A rare case of intestinal obstruction.ppt

8/14/2019 A rare case of intestinal obstruction.ppt

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History of presentingillness

57 yrs old Mr.x. presented with

Abdominal distension 2days Vomiting bilious 2days Obstipation 2 days

- not on oral feeds 2days- oliguria 2days


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GENERAL EXAMINATIONconscious,oriented,afebrile with an anxious look,answeringquestions.

moderately built/nourishedhydration fair

*patient is pale

VITALSpulse:88/mBP :100/70mm HgTemp: NRespiratory rate:20/min


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Past history k/c of APD 30years on peptic ulcerdrugs.Advised surgery

Vague abdominal discomfort yrspersonal history

. Not a known smoker/alcoholic

.bowel/bladder habits normal


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SYSTEMIC

EXAMINATIONCVS :s1,s2 present.no added sounds,no murmurs

RS: NVBS ,occasional creps heard in both lowerlobes

CNS: no FND


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PER ABDOMENINSPECTION : abdomen distended

flanks fullhernial orifice/scrotum-N

PALPATION : no warmthtenderness + in epigastric and umblical regionguarding/rigidity + in upper abdomen

no mass palpableshifting dullness present

PERCUSSION : resonantno obliteration of liver dullness

AUSCULTATION : BS- sluggishP/R : sphincter tone N ,rectum empty,no fecal staining.


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INVESTIGATIONSCBC: TC - 10200DC - P65,L32,E3ESR -20 mm-first hourHb -7.6g/dlPCV -24Plt - 1.9 lacs

RFT: Sugar 96Urea -38Crt - 1.1

Na 133K 3.2


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CHEST X-RAY


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X-RAY ABDOMEN - erect

L R


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X-RAY ABDOMEN -supine

L R


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ECG small q waves in leads 2,3,aVfUSG abdomen distended stomach

with food particles withmultiple dilated bowel loops


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DIAGNOSISACUTE INTESTINAL OBSTRUCTION

PLANLAPROTOMY AND PROCEED..


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Management Iv fluids Ryles tube aspiration : bilious

Bladder catheterisation Abdomen girth chart

DRIP AND SUCK EVERY CASE OFINTESTINAL OBSTRUCTION


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ON LAPROTOMY. Abdomen opened midline incision Findings

* minimal purulent peritoneal fluid* flakes adherent to intestine


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FINDINGS

*multiple diverticulum seen in antimesenteric border of jejunum with peri diverticular adhesions to otherdiverticula and to other small bowel loops.

*kinking of ileum about 3 feet proximal to ileocaecal

junction with distension of proximal loop withcompressed distal loops.

*perforation about 0.5cm seen in one of thediverticula.


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PROCEDURE DONE*adhesions released*resection of about 1.5feet of jejunum

starting 15cm from DJ flexure*two layered end to end anastamosis done*thorough laprotomy done .No other

diverticulum seen

*peritoneal wash given*DTs in pelvis and morrisons space.


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POST OPERATIVE

PERIOD*On ET tube- extubated on 3 rd day*started sips of fluid 5 th day

*LFT increased [TB- 6mg/dl] on 6 th day.settled with lactulose.


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MICROSCOPY Ulceration of thediverticular mucosaand denseinflammatory cellinfiltrate in all fourgut layers.

IMP:diverticulitis with

perforation


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DIVERTICULAR

DISEASE TRUE*mostly congenital

*has all 4 layers

FALSE*mostly acquired

*has mucosa andsub mucosa andserosa


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DIVERTICULUM IN

SMALL BOWEL Congenital M/c meckels Acquired - M/c duodenum (75%) >

jejunum (20%) > ileum (5%)Ref:

Edwards HC. Diverticulosis of the small intestine. Ann Surg 1936; 103: 230-54.


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JEJUNAL DIVERTICULA

*incidence 0.1% - 1.5%(men 58% > women42%)

*mostly false

*old age > 6th decade*multiple mostly in mesenteric border*may contain ectopic gastric/pancreatic

tissue at base*may associate with connective tissuedisorders


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JEJUNAL DIVERTICULUM

IN MESENTERIC BORDER


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IN ANTI-MESENTERIC

BORDER


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CAUSE : motor dysfunction of myentricplexus/smooth muscle.

disordered contraction

increased intra luminalpressure

herniation


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CT ABDOMEN

INVESTIGATION


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INVESTIGATIONENTEROCLYSIS

BARIUM MEAL

FOLLOW THROUGH

REF:Benya EC, Ghahremani GG,. Diverticulitis of the jejunum:clinical and radiological features. Gastrointest Radiol 1991; 16:24.


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CLINICAL FEATURES

mostly incidental (42%)Acute complications(6-10%)*Diverticulitis

.perforation

.abscess*hemorrhage*obstruction

.enterolith

Chronic complications*vague abdominal pain(51%)*diarrhea (58%)*bloating (44%)*low grade GI hemorrhage*functional pseudo

obstruction*malabsorbtion

.blind loop syndrome

.megaloblastic anemia

.steatorrhea

REF:Tsiotos GG, Farnell MB, Ilstup DM. Non-Meckelianjejunal orileal diverticulosis: an analysis of 112 cases. Surgery 1994; 116:


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TREATMENT*Asymptomatic no treatment*malabsorbtion antibiotics,nutrient

supplements*with acute complications intestinal

resection and end to end anastamosis(surgery of choice)

REF:A. Gotian and S. Katz, Jejunal diverticulitis with localizedperforation and intramesenteric abscess , American Journal of

Gastroenterology ,
http://dx.doi.org/10.1111/j.1572-0241.1998.00357.xhttp://dx.doi.org/10.1111/j.1572-0241.1998.00357.xhttp://dx.doi.org/10.1111/j.1572-0241.1998.00357.xhttp://dx.doi.org/10.1111/j.1572-0241.1998.00357.xhttp://dx.doi.org/10.1111/j.1572-0241.1998.00357.xhttp://dx.doi.org/10.1111/j.1572-0241.1998.00357.xhttp://dx.doi.org/10.1111/j.1572-0241.1998.00357.x


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TREATMENT*enterolith causing obstruction -enterotomy and removal

*simple closure,excision-greatermortality (25-50%) and morbidity*diffuse peritonitis-enterostomy

REF:Chendrasekhar A, Timberlake GA. Perforated jejunal diverticula: an analysis of reported cases. Am Surg1995;

A rare case of intestinal obstruction.ppt

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