Mr. Sulaiman is a 69-year-old gentleman who presented to the hospital on 28 February 2011 with complaints of colicky abdominal pain associated with abdominal distention, vomiting and constipation for two days prior to admission. Mr. Sulaiman is a known case of hypertension for the past 10 years, and has had a previous sigmoid colectomy for a sigmoid volvulus with necrosis. Mr. Sulaiman was well prior to his admission. He has no fever, shortness of breath, chest pain, and denies any urinary symptoms. Mr. Sulaiman has a family history of colorectal carcinoma, and has been smoking for the past 50 years. He does not have loss of weight or change in bowel habits. He is asymptomatic of anemia.
On admission, he was well hydrated and haemodynamically stable with stable vital signs. There was generalized abdominal tenderness most severe over the periumbilical area. Bowel sounds were heard and the abdomen appeared distended with bowel gas.
Investigation showed dilated loops of small bowel located centrally, enabling the diagnosis of an intestinal obstruction, most likely secondary to adhesions from the previous surgery. He was managed conservatively in the ward, given intravenous ranitidine and intramuscular pethidine as well as maintenance intravenous fluids. His clinical condition improved and he was discharged well after four days of being warded. He is to be seen again as an outpatient in 3 months.
2) CLINICAL HISTORY
Mr. Sulaiman, a retired 69-year-old Malay gentleman presented with severe generalized colicky abdominal pain, abdominal distention and vomiting for two days prior to admission. The pain was sharp in nature, being maximal in the periumbilical region with no radiation. The severity of pain increased with time, with no identifiable precipitating or relieving factors. It was associated with abdominal distention, nausea and vomiting. The abdominal distention was progressive, uncomfortable, and came together with the abdominal pain. Also associated were 4 episodes of vomiting which aggravated the abdominal pain and discomfort. Vomitus consisted of partially digested food particles which are not bile-stained and not bloody. He had 1 episode of loose stool and subsequently did not pass any flatus or stools. There is no fever, chills, or rigors. There are no changes in bowel habits: no rectal bleeding, melaena, or mucus discharge. There are no symptoms of a urinary tract infection or benign prostatic hypertrophy.
Mr. Sulaiman had reduced appetite for the past 2 days, but has no noticeable loss of weight. There are no symptoms of anaemia: no lethargy, palpitations, reduced effort tolerance, dizziness or syncopal attacks. Mr. Sulaiman has no shortness of breath.
Mr. Sulaiman has hypertension for the past 10 years and is on regular follow ups. His blood pressure was told to be well-controlled on oral medication. In 1998, he was admitted for similar symptoms and was diagnosed to have sigmoid volvulus with necrosis on laparotomy. Sigmoid colectomy was performed and he was discharged uneventfully. There is no family history of hypertension or diabetes mellitus. His elder sister passed away due to advanced colon cancer in year 2000. His wife has passed away in year 2007 due to advanced ovarian cancer. He does not consume alcoholic drinks. Mr. Sulaiman has smoked 10 cigarettes a day for the past 50 years. He lives alone in Batu Pahat in a village, with a son living nearby. He is supported financially by the said son, who also visits him regularly.
3) FINDINGS ON CLINICAL EXAMINATION
Mr. Sulaiman is a Malay elderly gentleman who is of medium size and build. He is conscious, alert and communicative. Patient is lying propped up on the bed. He looks distressed and appears to be in pain. However, he is not in respiratory distress. Pulse rate is 90 beats per minute, regular in rhythm, strong in volume and there is no radio-radial delay. His respiratory rate is 16 breaths per minute, temperature is 37.0°C and the blood pressure is 140/88mmHg. Hydration status is good. Capillary refill time is less than 2 seconds. Mr. Sulaiman has several gadgets attached: a venous cannula over his right arm for intravenous fluid replacement, a nasogastric tube, and a urinary catheter. He has no jaundice or pallor. Jugular venous pressure is not raised. Cardiovascular and respiratory examinations are normal. No cervical lymphadenopathy.
The abdomen is distended with a flat umbilicus. There is a well-healed midline scar on the abdomen measuring 20cm, originating from 6cm above the umbilicus. The abdomen moves up and down with respiration. There are no striae, visible dilated veins, visible pulsations, visible peristalsis or obvious masses. There is no visible cough impulse. There is no guarding, but there is generalized tenderness over the whole abdomen most severe over the umbilical region. No masses are felt. The liver is not palpable with a liver span measuring 9cm. The spleen was not palpable and the Traube space was resonant. There is neither shifting dullness nor a fluid thrill. Auscultation of the abdomen demonstrated active bowel sounds. No bruit is heard over the abdominal aorta, renal arteries and iliac arteries. The kidneys are not palpable or ballotable. The renal punch on the patient elicited no tenderness. No hernia on groin and scrotal examination. Per rectal examination revealed an empty rectum with normal prostate gland. No rectal masses are felt. No perianal pathology seen.
4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING
Intestinal obstruction due to adhesions
Reasoning: History of colicky abdominal pain and abdominal distention associated with vomiting, followed by constipation is suggestive of an intestinal obstruction. A previous history of abdominal surgery due to a sigmoid volvulus complicated with gut necrosis favours this diagnosis.
Reasoning: The symptoms of intestinal obstruction maybe due to a circumferential carcinoma obstructing the bowel lumen. There is a positive family history of colorectal malignancy and Mr. Sulaiman has been smoking for a long time. However, there are no masses felt, and no signs of advanced or metastatic disease, with no hepatomegaly, jaundice, chest symptoms, or a history of pronounced weight loss. Additionally, there is no change in bowel habits and no anaemic symptoms.
Perforated abdominal viscus with peritonitis
Reasoning: This may be secondary to an obstructed bowel due to adhesions. The onset of severe generalized abdominal pain and vomiting support this, however, the colicky nature of the pain, presence of bowel sounds and the lack of guarding make this diagnosis unlikely. Besides that, patient is afebrile and not tachycardic.
5) IDENTIFY AND PRIORITISE THE PROBLEMS
1. Hypovolaemia and electrolyte imbalance. This will be due to fluid and electrolytes sequestration into the intestines which does not get reabsorbed distal to the site of intestinal obstruction. There is also profuse vomiting contributing to the loss of fluids and electrolyte imbalance. Patient should be resuscitated with adequate intravenous fluid and the electrolyte abnormalities to be corrected promptly to prevent hypovolaemic shock and arrhythmias.
2. Strangulation of the intestine and perforation of the intestine may occur if the dilatation of the small bowel compromises the blood supply to the segment that is obstructed. This may lead to a disastrous consequence of shock, chemical and bacterial peritonitis and sepsis.
3. Metabolic acidosis and other electrolyte abnormalities may occur with prolonged intestinal obstruction, and this may lead to coma, seizures, respiratory distress or cardiac arrest.
4. Vomiting may introduce caustic and non-sterile matter into the respiratory tract, leading to aspiration pneumonia or Mendelson’s syndrome. This may cause respiratory failure and compromise the chance of a surgery that may be needed to resolve his patient’s intestinal obstruction.
5. Abdominal pain and distention causing significant discomfort in this elderly gentleman would not be desirable, as he might become uncooperative or he may easily go into an unmanageable acute confusional state, or may no longer be able to give accurate points in history. This would make screening for peritonitis or bowel ischaemia challenging.
6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS
Full blood count: To look for leukocytosis which indicates an infection. To assess the haemoglobin level, mean cell volume and mean cell haemoglobin level for signs of occult blood loss and the type of anaemia patient has. The results showed no abnormalities.
Renal function test: Screening for electrolyte abnormalities or renal impairment. Mr. Sulaiman has high urea 8.3mmol/L; low potassium 3.2mmol/L. High urea is an indicator of dehydration, which needs to be corrected to ensure haemodynamic stability. Low potassium could be due to the fluid losses and should be corrected urgently to prevent cardiotoxic levels of hypokalaemia.
Arterial blood gas (ABG): To screen for respiratory or metabolic acidosis. ABG result was normal.
Electrocardiogram (ECG): To screen for any ischaemic changes especially since Mr. Sulaiman is a known hypertensive, who may have ischaemic heart disease, as well as to monitor the ECG for changes consistent with hypokalaemia or hyperkalaemia. Mr. Sulaiman’s ECG was normal.
Chest Radiograph: Look for air under the diaphragm (to rule out perforated abdominal viscus) as well as lung consolidation which may occur due to aspiration pneumonia. It is also used as a baseline assessment of the lungs in view of possible surgery.
Abdominal supine X-ray: To look for radiographic features of intestinal obstruction. There are dilated loops of small bowel located centrally, less than 6cm in caliber, with plica circularis seen. This indicates that there is a small bowel obstruction.
Abdominal erect X-ray: May have been performed to look for air-fluid levels, consistent with intestinal obstruction.
7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION
My working diagnosis is small bowel intestinal obstruction secondary to adhesion due to previous laparotomy.
– Initiate aggressive intravenous fluid replacement, with titration to keep vital signs within normal limits, and correct hypokalaemia via intravenous potassium chloride.
– Instruct the patient to be nil by mouth for 48 hours, and monitor progress.
– Nurse the patient in the head up position to prevent gastric aspiration, insertion of a nasogastric tube for aspiration of gastric contents.
– Perform urinary catheterisation to accurately monitor urine output.
– Provide pain relief via intramuscular pethidine 50mg tds
– Intravenous ranitidine 50mg tds
– Keep a strict input/output chart
– Monitor vital signs 4 hourly
– Prepare for laparotomy if the patient’s condition deteriorates or does not resolve within 48 hours.
– Obtain written consent for the surgery and treatment in the ward.
8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)
Mr. Sulaiman was warded for 4 days. On admission he was fasted and had a nasogastric tube inserted. He had 2 bouts of severe vomiting which gradually subsided throughout his stay here. For the first and second day, aspiration of the stomach contents was performed through the nasogastric tube. It was removed on the 3rd day of admission, as he did not have any more vomiting, however he still failed to pass flatus or stools. On that day, however, he was markedly well, and had the attached gadgets, the urinary catheter and the intravenous cannula removed. On the 4th and last day of admission, the abdominal distension had resolved completely, with a return of bowel function heralded by the passing of flatus and stools and the absence of vomiting or abdominal pain. He was tolerating well orally, and the decision to discharge Mr. Sulaiman was made.
He was discharged on 4 March 2011 healthy.
9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION
An appointment has been made with Mr. Sulaiman for him to come for follow-up three months later in the surgical outpatient department (SOPD). The aim is to review him clinically and monitor his disease progress.
I will advise patient to continue to take his antihypertensive medication. Educate the patient regarding the possible side effects of medication, complications of uncontrolled hypertension and the importance of compliance to treatment. I will also encourage him to go to the nearest Klinik Kesihatan for regular follow-up. I will also motivate him to stop smoking by explaining to him the harmful effects of smoking.
I would like to prescribe the anti-hypertensive which Mr. Sulaiman has been taking in the past and has responded well to treatment:
Tablet Nifedipine 10mg tds for three months
10) REFERRAL LETTER (MANDATORY)
Ward 8 (Surgical),
Hospital Batu Pahat,
Batu Pahat 83000, Johor.
To: Surgeon in Charge, Surgical Outpatient Department, Hospital Batu Pahat
Re: Mr Sulaiman (IC Number: 410828-01-5467)
Dear Dr, thank you for seeing this patient, Mr Sulaiman, a 69-year-old elderly Malay gentleman with hypertension for the past 10 years. He was admitted on the 28 February 2011 due to abdominal obstruction secondary to adhesions. He has past history of laparotomy in 1998 due to sigmoid volvulus. He has family history of colon cancer. He was discharged well on 4 March 2011 after conservative management.
I am referring this patient to you for a colonoscopic examination to rule out any colorectal cancer, in view of his positive family history, heavy smoking history and his advancing age. Please do not hesitate to contact me if there is any doubt regarding this patient.
Kow Lip Jeen (C1/09)
International Medical University
11) LEARNING ISSUES IN THE 8 IMU OUTCOMES
Application of basic science in the practice of medicine
1. How does post-operative adhesion leads to intestinal obstruction?
In essence, there are two types of adhesions namely the fibrinous and the fibrous adhesions. Fibrinous adhesion is the development of fibrin strands as part of the body’s natural response to tissue injury, which also constitutes the major part of the healing process. Fibrins are usually laid down on the surface of the injured tissue. Excessive deposition of fibrin is kept in check by the fibrinolytic enzymes so that there will not be unnecessary deposition of fibrin on the surface of normal tissue. When these fibrinolytic enzymes fail to carry out their functions, the fibrin deposition goes unchecked. This can lead to the eventual development of fibrous adhesions which bridge the surfaces of the neighbouring structures which in the peritoneal cavity. Sometimes the neighbouring loops of intestine can be pulled by these fibrous strands and get twisted. These lead to intestinal obstruction. Mr. Sulaiman underwent open laparotomy in 1998 for sigmoid volvulus and may have developed adhesions post-operatively and caused the intestinal obstruction for his current admission.
2. What are the different approaches in managing patients with intestinal obstruction?
The first step in managing patient with intestinal obstruction is resuscitation. As large amount of fluid is lost in the form of digestive secretions and profuse vomiting, intravenous fluid resuscitation should be initiated as soon as possible after the initial assessment of patient’s general condition as these patients are vulnerable to hypovolaemia. Conservative treatment should be employed in cases of simple intestinal obstruction. Oral intake should be discontinued. Any plasma electrolyte abnormalities should also be corrected. Nasogastric tube is inserted and gastric contents are aspirated to prevent gastric aspiration. Surgical intervention is only indicated in cases of complicated intestinal obstruction such as strangulated bowel, perforated bowel, peritonitis or those patients who do not respond to conservative treatment after 48 hours.
Professionalism, ethics and personal development
3. Is adhesiolysis justified in the case of Mr. Sulaiman in view of his recurrent episodes of intestinal obstruction?
Adhesiolysis in this case should not be performed hastily. This is because the cause of the current admission is due to adhesions and adhesiolysis will further predispose the patient to further problems of this nature. The handling of the intestines will cause inflammation and hence the formation of fibrin adhesions. Therefore, in this case, even in view of the recurrence of intestinal obstruction, there is no role for adhesiolysis. Conservative management should be prioritised as the first-line of treatment in Mr Sulaiman, and similar cases.
Self-directed life-long learning and information management
4. The role of adhesion barrier in prevention of post-operative adhesions formation and its related complications such as intestinal obstruction.
The advancement in biomedical technology has led to the development of synthetic films or even gels which function as adhesion barrier. These can be applied between layers of tissues before the end of surgery to provide a barrier between the traumatised tissue surfaces. This technique allows the injured tissues to heal while preventing the adjacent injured tissue surfaces to adhere to each other through the formation of adhesive fibrins. Up till now, the use of adhesion barrier is till very limited in Malaysia due to its questionable efficacy and limited availability. Hopefully through further improvement of the product in the future, patients like Mr. Sulaiman will benefit from this and this will greatly reduce the morbidity and mortality associated with intestinal obstruction secondary to adhesions.