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
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