Case Presentation
004 Yanisa Jarusyingdumrong
014 Intouch Sopchokchai
021 Kompiya Thongakaraniroj
041 Kritrath Panittaveekul
058 Todsapon Praphanuwat
063 Tanaporn Sangsuwan
132 Supitchaya Phirom
152 Apiphan Theeraphattana
Case• HN: 020546-44
• Age: 67 years old
• Sex: Female
• Ward: 13/2
• Religion: Buddhist
• Martial status: married
• Occupation: Homemaker
• Domicile: Nakhon Nayok Province, Thailand
• Medical eligibility: Social security
The following history is obtained from the
patient and her medical record and is reliable.
• Chief Complaint:
Tight squeezing abdominal pain 2 weeks prior
to admission
History of present Illness
• 2 weeks prior to admission
– Tight, squeezing pain at right and left lower
quadrants of the abdomen (Pain score = 5)
–Occurs in 30 minute durations with 30
minute intervals
–No radiation
–Nausea without vomiting
–Normal bowel habits; normal flatulence
History of present Illness
• 2 days prior to admission
–Pain and nausea continued in the same
manner but vomited after waking up
–Went to HRH Maha Chakri Sirindhorn
Medical Centre for treatment and received a
certain analgesic
–Pain subsided but recurred when the patient
returned home
History of present Illness
• 1 day prior to admission
–Tight, squeezing pain continues
–Vomited 2-3 times at random points during
the day, despite not eating
– Ingested a certain over-the-counter laxative,
subsequently resulting in 5 bowel
movements. All were watery; no mucous, no
fresh blood
Past History
• 1 year prior to admission
–Gut obstruction; treated by NG tube
insertion for decompression
–Gallstones; treated with laparoscopic
cholecystectomy at the MSMC
• Cervical cancer continuously receiving
treatment by brachytherapy and external beam
radiation therapy for 3 years at Maha
Vajiralongkorn Thanyaburi Hospital
• Underlying diseases:
–Diabetes mellitus
–Hypertension
–Dyslipidaemia
–Chronic kidney
disease
• Current medications:
–Omeprazole
–Dimenhydrinate
–Domperidone
–Alumina magnesia
–Simethicone
–Folic Acid
–Glipizide
• Allergies: None
• Accidents: None
• Blood transfusions: None
• Social History: No tobacco/alcohol
–Occupation : Homemaker
• Family History:
–Mother and younger sister has lung cancer
–2 younger brothers: both have DM and HT,
one has liver cancer
Physical Examination
• Vital sign : BP 103/70 mmHg , BT 36.5 C,
RR 20 /min, PR 95/min
• General appearance : A Thai woman, good
consciousness, co-operative, not pale, no
jaundice, no cyanosis
• Skin : no abnormal pigmentation, no rash, no
ecchymosis, no petechiae
• HEENT
–Head: normocephalic shape, no evidence of head
trauma, no mass, no lesion, no scar
–Eyes: no pale conjunctivae, anicteric sclerae, no
ptosis, no exophthalmos, no lid lag, no lid
retraction
–Ears: no deformity, no discharge, no hearing loss
–Nose: normal shape, no septal deviation, no
nasal swelling, no discharge
–Throat: no oral ulcer, pharynx and tonsils are not
injected, no tracheal shift, no cervical
lymphadenopathy
• CVS : normal s1s2, no murmur, PMI at 5th
intercostal space at midclavicular line, no
heaving, no thrill
• RS : clear both lungs, symmetrical chest wall,
no abnormal breath sounds, no adventitious
sounds
• Abdomen : hyperactive bowel sound, soft,
abdominal distension, tenderness at right and
left lower quadrants, no rebound tenderness,
no guarding, no palpable mass
Problem list
1. Colicky pain at right and left lower quadrants
2 weeks PTA
2. Nausea and vomiting 1 day PTA
3. Abnormal physical examination
- Abdominal distention
- Tenderness at right and left lower quadrants
Problem list
4. Underlying disease :
• Diabetes mellitus
• Hypertension
• Dyslipidemia
• Chronic kidney disease
• Post radiotherapy cervical cancer 3 years PTA
Differential diagnosis
1. Small bowel obstruction
2. Large bowel obstruction
Provisional diagnosis
• Partial small bowel obstruction
Lab Investigation
1. Complete Blood Count
Hb 10.1 g/dL
Hct 30.0 %
WBC count 9,250 / mm3
neutrophil 79.5%
lymphocyte 12.9%
monocyte 6.5%
eosinophil 0.9%
basophil 0.2%
Platelet 480,000 /mm3
Lab Investigation
2. Electrolyte
Na 134 mmol/L
K 3.86 mmol/L
Cl 91.4 mmol/L
HCO3- 23.2 mmol/L
Anion gap 23.28
Lab Investigation
3. DTX blood sugar = 155 mg/dL
Plain film
Treatment
Primary Management
• Resuscitation and rehydration : IV fluid and
electrolyte therapy
• NPO
• Retain nasogastric tube : decompression
• Foley catheter : monitor hourly urine
Specific Treatment
• Conservative treatment
• Surgical treatment
Conservative Treatment
• Intravenous fluid
• Nasogastric tube with suction
• Serial physical examination
• Serial film acute abdomen series
Surgical Treatment
• Indication
– complete small bowel obstruction
–during conservative treatment
• worsening abdominal pain
• peritoneal sign or sign of strangulation
• symptom not improved within 48 hrs.
Algorithm
ABDOMINAL DISTENSION
ileus mechanical obstruction
observation
IV fluid, NG suction, serial evaluation
improved not improved progressed
off NG tube,
start oral diet
continue observation fever, colic,
abdominal sign,
leukocytosis
discharge laparotomy
Knowledge
• Role of ultrasonography
– Limitation of plain film in proximal GI obstruction
– Bedside procedure
– No radiation -> safe in repeated scanning
– Real-time -> bowel movement
– Detect cause & site of obstruction
– Doppler -> Bowel wall perfusion
– Evaluate status for resuscitation
– High specificity
Typical SBO findings
1. Dilated bowel loops
2. Increased intraluminal fluid
3. Characteristic alternating peristalsis
4. Valvulae conniventes in jejunum “keyboard sign”
5. Circumscribed free fluid “Tanga sign”
*Surgical case?
1. Intraperitoneal free fluid
2. Bowel wall thickness of more than 4 mm
3. Decreased or absent peristalsis in previously
documented mechanically obstructed bowel
Take Home Message
Di
Dis
Dif
String
Step
Thank you