Small Bowel Obstruction
Patient Presentation:
KM, a 71-year-old female, presented to the emergency department with abdominal pain, abdominal distention, and vomiting. She reported not having a bowel movement for the past 5 days. KM has a past medical history of hypertension, congestive heart failure, coronary artery disease and past coronary artery bypass graft surgery. KM describes her abdominal pain as cramping and intermittent, and located in the mid-abdominal region. High-pitched bowel sounds were auscultated on exam. Lab work showed that the patient was dehydrated, hypokalemic, and was in hypochloremic metabolic alkalosis. LFT’s, lipase, lactate, and UA were normal. Rectal exam was negative for blood.
Differential Diagnoses:
A likely diagnosis for abdominal pain and distention, vomiting, and constipation is obstruction, which could be due to hernia, intussusception, tumor, volvulus, ileus, intestinal stricture, or fecal impaction. Other diagnoses to consider are gastroenteritis, appendicitis, pancreatitis, peritonitis, diverticulitis, and severe constipation. Would consider adhesions if KM had history of abdominal surgery, diverticulitis, Crohn’s Disease, or other bowel infection.
Diagnosis:
KUB (kidneys/ureters/bladder) abdominal X-Ray showed air/fluid levels, confirming diagnosis of small bowel obstruction.
Treatment:
KM was taken to the OR for an exploratory laparotomy. The surgeons discovered an obstructive mass in the patient’s jejunum. KM underwent jejunal mass resection with gastro-jejunal anastomosis and cholecystectomy. Tumor biopsy was sent for testing. An NG tube was placed to low continuous suction to decompress the stomach, and the patient was admitted to the SICU for further management. Postoperatively, the patient experienced complications due to respiratory distress due to fluid overload/pulmonary edema. The patient was diuresed, weaned from the ventilator within 3 days, and she was started on TPN.
On post-op day 5, KM had 500ml of bloody drainage from the NG tube. The patient became hypotensive and her hemoglobin and hematocrit dropped to 4.8 and 15.2, respectively. KM was transfused with 4 units of PRBCs and 2 units of FFP. She was started on a Protonix® IV drip. An Esophagogastroduodenoscopy was done at the bedside, which revealed a gastrojejunal anastomotic non-bleeding ulcer. Treatment was to continue resting the bowel, continue the Protonix® drip and the TPN, and monitor for further signs and symptoms of bleeding while trending H/H every 4 hours. Once vitals remained stable, the patient was restarted on Lasix® for diuresis.
Outcome:
The patient had melena stools for the next few days as the blood from the upper GI tract passed through the small and large intestines. However, KM had no further episodes of acute bleeding. Her H/H and vitals remained stable. Biopsy confirmed that the mass was non-cancerous. She was transferred to the floor where tube feeds were slowly started and advanced as tolerated.