine) Urea, and creatinine for perfect assessment of her kidney function as a result of the disease and as treatment progresses.

She was given intravenous access to intravenous Mesporin (Ceftriaxone) and Tinidazole that could be changed with metronidazole.

She had feces in her rectum when a digital rectal examination was done to access for the tone of the sphincter and if the fecal matter was in her rectum. Signifying that the obstruction had relieved. Finding feces meant that she was pushing feces past whatever obstruction.

After that, the Obstetrics and the gynecological team were called to review her condition because on further assessment she had features that were suggestive of reproductive system affection.

Factors that led to the Consult

The intestinal pain was not colicky as is seen with intestinal obstruction. Colicky pain is a pain that comes and goes and it is because of normal gut movement (peristalsis).

As opposed to being colicky, her abdominal pain was constant and confined to her abdomen's lower aspect.

She also had vaginal discharge that had lasted close to a week. In addition, she had cervical motion tenderness as found by vaginal examinations.

She had a fever that only started resolving following the administration of antibiotics dealing with the infective process and PCM that dealt with the inflammatory process.

I dropped the consult letter with the Obstetrics and Gynecology team and they came to review the patient. What we suspected was pelvic inflammatory disease and that is why we asked for a consult from the Obstetrics and Gynecology team.

When they reviewed, they found the same symptoms and the same signs, however, nothing was able to be tied to the abdominal pain, the distention, and the vomiting she had a while ago.

All the while she had been receiving intravenous fluid and the medication.

I was asked recently to take out the nasogastric tube and I did.

What is an adhesion band intestinal obstructions?

Before we attempt to discuss what an intestinal obstruction caused by adhesion bands is, let us first understand intestinal obstructions as a whole.

According to the University of Ibadan Teaching Hospital, intestinal obstruction is:

A gastrointestinal condition in which digested material is prevented from passing normally through the bowel. It can be caused by fibrous tissue that compresses the gut, which can develop many years after abdominal surgery. It can also be caused by certain medications.

In Nigeria over 100,000 cases are seen every year. It can be managed in different ways depending on the cause of the obstruction.

Causes of Intestinal Obstruction

For simplicity, intestinal obstructions can be divided into mechanical and functional causes.

Mechanical causes have nothing to do with the musculature of the bowels but usually arise from factors that affect the lumen of the bowels such as adhesions, strictures, tumors, and pressure from neighboring structures that press into the lumen.

Functional causes are due to musculature problems that lead to less force of contraction during peristalsis. A common cause of functional intestinal obstruction is seen in pediatrics patience (Children) where there is a portion of the bowel that lacks the normal innervation of the gut. This is known as Hirschsprung's disease and affects 1 in 5,000 live births in Nigeria.

We are going to be discussing intestinal Obstructions caused by Adhesions but all obstructive diseases have similar presentation except for some minor clinical differences.

Signs and symptoms of Intestinal Obstruction

The classical symptoms of intestinal obstruction in order of how they progress are abdominal pain/abdominal distention and inability to pass feces/vomiting.

For those brought about by adhesion, there is usually a history of a surgical procedure involving the abdominal organs such as appendectomies, Cholocystetomies, colon or rectal or large bowel surgeries, hernia surgeries, and small bowel resections. It is also possible to have this presentation after a gynecological or obstetric procedure.

Check in the case review to find out what the consensus is about intestinal adhesions.

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In hernias, there will be a segment of the bowel that protrudes into a cavity. Most hernias are external but at times they may protrude into cavities inside the body. An abdominal CT is the best modality that can tell the clinician what is going on inside the abdomen.

Intestinal tumors can also narrow the lumen of the gut and prevent the content of the bowels from moving freely through. In addition to the obstructive symptoms of an intestinal mass, there may be also the inability to pass urine as the mass presses on the bladder. Read more here.

Inflammatory bowel disease shows features of the inflammation going on in the bowels. There is bloody stooling, weight loss, and iron deficiency anemia associated with this condition.

Diverticular disease arises when there is a pouching in the lumen of the intestine. One way to look at it is like having a pothole in the intestine, so as food is traveling it can get stuck and obstruct other food particles, leading to constipation. It can also present with diarrhea. A colonoscopy usually shows the areas of pouching in the lumen.

In a volvulus, there is an abnormal twisting of the bowel causing an obstruction. It is usually diagnosed with an X-ray image that shows the abnormal rotation of the bowel loop. This is what the International Foundation for Gastrointestinal Disorders had to say.

Intussiceptions are also very common in children just like Hirschsprung's disease and present with all the features of intestinal obstruction but can also have some unique features like the currant jelly feces that is seen in just intussusception and also because in this condition the bowel is invaginating into itself you might find a part of the gut protruding out of the anus. Check out Mayo clinic for more.

When there is fecal impaction, the feces becomes very hard and obstructs the gut. The normal features of intestinal obstruction once again present themselves except there is less incidence of vomiting. There is a type of diarrhea that is commonly seen in this type of obstruction usually described as explosive because the liquid fecal matter forces itself through tiny gaps in the rectum and anus.

Paralytic ileus is a paralysis of the bowel that arises after an intrabdominal surgery. It is usually accounted for after surgery and that is why the patient is placed on Nil Per Oral (NPO) after the surgery...all their nutrition is received intravenously. It can also be caused by some medications like opioids and diseases like Parkinson's have a similar effect on the bowel.

Risk factors

Some conditions can increase the risk of intestinal obstruction. From the above clinical features, it is evident that the intestines can be obstructed from surgical procedures, immediately in the case of paralytic ileus and over a long period of time as in the case of adhesions.

Crohns disease also significantly increases the risk of intestinal disease as does Tumor (particularly cancers) in the intestine.

Treatment

Intestinal obstructions are typically managed by the surgical team because if conservative measures do not work, then surgery may be needed and sometimes immediately.

The main conservative means of managing intestinal obstruction is through the use of a nasogastric tube. Check in the case discussion for more on what a nasogastric tube is.

The main surgical procedure done for intestinal obstruction is a laparotomy that is used to visualize the whole abdomen especially in the case of bleeding that does not have a focus. It is used to find the particular area that is bleeding to arrest it and take out the cause.

Surgical decompression can be done to the bowel emptying the area that had been obstructed by the fecal matter.

Sometimes the intestine may need to be excised and anastomosed especially when there is a nonfunctioning segment. This is done in Hirschsprung's disease to deal with the non-functioning segment.

Complications

Intestinal obstruction can be complicated by the condition itself and the surgical procedure.

The condition can lead to tissue death or worse intestinal rupture, both life-threatening.

With tissue death, the blood supply to the intestine gradually diminish until the cell of the particular portion die and cause harm to the body.

Intestinal rupture can occur due to the continuous peristaltic force placed on the already distended and weakened bowel segment. This then causes the content of the bowel to leak into the peritoneal cavity and infects the cavity.

The surgical complication of intestinal obstruction is typically adhesion bands or paralytic ileus and you can find that almost everywhere in this article, including how to prevent it.

Conclusion

Intestinal obstructions are surgical cases and are managed typically by the surgical team. They have symptoms that the patient can give you that may reveal what they are or there may be signs that can be elicited

After investigations are done it is possible to be sure of the specific cause of the obstruction but sometimes it may not be clear and may require a laparotomy.

Treatment may be conservative especially if the case is not life distressing. Patients who can present very distressed typically require surgical management.

References

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A lot of information to consume here. For a few minutes, I felt like I was in a hospital environment with your team. I thought her case would require another surgery. So, when does intestinal obstruction requires surgery?

Mostly if the conservative management fails.

Marked by increase in abdominal detention and worsening of pain.

Thank you for reading through...I'm glad you pick up stuff from it.

Interesting read. !discovery 30


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