Intestinal or bowel obstruction is the stoppage of passage of the contents of the intestine. These bowel contents could be gas, food or digestive juices. You will learn how to take history of a patient with intestinal obstruction, examination of the patient with bowel obstruction, investigations and treatment; this is a prototype of history, examination and investigation of intestinal obstruction and may vary, you can add or remove other parts of it that may suit you.

The Biodataof the Patient:

I present Mr Steven Sanders, a 27 year old Christian farmer who is German and resides in Ohio, United States.

PRESENTING COMPLAINTS:

He presented 6 days ago with complaints of abdominal pain of 3 weeks duration and constipation of 4 days duration.

HISTORY OF PRESENTING COMPLAINTS:

Patient was apparently well until about 3 weeks prior to presentation, when he started having abdominal pain which was of insidious in onset, generalized, colicky and with increasing severity. It was severe enough to stop him from his daily activities. It does not radiate to any part of the body but referred to the umbilicus. No known aggravating factor but its relieved by taking Paracetamol (acetaminophen). It is not related to meal or anytime of the day.

4 days prior to presentation, he had constipation and also noticed distension of his abdomen with associated weight loss, easy fatigability, weakness and early satiety. However, theres no history of vomiting, anorexia, diarrhoea, dark coloured stool and difficulty in swallowing.

[Clerk to know the CAUSE of the Intestinal Obstruction]

Rule in or Rule out the Risk Factors and Differential diagnosis

Rule in Post-operative adhesion: 7 years prior to onset of illness, patient had surgery here following a diagnosis of gastric Cancer. He was told that a part of his stomach was removed. Theres positive history of Ibuprofen (NSAID) ingestion after the surgery and patients blood group is A, however theres no family history of similar illness. Patient does not smoke cigarette or drink alcohol and theres no history of excessive intake of smoked food.

Rule out differential diagnosis of Colorectal cancer, amoebiasis etc: No history of Tenesmus, no rectal bleeding, no passage of mucoid stool or worms in stool. No history of accidental ingestion of foreign bodies.

Rule out Tuberculosis (TB): No history of chronic cough, low grade fever, drenching night sweat or contact with a chronic coughing adult. No history of ingestion of unpasteurized milk.

Complications of the Obstruction or the conditions the Patient is presenting with

No yellowish discolouration of the eyes, right upper abdominal pain, no passage of pale, bulky, foul-smelling stool, no back pain or inability to walk (metastatic complications). No history of pain becoming constant at any time (strangulation of bowel), no loss of consciousness (from dehydration)

Care the Patient has received so far

With worsening of symptoms, patient presented at the Emergency (casualty) where blood sample was taken, Intra Venous fluids given and Naso-Gastric tube inserted. Since admission, patient was placed on some drugs, (names unknown to patient) and was said to be responding positively to treatment as the pain has subsided and he can move his bowel once a day. However, he is awaiting surgery in 2 days time.

REVIEW OF SYSTEMS

No headache, no blurring of vision

No difficulty in breathing, no palpitations

PAST MEDICAL HISTORY:

He is not a known hypertensive, Diabetes Mellitus or HIV positive patient. He has had surgery 7 years ago for gastric cancer and has had blood transfusion during the surgery

FAMILY AND SOCIAL HISTORY:

He is the second out of 8 children in a monogamous setting. The father is late. He died of an unknown cause. No Multiple sexual partners.

DRUG HISTORY:

No known drug allergy.

SUMMARY:

Ive presented a 27 yr old man who was admitted 6days ago on account of generalized colicky abdominal pain of 3 weeks duration, constipation of 3 days with associated abdominal distension and previous abdominal surgery 7 years ago following gastric Cancer, who is responding to treatment while awaiting surgery.

DIFFERENTIAL DIAGNOSIS

1. Intestinal obstruction secondary to post-operative adhesions due to:

• Abdominal pain of insidious onset
• Previous history of abdominal surgery
• Constipation
• Abdominal distension

2. Recurrent gastric Cancer due to:

• Previous history of gastric Cancer
• History of gastrectomy
• Blood group A
• Weight loss, easy fatigability and weakness

3. Peptic Ulcer Disease (PUD)

History of prolonged ingestion of Ibuprofen predisposes to PUD

Physical Examination of the Patient

General Examination:

I saw a man lying calmly in bed not in any distress. He is not pale, afebrile (36.4C), anicteric, not cyanosed and not dehydrated.

No significant peripheral lymphadenopathy. No pedal oedema.

Abdominal Examination

– Abdomen is full, moves with respiration. Theres a midline surgical scar, running from the Xiphisternum to the midpoint between the umbilicus and pubic symphysis. There is Sister Mary Joseph node

– Theres a mass in the right lumbar quadrant which measures 6 by 6cm in the widest diameters. No differential warmth, non-tender, firm in consistency and has a regular edge. It is not attached to overlying skin but is mobile in the two planes. You can get above and below the mass. There is Negative Carnette sign. No hepatomegaly, no splenomegaly, kidneys non- ballotable.

-Also do Digital Rectal Examination (DRE)

INVESTIGATIONS

1. To confirm diagnosis:

• Plain abdominal x-ray (erect and supine)

Erect x-ray shows – multiple air fluid levels with absence of rectal shadows. Framanda lines are seen if it is due to volvulus.

Supine x-ray shows – dilated loops of bowel, central dilatation for small bowelobstruction and peripheral dilatation for large bowel obstruction.
Valvular culeventis (complete concentric thickening of the Jejunum) due to oedema shows concertina effect or step ladder effect.
If its in the ileum, its characteristically characterless.
If incomplete bowel markings or haustrations are seen, they are suggestive that the obstruction is in the large bowel.

• Gastroduodenoscopy – To visualize the stomach and to take biopsy.
• Double contrast barium meal to confirm associated gastric Cancer. This shows a filling defect around the tumour. If there is an ulcer, it will show ulcer craters

2. Investigations to determine the extent

• Abdominal USS and endolumial Ultrasound scan
• Barium enema to find out any tumour in the Gastrointestinal tract
• Chest X-ray
• Intravenous Urogram (IVU) for renal involvement

3. Investigations to prepare patient for surgery:

Packed cell volume (PCV), Full blood count (FBC), Random Blood Glucose, Urea/Electrolyte/Creatinine, Group and Cross match blood

TREATMENT of the Intestinal Obstruction

1. Resuscitate the patient

1. Pass 3 tubes: NasoGastric tube, urinary catheter and set an Intravenous line.
2. Administer broad spectrum antibiotics.
3. Correct dehydration and electrolyte imbalance.
4. Clinical evaluation for improvement.

2. Expectant management for adhesive intestinal obstruction

• Monitor abdominal girth.
• NG tube drainage monitoring.
• Monitor vital signs.

3 Surgical treatment

1. If for adhesive intestinal obstruction, do exploratory laparotomy with or without adhesiolysis (depending on whether there is adhesion or not).
2. For gastric Cancer, do partial or total gastrectomy, depending on the extent of the disease