 |
| About Bioline | All Journals | Testimonials | Membership | News |
|
||||||
|
||||||
Indian Journal of Surgery, Vol. 65, No. 3, May-June, 2003, pp. 281-282 Case report Acute small bowel volvulus: two cases managed in rural practice Sunil C. Nandgaonkar Om Clinic, Nathkunj Apartments, Chhatrapati Shivaji Road, Mahad, Dist.- Raigad 402301, Maharashtra.
Paper Received: June 2002. Paper Accepted: December 2002. Source of Support: Nil Code Number: is03057 ABSTRACT Two cases of acute small bowel volvulus (SBV) with gangrene, which were successfully treated in a nursing home in a rural set-up are presented. Agriculture is the main occupation in this area. Poverty, poor transport facilities, delayed referral from peripheral doctors, and lack of institutional facilities are some of the problems faced by us while treating patients with acute abdomen. In such a situation, where modern diagnostic tools are not available, knowledge of reported cases will certainly help in the diagnosis and further treatment. While practising surgery in a rural set-up, an exploratory laparotomy often remains the only diagnostic and therapeutic method in the absence of modern diagnostic tools. KEY WORDS: Volvulus, Small bowel. How to cite this article: Nandgaonkar SC. Acute small bowel volvulus: two cases managed in rural practice. Indian J Surg 2003;65:281-2. INTRODUCTION Idiopathic SBV is not an uncommon condition. It is common in farmers and farm labourers, as their diet consists of high fibre which is the predisposing factor in primary SBV.1,2,4 It is commonly seen in parts of India, Africa and Iran. The SBV is termed secondary SBV where the rotation is caused by abnormal fixation due to congenital or acquired lesions such as adhesions, Meckel's diverticulum, tumour, worm obturation, duplication etc. CASE REPORTS Case 1 A 67-year-old man presented with history of sudden onset of abdominal pain after lunch. Initially, he was treated by his family doctor with injectable painkillers and narcotics. Due to increased severity of pain, he was referred for surgical opinion. Except colicky abdominal pain, no other symptoms suggestive of intestinal obstruction were present,. On arrival he presented with typical gait of acute abdomen, pulse rate was 120/minute and blood pressure 100/70 mm Hg. He was dehydrated and pale, and had a visible intraabdominal bowel loop in the right iliac fossa. There were no other signs of intestinal obstruction, tenderness, and rigidity in other parts of the abdomen. X-ray abdomen was not contributory. As the patient came walking with only a complaint of severe abdominal pain and had stable haemodynamics with no other documentary evidence of diagnosis, the relatives denied surgical treatment. It took two hours to convince the relatives about the importance of exploratory laparotomy and that delayed the surgery too. Finally, the patient was taken up for exploration late in the night. At laparotomy, approximately 3 feet of terminal ileum was found to be gangrenous with multiple twists and the caecum was normal. No obvious cause was noted. Resection of gangrenous ileum with a quarter colectomy was followed by ileo-ascending colonic anastomosis done in two layers. This patient had postoperative diarrhoea for two weeks that settled down without intervention. He remains well at follow-up. Case 2 A 19-year-old woman with amenorrhea of 7 months, was admitted under the care of an obstetrician for vague abdominal pain. She developed haematochesia leading to hypovolemic shock and was at that point transferred to surgical care. On examination, she had cold clammy extremities, thready pulse, and her blood pressure was non-recordable. The abdomen was distended and hyperperistalsis was noted. Along with the routine investigations, she was investigated to rule out haemorrhagic disorders. Abdominal sonography showed evidence of intra-uterine foetal death. The surgical shock was treated with crystalloid fluids and 3 blood transfusions. The patient showed a little improvement but the distension was persistent. The obstetrician had to induce labour. Over the next four hours the abdominal distension, tachycardia and hypotension were persistent. An X-ray of the abdomen showed multiple air-fluid levels. The patient was explored with a high-risk consent. Operative findings showed complete volvulus of the small bowel with gangrene. Only around 30 cm of the proximal jejunum and 8 to 10 cm of the distal ileum were viable but oedematous. No obvious cause was noted. Resection of gangrenous bowel and a jejuno-ileal anastomosis was done in two layers. The patient made an uneventful postoperative recovery. The patient is living a healthy life and is coming for a regular follow-up. DISCUSSION Small bowel volvulus is common and potentially dangerous. The diagnosis and treatment are often delayed resulting in mortality as high as 40% in the presence of gangrene.5 Though a rare cause of acute abdomen in pregnancy, small bowel volvulus should be kept in mind as it may go undetected because the symptoms may be attributed to common complaints of pregnancy. Persistent vomiting in the second or third trimester without nausea, obstipation, leucocytosis, tachycardia, hypotension and fever should arouse suspicion. Presence of previous scars on the abdomen support the diagnosis.3 In healthy individuals, sudden onset of colicky periumbilical pain not responding to narcotic analgesia should arouse suspicion of SBV. In rural areas, farmers and labourers perform hard work in an erect posture after meals which consist of coarse cereal, which is probably the cause of primary volvulus and is reported.1,2 A small bowel reconstruction may be possible when 5 to 10 cm of distal ileum is present and clearly viable.5 This preserves the ileocaecal junction and prevents postoperative diarrhoea. In conclusion, while treating acute abdominal cases in a rural set-up, in the absence of institutional facilities, a thorough clinical assessment, early exploration and aggressive postoperative management is mandatory to help save the lives of the patients. REFERENCES
Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com |
| |||||||||
