martedì 27 gennaio 2015

Similar presentations but different outcomes

We had 2 cases of intestinal obstruction in 2 consecutive days. Both of them were clearly due to mechanical causes.
The first patient was referred to us by someone who had done an explorative paracentesis with a syringe (without U/S guide) in another facility. 
He reported that the material collected was fecaloid and so he was thinking of intestinal perforation with peritonitis.
Visiting the patient I have realized that the presentation was classical for mechanical obstruction: hyperactive intestinal sounds, important abdominal distension, absence of peritonism and evidence of tympanic percussion.
I have done a U/S to find out if there was free fluid in the peritoneum, as the previous clinician was proposing, but I did not find any. There was only an enormous gaseous distension.
I have thought that my colleague had been very imprudent in doing a paracentesis without the support of an ultrasound, and probably he had perforated an intestinal loop from which the fecaloid matter was coming from.
We have entered theater for an emergency laparatomy  and we have found an enormous sigmoid volvolus.

It was so big that Dr Max had never seen something like that in the whole of his long career. I have told Max that for me it was already the second time to see such a huge sigmoid because dolicocolon here is more common than in Europe.
Derotation was somehow cumbersome, either because it was difficult to find the exact location of the twist and because the extreme dilatation was rendering the maneuver risky and more complicated. 
Eventually we succeeded to derotate the gut but the problem was now how to squeeze the enormous amount of flatus out of it: without doing that, it would never have been possible to close again the abdomen. We have tried milking the sigmoid down to the rectum with our fingers, but the method seemed to be pretty useless: the flatus was slipping back any time we tried to push it down. The only solution has been to create a small opening on the coecum and to allow the flatus to come out.
The maneuver was in fact quickly successful.
After suturing the intestinal opening we had created, the closing of the abdominal wall was actually not difficult at all, because the intestine was completely back to the normal size.
Therefore the operation finished well, the condition was benign and the prognosis pretty good.
The following day we have received a similar case. The abdomen of the patient was so distended; the intestinal sounds were metallic and increased. He had not passed stool for some days and he was vomiting. The ultrasound showed gaseous distension with no free fluid in the peritoneal cavity.
Thinking of a similar condition we have entered theater with high hopes of helping this patient as well. Unfortunately we got a nasty surprise when we opened his abdomen.
The dilatation involved only the ascending colon and the small intestine. Palpating just above the distended colon we found a big tumour of the hepatic flexure, causing total stenosis and obstruction. 
The tumour also involved the posterior wall of the peritoneum, and around it there were many enlarged lymphnodes.
Dr Max decided that the malignancy was beyond any possibility of resection: therefore we decided on biopsy and bypass with anastomosis between ascending and transverse colon. The operation was successful and the anastomosis very neat, but obviously in this case our work has been exclusively palliative and did not change the long term prognosis of the patient.
As we can appreciate, the cases were very similar at presentation, but the conditions were completely different, and so it will also be the long term prognosis: for both we have solved the intestinal obstruction, but only in one case we will be able to write “healed” on the discharge sheet.

Bro Dr Giuseppe  Gaido

Nessun commento:

Chaaria è un sogno da realizzare giorno per giorno.

Un luogo in cui vorrei che tutti i poveri e gli ammalati venissero accolti e curati.

Vorrei poter fare di più per questa gente, che non ha nulla e soffre per malattie facilmente curabili, se solo ci fossero i mezzi.

Vorrei smetterla di dire “vai altrove, perché non possiamo curarti”.

Anche perché andare altrove, qui, vuol dire aggiungere altra fatica, altro sudore, altro dolore, per uomini, donne e bambini che hanno già camminato per giorni interi.

E poi, andare dove?

Gli ospedali pubblici hanno poche medicine, quelli privati sono troppo costosi.

Ecco perché penso, ostinatamente, che il nostro ospedale sia un segno di speranza per questa gente. Non ci sarà tutto, ma facciamo il possibile. Anzi, l’impossibile.

Quello che mi muove, che ci muove, è la carità verso l’altro, verso tutti. Nessuno escluso.

Gesù ci ha detto di essere presenti nel più piccolo e nel più diseredato.

Questo è quello che facciamo, ogni giorno.

Fratel Beppe Gaido

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