Transcript A Catastrophic Bowel Obstruction

A Catastrophic Small Bowel
Obstruction
DR ZOE D SCOUNOS
THORACIC AND SLEEP PHYSICIAN
THE PRINCE CHARLES HOSPITAL
HOLY SPIRIT NORTHSIDE HOSPITAL
BRISBANE, QUEENSLAND, AUSTRALIA
Case Presentation
 76 yr old male (father of presenter) presented 21 May
2013 with:
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Vomiting, diarrhoea, along with haematezia for 4 days,
intermittent fevers, and eventual abdominal pain, with
distension necessitating presentation to the emergency
department.
Relevant background includes;
Ischaemic heart disease- MI 25 yrs ago, thrombolysed
 Cerebrovascular Accident, left ACA territory, 10 yrs ago, no
residual neurological deficit
 Former smoker (at least 30 pack yr history)
 Therapeutic regime: Aspirin, Clopidogrel, Simvastatin
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Clinical Evaluation
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Clinically , appeared unwell, afebrile, haemodynamically stable, with
mild tachycardia (110bpm), tachypnoeic (28), poor peripheral
perfusion with SpO2 90% on room air. Rest of cardiovascular
examination unremarkable, and chest was clear. Abdomen
distended , mottled, and absent bowel sounds.
Further evaluation revealed a leucocytosis, with a neutrophilia (22.3,
and 17.6, respectively), mild acute renal impairment, cr 146, ur 13.5,
along with abnormal LFT’s, lipase normal. ECG revealed sinus
tachycardia and poor r wave progression anteriorly.
AXR confirmed multiple loops of dilated fluid filled small bowel in
keeping with a small bowel obstruction.
Abdominal & Pelvic CT scan with IV contrast revealed moderate to
marked dilatation of the stomach, proximal and mid small bowel in
keeping with distal small bowel obstruction. A thick walled distal
ileum was noted in the right iliac fossa. At least 70% stenosis of the
origin of the coeliac axis and superior mesenteric artery.
AXR SUPINE
AXR ERECT
CT ABDOMEN WITH CONTRAST PRE SX
Provisional diagnosis
Distal small bowel obstruction:
- cause unclear, with high index of suspicion
for ischaemic bowel until proven otherwise.
Immediate treatment of acute abdomen
 Fluid replacement, nil by mouth
 Nasogastric tube insertion, with adequate drainage
 Low flow oxygen therapy
 Close clinical monitoring in general and of fluid balance
 Surgical opinion sought, supportive treatment continued
as was found clinically stable post admission
 Follow up blood tests confirmed normalization of renal
function (cr 98), an improvement in the neutrophilic
leucocytosis, despite a shift to the left and an
improvement to the liver function tests.
Progress –a turn for the worst
 Within hours of surgical review after being deemed clinically
stable, progressive deterioration ensued
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Worsening tachycardia, up to 130bpm, haemodynamics maintained
Worsening hypoxemia, requiring high flow oxygen
Fever ensued
Thus transferred within hours to ICU for appropriate monitoring and
treatment
Urgent re-evaluation confirmed early sepsis with ischaemia being the
likely cause given an elevated lactate level. Broad spectrum antibiotics
commenced.
Emergent exploratory laparotomy performed with intubation and
ventilation had in theatre. This confirmed suspicion of an infarcted
bowel. A right hemi-colectomy was required along with resection of part
of the ileum.
Inotropic support commenced with noreadrenaline.
Continued precarious state
 Repeat laparotomy had within 12-24 hours as per
standard;
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Rest of ileum required resection, and 20cm of jejunum as it
appeared ischaemic. The concern was that the jejunostomy
created proved that the inner lining appeared ischaemic,
hence remaining bowel likely also ischaemic. A mucous
fistula created for the redundant colon.
Deemed limited chance of survival. Family meeting had as
prognosis was poor, and guarded.
Supportive care continued, including the commencement of
TPN.
Mean arterial pressure was aimed at 65-70mmHg.
Pathological Diagnosis
 Histopathological report of the right hemicoletomy
revealed extensive mucosal ulceration consistent
with an ischaemic aetiology. Further examination
had with further tissue submitted of involved areas
confirmed the presence of partial thickness necrosis,
consistent with the diagnosis of ischaemic colitis.
 Further resection of ileum, confirmed ischaemic
ileitis.
The Prayer
 At completion of family meeting we were faced with
an impossible situation medically.
 A unanimous prayer had with mother (wife) and
younger sister, with joining of hands:
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“Father God, your Word says when 2 or more people gather
together in prayer you are present. Please restore the
circulation through the rest of the bowel and restore Dad
completely.”
Praise God – Prayer answered expediently
 The following day after the prayer, the surgical team
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decided to repeat the CT abdominal angiogram to
determine whether revascularisation was suitable to
provide a chance of survival.
The result was astounding: No evidence of vascular
disease was identified intra-abdominally.
(vasculature was divinely restored)
Within further 24 hours inotropic support was begun to
be weaned as was clinically appropriate.
Active treatment continued.
5 days later successfully weaned off mechanical
ventilation.
CT ABDOMINAL ANGIOGRAM POST SURGERY
Ongoing clinical progress
 Critical illness proximal myopathy ensued
 After 9 days in ICU transferred to acute surgical ward.
 Within 2 days TPN no longer required. Oral nutrition
encouraged, however the NGT which was in-situ from
outset had caused local trauma impeding natural swallow
hence a finer one was inserted and oral hydration a
nutritional intake were commenced.
 Due to a high output stoma, high dose Loperamide was
commenced and ongoing close monitoring of
biochemical profile was had and maintained to adequate
avail.
Continued progress
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NG feeding commenced and continued until oral nutrition was achieved, including St Mark’s
solution.
Week 2 on acute surgical ward, fever developed and septic screen, including CT abdomen
confirmed an intra-abdominal collection (para-colic gutter collection) of which was loculated
and not amenable to percutaneous drainage. Maximum diameter 10.4cm x 7.4cm x 6.4cm.
IV Piperacillin/Tazobactim course had for 2 weeks followed by Augmentin duo forte for a few
weeks only as this contributed to increased stoma output.
Follow-up abdominal u/s within weeks confirmed marginal reduction in size of collection.
Clinical status improved slowly but surely. Functional capacity included.
As nutritional status improved within weeks NG feeding no longer required.
Two weeks were spent in rehabilitation as full independence was achieved along with
maintenance of the care and dressing of the jejunostoma, and mucous fistula.
After 7 weeks in hospital, discharged home, on multi-vitamins,, low dose aspirin, and St Mark’s
solution.
Post –operative anaemia resolved within weeks along with normalisation of the albumin which
had reached a nadir of 19 during hospitalisation.
 Hydration and nutrition remained optimal at all times, in the absence of complications.
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Complete restoration attained
 Within 2 months decision made given excellent recovery for
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the reversal of jejunostomy and mucous large bowel fistula.
This was had with a laparotomy restoration of bowel
continuity to adequate avail.
Within a week post-operatively an entero-cutaneous fistula
was identified having complicated the surgery.
Treated with IV broad spectrum antibiotics prophylactically
along with TPN, and hence nil by mouth, conservatively for 4
weeks to adequate avail.
Discharged thereafter with maintenance of nutrition and
complete healing of abdominal wound within 3 months.
• HEALED BY THE GRACE OF GOD
The Power of the Word
Matthew
18:19-20
Mark
10:27
Mark 9:23
• “Again I say to you that if two of you agree on earth concerning
anything that they ask, it will be done for them by My Father in
heaven.
• “For where two or three are gathered together in My name, I am
there in the midst of them.”
• “with God all things are possible”
• “all things are possible to him that believeth”
My Father’s Testimony
An example of healing by the Grace of God
• Restoration of the vasculature of the bowel, with
healing of an ischaemic organ to normality, and
complete restoration of functional/physical
capacity.
My Father’s Faith made him well
• Request of prayer prior to presenting to hospital
with an abdominal catastrophe in the outset.