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Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 104-105 Challenges in Rural Surgery A Difficult Case of Acute Intestinal Obstruction Managed in a Rural Set-upH. K. Ramakrishna Lakshmi Surgical and Endoscopy Clinic, New Bridge Road, Bhadravati-577301.
Paper received: June 2002
Code Number: is03022 A 40-year-old male patient was admitted with history of acute abdominal pain of one-day duration. He had vomited 4 times. There was history of similar colicky abdominal pain for the previous 3 months. The patient was a chronic alcoholic, but had stopped drinking alcohol 3 months back. Past history: The patient was admitted to another nursing home 3 months earlier with h/o acute abdominal pain and vomiting. He was investigated with plain X-ray abdomen, which didn't show any gas under diaphragm or fluid levels. The ultrasound scan was normal. Clinically diagnosed as acute pancreatitis and managed conservatively. During his stay his general condition was considered bad and he was in shock for 4-5 days. He had developed oliguria. He was treated with I.V. fluids and analgesics. With conservative treatment, he improved. A month earlier, he developed severe hiccoughs. Examination revealed an irregular, tender and fixed mass in RIF measuring about 10x10 cm. To correlate with the previous history of pain in the abdomen, an appendicular mass was suspected. (However, if it was appendicular, the mass should have disappeared in two months time.) His blood urea and serum creatinine were normal. Upper G.I. endoscopy showed congestion of lower oesophagus. He was treated with omeprazole and domperidone. He improved in about one week. On examination at this time, the abdomen was soft and moderately distended. The mass remained same, except that it was not tender. Intestinal peristalsis was seen next to the mass. A clinical diagnosis of carcinoma of caecum with obstruction was thought of. (Though, obstruction is rare with a right-sided colonic carcinoma.) Plain X-ray abdomen erect revealed a grossly dilated loop of ileum with a fluid level. Blood investigations were normal. E.C.G. showed "T" wave inversion in leads II III & AVR. Considering the risks involved, the patient was advised to go to a major hospital. But the patient was very poor. He had two young children of 12 and 14 years old, who were unable to take their father to any other place. Other than these two children, he had nobody to help take him to a major hospital. Therefore, to help a poor patient, it was decided to take him up for a laparotomy. Laparotomy was done through a right paramedian incision. There was a mass formed by the adhesion of two loops of the ileum to the anterior abdominal wall in right iliac fossa. Proximal loops of jejunum and ileum were grossly dilated. Adhesions were very dense and difficult to release. With patient and gentle dissection, using both blunt and sharp techniques, most of the length of the bowel was released. However, at one point, ileum was injured because of dense plastering of the bowel to the abdominal wall. That was also the point where a kink was present, which had produced intestinal obstruction. The discrepancy in the diameter of the two ends of the bowel was gross. The smaller diameter bowel end was cut longitudinally at the anti-mesenteric border to match the larger segment of the bowel and an end-to-end anastomosis was carried out. After a thorough peritoneal wash, the abdomen was closed. Postoperatively he had hypotension for 48 hours. Two bottles of blood were given. I.V. ciprofloxacin, metronidazole and gentamicin were administered. On 26/11/2001, the 6th postoperative day, Ryle's tube aspiration was 75 ml in the previous 24 hours. There was no vomiting. Therefore, oral liquids were started. But the patient didn't tolerate oral feeds. He started vomiting. On examination, upper abdominal distension was present and therefore the patient was treated with IV fluids. On 28/11/2001, while reviewing the patient's condition (which was not improving), it was decided to do re-laparotomy the next day. In the morning, during ward rounds, the patient said that he had passed stools. With much hope that bowel would move, conservative management was continued. Another attempt at oral feeding was made on 30/11/2001, based on the fact that he had passed flatus and R.T. aspiration was 170 ml /24 hours. Sadly, he vomited again and developed fever with chills and rigors. There was abdominal distension. Temperature was 101ºF, pulse was 110 and BP 110/70. Ultrasound examination showed lot of free fluid in the abdomen. So, re-laparotomy was decided. On 02/12/2001, re-laparotomy was done through the same incision. There was a lot of pus just underneath the incision and also in the left paracolic gutter. All the pus was cleared and a thorough peritoneal wash was given. Anastomosis was checked. It was intact. Two drains were kept in the abdomen, one near the anastomosis and the other in the left flank. Infection was due to the remains of the faecal contamination (which occurred during bowel injury), in spite of a thorough peritoneal wash given at the time of the first laparotomy. Fascial layers closed with prolene. Skin and subcutaneous tissue left open for healing by secondary intention. Postoperatively, the patient was in shock for 6 days. His systolic BP remained between 60 and 80 mm Hg, in spite of dopamine drip. 4 more bottles of blood were given in the postoperative period over 4 days. I.V. ciprofloxacin and metronidazole were started again. On 06/12/2001, faecal leak started through the drainage site. Ryle's tube aspiration gradually decreased to 260 ml on 06/12/2001. Oral liquids were started. This time, he tolerated the feeds well. Gradually, semisolids were introduced. Five to six eggs were given daily. Drainage tubes were removed on 11/12/2001. Later, faecal output gradually decreased and stopped altogether on 14/12/2001. The wound also gradually improved and healed by secondary intention in about a month. Considering the patient's poverty, no professional charges were charged. Hospital charges were also waived. Together, the patient received about 110 bottles of I.V. fluids, 6 bottles of blood and antibiotics for about 25 days. We could arrange all these with the help of the hospital (for drugs, free service), laboratory (for blood), a hotel (for food) and friends (for money, blood). I.V. fluids were got at the wholesale price, which was almost half the retail price. Physician samples were collected and supplied to the patient. By arranging voluntary blood donors, transfusion charges were reduced. The patient's condition was explained to a hotel owner and we requested him to supply free food to the patient. Whenever we sent a slip from the hospital, the hotel owner used to send food for the patient and also for his two children. There was no way the patient would have survived without these charitable efforts. During this period we could stand firm because we had a very cooperative patient, with a strong will power. He and his sons never grumbled at any time about us. They had unshakeable faith in the surgeon and the hospital. There was no fear about consumer protection act or any court. There was an excellent patient-doctor relationship. We could always think and decide with an unbiased mind. These things gave us courage to take risks and do whatever best we could. In conclusion, we present a typical rural patient managed in a typical rural set-up. He had inflammatory adhesion of small bowel loops to the pareites producing acute intestinal obstruction. Clinically judged as a high-risk case because of poor general condition and E.C.G. changes. Surgery was difficult. He developed life-threatening postoperative complications. There was neither I.C.U., nor the facility (and affordability) for parenteral nutrition to manage these complications. In spite of all these problems, the patient could be saved with good professional services and help from various sources. Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com |
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