Small Bowel Obstruction
Patient Presentation:
D.H. is a 42 year old female who presented to the emergency department with complaints of abdominal cramping, nausea, vomiting and constipation. D.H. states that two days ago she began vomiting brown to greenish watery emesis and has not been able to keep down any food or liquids. She also states that she has not been able to pass gas or have a bowel movement in the past five days which is abnormal for her. D.H.’s past medical history is unremarkable with the exception that she underwent a total abdominal hysterectomy four years ago. On examination, her abdomen is distended and firm to palpation with hypoactive bowel sounds audible in all four abdominal quadrants.
Differential List:
Small Bowel Obstruction; Inflammatory Bowel Disease (IBD) – Crohn’s Disease, Ulcerative Colitis; Volvulus; Abdominal Neoplasm
Diagnosis:
An abdominal x-ray and CT scan were completed and showed a small bowel obstruction due to mechanical obstruction from fibrous tissue or adhesions most likely from D.H.’s prior TAH.
With medical interventions such as insertion of a nasogastric tube or surgery, small bowel obstructions can be successfully resolved. However, without such interventions, small bowel obstructions can cut off blood and oxygen supply to the intestines and can lead to complications such as death of intestinal wall tissue or peritonitis.
Treatment:
D.H. was admitted to a gastrointestinal surgical floor where a NGT was inserted through her nose into her stomach. The NGT was connected to low continuous wall suction to decompress the bowel. D.H. was kept NPO and was given 4 mg Zofran® IV as needed every 6 hours to help with nausea. She was also on 2 mg morphine IV for pain every 2 hours as needed. She received Lactated Ringers at 125 mL/hr as well.
D.H.’s doctors wanted to see if the obstruction would resolve without surgical intervention but ultimately D.H. went to the operating room for an exploratory laparotomy with lysis of adhesions.
Outcome:
Postoperatively, D.H.’s NGT remained in place until she began passing gas. Before discontinuation of the NGT, a clamping trial was performed. D.H.’s NGT was clamped for 6 hours and residuals were checked. Her residuals were less than 200 mL so the NGT was removed and D.H. was started on a clear liquid diet and was slowly advanced to a regular diet as tolerated.
During the course of her hospitalization, D.H.’s potassium and magnesium levels were low at 3.4 mEq/L and 1.5 mEq/L, respectively. To treat her hypokalemia and hypomagnesemia D.H. received 40 mEq of potassium chloride IV and 2 grams of magnesium sulfate IV. D.H. continued to pass gas and on post operative day 3 began having bowel movements. She was discharged home on post operative day 4 with instructions to follow up with her surgeon in a few weeks.