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Is Laparotomy The Right Treatment For Small Bowel Intestinal Obstruction?
Question: Dear Dr.
I have a patient, 68 years old female known diabetic, hypertensive and having hypercholesteremia. She presented with history of central bloating, abdominal pain and vomiting for 3 days. She had intermittent cramp like pain. She has not passed stool or gas for 3 days. She also gives history of constipation, with 3 - 4 days length but without pain. Initially she was presented in OPD a day ago where she was diagnosed with gastritis can was given symptomatic treatment. But she presented the following day as she continued to vomit. She was admitted and was started on simple analgesia and anti-emetic, with which her pain and vomiting settled down. She was kept in the hospital for further investigations.
Clinical Examination:
Her clinical examination revealed that she was tender in her epigastrium.
Investigations:
X-Ray Abdomen: dilated small bowel loops]
CT Abdomen: consistent with small bowel obstruction, cutoff point seen in mid small bowel on left side.
Laboratory investigations: mildly raised bilirubin (19.6 umol/L), raised CRP (34.7 mg/L) no abnormality detected in urine analysis.
Past medical history: Umbilical hernia repair (15 years ago) along with abdomenoplasty.
She was diagnosed with small bowel intestinal obstruction and was advised NGT which she denied.
Her plan of management was to observe her for 48 hours and if obstruction is not relieved, she will be operated for laparotomy for release of obstruction.
It is requested to kindly give us your expert opinion on the case if the treatment offered is appropriate for my patient, and if she will require laparotomy on the proposed day i.e. after 48 hours of conservative management, kindly update me if there is a chance that the surgery can be avoided. What should be plan of management for such patients as per the international guidelines.
I have a patient, 68 years old female known diabetic, hypertensive and having hypercholesteremia. She presented with history of central bloating, abdominal pain and vomiting for 3 days. She had intermittent cramp like pain. She has not passed stool or gas for 3 days. She also gives history of constipation, with 3 - 4 days length but without pain. Initially she was presented in OPD a day ago where she was diagnosed with gastritis can was given symptomatic treatment. But she presented the following day as she continued to vomit. She was admitted and was started on simple analgesia and anti-emetic, with which her pain and vomiting settled down. She was kept in the hospital for further investigations.
Clinical Examination:
Her clinical examination revealed that she was tender in her epigastrium.
Investigations:
X-Ray Abdomen: dilated small bowel loops]
CT Abdomen: consistent with small bowel obstruction, cutoff point seen in mid small bowel on left side.
Laboratory investigations: mildly raised bilirubin (19.6 umol/L), raised CRP (34.7 mg/L) no abnormality detected in urine analysis.
Past medical history: Umbilical hernia repair (15 years ago) along with abdomenoplasty.
She was diagnosed with small bowel intestinal obstruction and was advised NGT which she denied.
Her plan of management was to observe her for 48 hours and if obstruction is not relieved, she will be operated for laparotomy for release of obstruction.
It is requested to kindly give us your expert opinion on the case if the treatment offered is appropriate for my patient, and if she will require laparotomy on the proposed day i.e. after 48 hours of conservative management, kindly update me if there is a chance that the surgery can be avoided. What should be plan of management for such patients as per the international guidelines.
Brief Answer:
I feel she would require laparotomy and earlier than later.
Detailed Answer:
Hello,
I would like to know a few things before opining.
1. How did she look? Is she looking ill or toxic?
2. What is her TLC?
3. Is she having fever?
4. You have not mentioned in examination if she has abdominal distension or not?
5. Are bowel sounds present on Right side of abdomen and if yes are they hurried?
6. Is there still no passage of gas or stools?
If all these pointers are towards a positivity for obstruction, then given the history of Diabetes she is most likely to land up in Sepsis earlier than a non diabetic and I would not wait before performing an Emergency laparotomy and relieving the obstruction to decrease the chances of Sepsis. Intestinal perforation and Sepsis are the greatest fear and should be allowed to happen. Even if perforation does not take place, Stasis due to obstruction will lead to bacterial translocation thereby leading to Sepsis.
I feel you should review the patient again and decide upon the laparotomy depending upon the points I have outlined. Or you could ask her and let me know the answers so I can help and guide further.
Take care and all the best.
Dr Rishi, New XXXXXXX XXXXXXX
I feel she would require laparotomy and earlier than later.
Detailed Answer:
Hello,
I would like to know a few things before opining.
1. How did she look? Is she looking ill or toxic?
2. What is her TLC?
3. Is she having fever?
4. You have not mentioned in examination if she has abdominal distension or not?
5. Are bowel sounds present on Right side of abdomen and if yes are they hurried?
6. Is there still no passage of gas or stools?
If all these pointers are towards a positivity for obstruction, then given the history of Diabetes she is most likely to land up in Sepsis earlier than a non diabetic and I would not wait before performing an Emergency laparotomy and relieving the obstruction to decrease the chances of Sepsis. Intestinal perforation and Sepsis are the greatest fear and should be allowed to happen. Even if perforation does not take place, Stasis due to obstruction will lead to bacterial translocation thereby leading to Sepsis.
I feel you should review the patient again and decide upon the laparotomy depending upon the points I have outlined. Or you could ask her and let me know the answers so I can help and guide further.
Take care and all the best.
Dr Rishi, New XXXXXXX XXXXXXX
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
kindly find the reply to the missing details in the previous report, it is requested to give your updated opinion on the management plan:
1. How did she look? Is she looking ill or toxic?
*She appears well nourished, well and no obvious signs of distress.
2. What is her TLC?
*Her TLC is 4.9 ^9/L (normal)
3. Is she having fever?
*She is afebrile since admission.
4. You have not mentioned in examination if she has abdominal distension or not?
*Abdomen distended, tender at the left and right side with slight guarding.
5. Are bowel sounds present on Right side of abdomen and if yes are they hurried?
*Bowel sounds were found sluggish, (report has not commented the sides).
6. Is there still no passage of gas or stools?
*There is no passage of stool and gas till today.
1. How did she look? Is she looking ill or toxic?
*She appears well nourished, well and no obvious signs of distress.
2. What is her TLC?
*Her TLC is 4.9 ^9/L (normal)
3. Is she having fever?
*She is afebrile since admission.
4. You have not mentioned in examination if she has abdominal distension or not?
*Abdomen distended, tender at the left and right side with slight guarding.
5. Are bowel sounds present on Right side of abdomen and if yes are they hurried?
*Bowel sounds were found sluggish, (report has not commented the sides).
6. Is there still no passage of gas or stools?
*There is no passage of stool and gas till today.
Brief Answer:
You could wait another 24 hours at XXXXXXX
Detailed Answer:
Hello,
Then the stools and gas have not passed for over three days.
This would be an indication for Laparotomy.
In view of the answers you have given I feel the treatment done is right so far.
There would definitely be an element of Diabetic Gastroparesis and decreased intestinal motility in this patient.
But to wait over three days(72 hours) in an obstipated patient would not be advisable.
I suggest you convince her for NG tube aspiration and she could get better with that. Also, she would be dehydrated due to third spacing of fluids into the bowel wall and bowel wall edema would be starting.
She should be on broad spectrum antibiotics and in close observation for any deterioration.
If the condition remains the same for another 24 hours then there would be no reason to wait and a Laparotomy would be warranted,
I hope I have answered your question.
Do let me know if there would be other concerns.
Take care,
Dr Rishi, New XXXXXXX XXXXXXX
You could wait another 24 hours at XXXXXXX
Detailed Answer:
Hello,
Then the stools and gas have not passed for over three days.
This would be an indication for Laparotomy.
In view of the answers you have given I feel the treatment done is right so far.
There would definitely be an element of Diabetic Gastroparesis and decreased intestinal motility in this patient.
But to wait over three days(72 hours) in an obstipated patient would not be advisable.
I suggest you convince her for NG tube aspiration and she could get better with that. Also, she would be dehydrated due to third spacing of fluids into the bowel wall and bowel wall edema would be starting.
She should be on broad spectrum antibiotics and in close observation for any deterioration.
If the condition remains the same for another 24 hours then there would be no reason to wait and a Laparotomy would be warranted,
I hope I have answered your question.
Do let me know if there would be other concerns.
Take care,
Dr Rishi, New XXXXXXX XXXXXXX
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Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
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