NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Figure 8-3: Small bowel obstruction—CT. Coronal-plane-reconstructed CT demonstrates abrupt transition (arrow) between dilated and nondilated small bowel in this patient with radiation enteritis causing small bowel obstruction. The small bowel feces sign (arrowhead) is also evident. (From Klein J, Brant WE, Helms CA, Vinson EN. Brant and Helms’ Fundamentals of Diagnostic Radiology , 5th ed. Wolters Kluwer Health; 2018, Fig. 40-22.) Q: What is the overall management plan? A: Rehydration and assessment of the patient’s overall condition are necessary. It is usually safe to manage small bowel obstructions with nasogastric (NG) drainage and IV fluids if there is no clinical sign of ischemic intestine or peritonitis . This management strategy may last for several days in the absence of marked leukocytosis, fever, acidosis, or local- ized tenderness and no radiographic findings suggestive of ischemia, closed loop obstruc- tion, or perforation. Serial physical examination, laboratory studies, and abdominal radiography are important parts of the observation plan. The patient improves over the next several days. The pain and distention resolve, and appetite returns. Q: What would be the management plan at this point? A: It would be appropriate to remove the NG tube and begin feeding. If the patient tolerates the food, then discharge is appropriate. No further radiographs or other evaluation is necessary. Many small bowel obstructions, particularly adhesive small bowel obstruc- tions or incomplete obstructions, resolve with nonoperative management. The final diagnosis is adhesions secondary to the prior appendectomy; this diagnosis is presumptive in that there is no way to prove this specific diagnosis except at laparotomy. The patient should return if symptoms recur. SAMPLE