Case presentation

Meet X
17 year old bahraini lady
Not known case of any medical illness

Came to a/e on sat 12 july @ 1700

Chief complaint:
Abdominal plain and vomiting since 2 days
History of presenting complaint
Abdominal pain
2 days duration
Started suddenly and progressed in severity
All over the abdomin, more toward umbelicus
No radiations
Colicky in nature, waxes and wanes, all day long
Rated 9/10 severe enough for her to scream and cry
from pain
Minimally reliefed by buscopan
Aggrevated by movement and coughing

History of presenting complaint
Associated:
Vomiting x3
2x on the first day, food content
1x on the 2
nd
day in the emergency. Green in colour
Anorexia and no appetite for food
? Constipation
has a hisotry of chronic constipation
normal bowel movement once in 1-2weeks
Past medical surgical hisotry
Appendectomy 4 years ago
Well otherwise

Non significant menstrual history
No known allergies

Never smoker
Never ethanol consumer

In high school, with good performance
lives with parents
On physical examination
Alert concious oriented, in pain and distress.
Mild pallor
Vitals:
HR 109
BP 107/76
T afebrile
RR
wt 40kg
p/a:
Generalized tenderness, and guarding more
toward the RLQ and epigastric area
Appendectomy scar (gridrion incision)
Sluggish bowel sounds

Cardio, respiratory, CNS
intact
Labs A/E
Wbc 28
86% PMN
2% bands
Hb 13.9
Plts 409
Urine r/m, LFT, amylase Normal


CXR


PFA


DDx
Acute abdomin
To r/o Intestinal obstruction
Managment in A/E

NPO
NS 1L over 3 hours
Morphine 4mg
Primpran 10mg
Omeprazole 20mg

Refer to surgery
Surgical senior review
Request CT scan:


Surgical senior review
CT:
Massive ascitis
Dilated small bowel loops, no wall thickening
Uterine Hyper-enhancement (reactive
inflammation)


Request ascitic fluid aspiration:
sample for c/s
On 15 july:
E.Coli + Klebsiella

Blood c/s:
Sterile (check)
Surgical senior review
Plan:
Admit
Start on metronidazole + ciprofloxacin
PRN IV paracetamol
PRN pethidine + promethazine
Surgical senior review
Next morning
Seen by firm consultant
Still in severe pain even after receiving pethidine 2
hours previously
Abdomen tender with guarding all over
Booked for emergency
expolatory laporotomy +/- proceed

In OT

Findings: 20cm gangrenous ileum rotated
around mesentery and trapped inside a
fibrous band. <5cm form ileocecal junction

Resection of gangrenous bowel with ileocecal
anastomosis

TOPIC: SMALL BOWEL VOLVULUS
Small bowel volvulus
rare condition that can become life-
threatening very quickly.

annual occurrence varies
1.7 to 5.7/100 000 in west
24 to 60/100 000 in Africa or Asia
volvulus
Volvulus occurs when an air-filled segment of
the colon twists about its mesentery

This may lead to recurrent or acute abdominal
pain from intestinal obstruction, ischemia or
gangrene and necrosis


causes
Primary
more common in Africa , Asia, middle east, india
normal abdominal cavity
aetiology is still poorly understood
Diet (large quantity of fibre foods after fast)
Gut motility
Secondary
Due to bands, adhesions, Meckel's diverticulum,
internal hernia, Ascariasis, and pregnancy.
Clinical features
central abdominal pain out of proportion to
the apparent degree of obstruction
classical features of intestinal obstruction
nausea (83%), vomiting (100%) and abdominal
distension (55%),
The diagnosis should be particularly
considered if the pain does not respond to
narcotic analgesia
RADIOLOGICAL INVESTIGATIONS
PFA:
non-specific
distended loops or a featureless/gasless abdomen
Upper GI study/barium:
corkscrew or spiral pattern suggesting SBV
Angiography
spiralling of the branches of the twisted superior mesenteric
artery produces a "barber pole
CT
whirl sign of the rotated mesentery and peacocks tail sign
(due to torsion of the bowel around the mesenteric axis)
bowel wall thickening, intra-mucosal air (pneumatosis) and
intra-peritoneal fluid suggesting ischemia or infarction



prognosis
overall mortality rate for all cases of SBV range
from 10% to 35%.

gangrenous SBV: from 20% to 100%
Especially if perforated bowels
non-gangrenous SBV from 5.8% to 8%

Thus prompt surgical treatment is warranted
to prevent life threatening complications
Thank you