NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Case Variation 8.1.11. WBC count of 24,000/mm 3 ◆ ◆ Marked leukocytosis is another indicator of a serious complication and warrants exploration. Case Variation 8.1.12. Moderate metabolic acidosis ◆ ◆ Metabolic acidosis with no other obvious cause warrants suspicion of ischemic or necrotic bowel . Depending on the patient’s overall status and the radiographic findings, there are two options: (1) urgent exploration or (2) mesenteric arteriography to check for an arterial occlusive lesion before exploration can be done, if clinically the intestine does not appear necrotic or perforated. Case Variation 8.1.13. Temperature of 103°F ◆ ◆ This degree of temperature, which indicates a bowel perforation or ischemic process with sepsis, warrants exploration.

Case 8.2 Crampy Abdominal Pain with Partial Improvement

You admit a 38-year-old with abdominal findings similar to the those of the patient in Case 8.1. You decide that your new patient has a small bowel obstruction and no evidence of complications. You place an NG tube, correct fluid and electrolyte ab- normalities, and plan to follow the progress of the obstruction. With observation and serial examinations, you note partial improvement with some flatus and one small bowel movement. You decide to remove the NG tube because the patient has made progress. When you do, the patient becomes nauseated and distended over the next 6 hours, and it appears that the obstruction has recurred. Q: What is the next step? A: The patient, who has failed nonoperative management, should go to the operating room for exploratory laparotomy. You decide to explore this patient. Q: What is the most likely operative finding? A: This band can be single, affecting a small amount of bowel, or multiple, affecting different segments of the bowel. The most likely finding is an adhesive band of scar tissue from the earlier procedure that is occluding a segment of bowel. Q: What operation would you perform? A: Lysis of adhesions to free up the entire section of involved bowel would be appropriate. Typically, you find one band that is highly obstructing, with distended bowel proximally and empty bowel distally. This definitively confirms the diagnosis of small bowel obstruction. Q: What is your postoperative plan? A: The patient remains nothing by mouth (NPO) with an NG tube for several days until bowel function returns. After eating is resumed, you may discharge the patient. Most patients who have undergone a lysis of adhesions are cured of obstruction in the short term. Follow-up primarily consists of wound observation to check for any signs of infection. No currently known therapy prevents recurrence of the adhesions or obstruction over the long term. SAMPLE