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An interesting case of small bowel obstruction
  1. N Pranesh,
  2. K Mainprize
  1. Milton Keynes General Hospital, Standing Way, Milton Keynes, Bucks MK6 5LL, UK
  1. Correspondence to:
 Mr Pranesh;
 npranesh{at}hotmail.com

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Answers on p 630.

An 86 year old women presented with a day’s history of sudden onset colicky central abdominal pain associated with several episodes of vomiting, some abdominal distension, and an episode of loose stools. She also gave a week’s history of dysuria and increased frequency of micturition. Her bowels were previously regular and normal with no history of rectal bleeding. There was no history of anorexia or weight loss. Past history included a right mastectomy and axillary clearance for carcinoma of the breast 11 years previously and a hysterectomy at the age of 29 for postpartum haemorrhage.

On examination her pulse was 88 beats/min, blood pressure 137/58 mm Hg, and temperature 37.7°C. She was clinically dehydrated and abdominal examination revealed mild distension and lower abdominal tenderness without guarding or rebound tenderness. Bowel sounds were increased and tinkling. The hernial orifices were normal as was digital rectal examination. Examination of the cardiovascular and respiratory systems was also unremarkable.

The initial investigations were as follows: haemoglobin concentration 133 g/l, white cell count 20.3 × 109/ l, platelet count 243 × 109/l, C-reactive protein 122 mg/l, serum sodium 139 mmol/l, serum potassium 2.8 mmol/l, urea 8.6 mmol/l, creatinine 134 mmol/l. Microscopy of a midstream urine sample revealed 200 pus cells and five red blood cells.

A supine abdominal radiograph (fig 1), an ultrasound scan, and a computed tomogram of the abdomen (fig 2) were requested and suggest the diagnosis.

Figure 1

Supine abdominal radiograph.

Figure 2

Abdominal computed tomogram.

Despite antibiotic treatment for the confirmed urinary tract infection, she remained unwell and continued to have a distended abdomen with intermittent diarrhoea. She underwent a laparotomy (see fig 3) which confirmed the diagnosis and enabled successful treatment such that the patient made a successful recovery and was discharged home a week later.

Figure 3

Findings at laparotomy.

QUESTIONS

  1. What is the diagnosis?

  2. What is the differential diagnosis?

  3. What are the other possible complications of the primary disease of the small bowel ?

  4. What are the possible treatments options?

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