Consult - History and Phy.
Sample Name: Small Bowel Obstruction
Description: History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.
HISTORY OF PRESENT ILLNESS: AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anything, and has vomited 8 times. AF reports 10/10 pain in the LLQ.
PAST MEDICAL HISTORY: AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain. Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain"
PAST SURGICAL HISTORY: AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: AF was born and raised in San Francisco. His father was an alcoholic. He currently lives with his sister, and does not work; he collects a pension.
HEALTH-RELATED BEHAVIORS: AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.
REVIEW OF SYSTEMS: Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.
Vital Signs: T: 37.1 BP: 127/94 HR: 125 RR: 16 O2 Sat: 95% room air.
General: 50 year old African-American man in acute distress, writhing on gurney and rubbing abdomen.
Skin: well healed abdominal scar extending along the linea alba, from the xiphoid process to the pubic tubercle; another scar at McBurney's Point, about 3 or 4 inches long.
HEENT: PERRL, EOMI, O/P clear-dry.
Neck: Supple, no LAD.
Heart: Tachycardic, regular rhythm; nl S1 & S2; 2/6 systolic murmur heard best over left sternal border.
Abdomen: Multiple scars (see Skin); firm and distended; TTP, especially in LLQ, with rebound tenderness; guarding difficult to assess secondary to distention; tinkling and high-pitched bowel sounds, particularly in upper quadrants; ventral hernia near umbilicus.
Rectal: Normal tone, guiac negative.
Vascular: Normal distal pulses.
Lymphatics: Enlarged, nontender anterior cervical and inguinal lymph nodes.
Neurological: A&OX4 and cooperative.
CXR: Clear lung fields; NGT in stomach.
Abdominal CT: Low attenuation signal in internal superior left lobe of the liver, distended sludge-filled gallbladder, 8mm dilated CBD, no free air, no free fluid, small bowel loops consistent with but not definitive of obstruction.
ASSESSMENT: AF is a 50-year-old African-American man with abdominal pain and distention, obstipation, and vomiting. The differential diagnosis includes paralytic ileus and mechanical obstruction. Paralytic ileus, which is characterized by absence of bowel sounds, gas scattered in the GI tract, dilation of the entire bowel, and a recent abdominal surgery, is unlikely in this case. AF is more likely suffering from a bowel obstruction: he has multiple risk factors (past abdominal surgery, multiple episodes of obstruction from adhesions) and symptoms and signs (bowel sounds, vomiting) consistent with obstruction.
Mechanical bowel obstruction can be caused by:
1. Adhesions (most cases): typically from prior surgeries.
2. Hernias (second most common cause).
3. Tumors (15% of cases): rare in small intestine; most common cause of large intestine obstruction.
4. Intussusception (especially in kids).
5. Volvulus (especially in elderly).
6. Obturation: fecal impactions, gallstone ileus, parasitic infections.
7. Inflammatory lesions: TB, regional enteritis, ulcerative colitis, amebiasis.
8. Vascular obstruction: embolism, increased venous pressure, hypercoagulability, vascular disease; especially in elderly.
Given the patient's history of multiple abdominal surgeries and adhesions causing small bowel obstruction, AF's obstruction is most likely caused by adhesions.
One question to answer in any patient presenting with bowel obstruction is whether the obstruction is in the small or large intestine. In small bowel obstruction, the pain is sharp and frequent, with early vomiting and electrolyte imbalance. In contrast, large bowel obstruction may present in elderly patients without vomiting, and typically without hernias or a history of abdominal surgery. Radiographic studies can definitively locate the site of the obstruction. In this patient, though the radiographic evidence was equivocal, the presence of vomiting and the quality and frequency of his pain suggested small bowel obstruction.
PLAN: There has been a great deal of debate about the best way to treat patients with mechanical obstruction. I will focus on the question of whether a patient should be managed conservatively or with an operation. This question is vital because mechanical obstruction may lead to strangulation and perforation, life-threatening consequences. There is no reliable way to determine whether the patient is already suffering from strangulated bowel, and next to impossible to predict which patients will suffer from strangulation.
Patients that have hernias are sent immediately to the operating room for a repair; the surgeon will resect any nonviable bowel. For patients suffering from an obstruction due to adhesions, the decision becomes difficult. Fifteen percent of these patients may have strangulating obstruction. Simple (nonstrangulating) bowel obstruction typically presents with intermittent, colicky pain. Strangulating obstruction, in contrast, usually presents with steady unrelenting pain. Other signs include a palpable mass, increased temperature and heart rate, and lab studies indicating acute inflammation.
Several studies have examined the ability of these signs to predict when strangulation is present. After a study of 238 patients with small bowel obstruction, Stewardson et al. (1978) suggest that physicians, instead of considering individual signs, look at a combination of "classic findings" including leukocytosis, fever, tachycardia, and localized tenderness. They recommend conservative treatment only for patients with none or only one of these signs. Ninety percent of patients with strangulated bowel had two or more signs. Bizer et al. (1981), on the other hand, found no correlation between these signs and the presence of strangulation. They did find a correlation with age, feculent vomiting, peristaltitic sounds, and a white cell count above 18,000.
It is clear that there are no absolute guidelines determining whether a patient can be treated conservatively or must get an operation. Improvements in imaging techniques in the recent past have aided in these critical decisions. Computed tomography can frequently be used to diagnose strangulation, however in the majority of cases misses the diagnosis. Apparently, the decision to operate ultimately falls on the judgment of the surgeon who must take into account all of the findings in combination.
The operative treatment of mechanical obstruction is removing the obstruction resecting nonviable bowel, and creating a bypass if necessary. Conservative treatment primarily includes decompression, rehydration, and frequent monitoring. The physician must also decide on what type of tube should be used to decompress, and how long the nonoperative treatment will be attempted before resorting to surgery. The question of the tube has been a controversy for years, some advocating the nasogastric tube for all patients, others advocating a nasointestinal tube for distal obstructions. Maglinte et al. (2001) explain that nasointestinal tubes are more effective at decompressing distal obstructions, and suggest that physicians use a multipurpose tube that can be used as a nasogatric tube, a nasointestinal tube, and a diagnostic tool (can provide route for enteroclysis). Nasogastric tubes are especially unable to decompress distal distention in patients with a competent pyloric sphincter.
Finally, the length of the trial period of nonoperative management is also debatable. Seror et al. (1993) suggest a 5-day trial to allow time for spontaneous resolution, and report a 73% success rate in a study of patients with a history of bowel surgery. In contrast, Deutsch et al. (1989) suggest only a 24 hour trial of conservative therapy, and only for patients with partial obstruction. Again, it appears as though this decision presently is at the discretion of the surgeon caring for the patient.
In the case of patient AF, his findings made the decision to operate particularly difficult. He was clearly tachycardic; his WBC was elevated, but not above 18,000. His abdominal pain was steady and unrelenting, and could be localized to the LLQ, but he was afebrile. His abdominal CT was consistent with small bowel obstruction, but not definitive. In the end, based on the team's desire to avoid another abdominal surgery that could lead to more adhesions and another obstruction, we chose conservative management, with nasogastric tube decompression, rehydration, and close observation.
Keywords: consult - history and phy., alcoholic hepatitis, small bowel obstruction, abdominal pain, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma, hodgkin's disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, bowel obstruction, strangulated bowel, bowel sounds, mechanical obstruction, hepatitis, bowel, obstruction, abdominal, distention, ileus, vomiting,