NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: What are the management options? A: An unplanned enterotomy is an undesirable event when it occurs during lysis of adhesions. If holes are small, primary repair is appropriate. If holes are large, are multiple, or involve densely adherent bowel, the segment of affected bowel may require resection. Q: What problems might you anticipate in the postoperative period? A: The greatest risk of an enterotomy is a postoperative leak and development of a small bowel fistula . Case 8.5 Crampy Abdominal Pain following Pneumonia You are asked to see a 49-year-old patient on the medical service who is recovering from pneumonia. Abdominal distention, nausea, and crampy abdominal pain have recently developed. Q: What might be causing the distention? A: Patients with multiple other diseases such as heart failure, sepsis, or chronic obstructive pul- monary disease (COPD) may look as if they have a bowel obstruction. This patient could have a small bowel obstruction; if this is present, treatment as described in the previous cases is warranted. However, distention has many additional causes, including paralytic ileus, air swallowing, and constipation . An ileus is a paralytic state in which the bowel fails to maintain peristalsis. Nausea, vomiting, and abdominal distention develop, and, from a functional standpoint, nothing can pass through the bowel. Q: If you are uncertain of the diagnosis of bowel obstruction in a complex situation such as this, is there any way you can confirm the diagnosis of a small bowel obstruction without an operation? A: If you are uncertain of the diagnosis or if NG drainage leads to only partial improvement, an upper GI series with small bowel follow-through or a CT scan with oral contrast prior to the decision to explore the patient is warranted. If the bowel is obstructed, the contrast stops at the obstruction, and this establishes the diagnosis. Severe constipation should also be evident with this study, although a colon full of stool is usually visible on a plain radiograph of the abdomen. If the contrast finds its way to the colon and eventually to the rectum, there is no mechanical bowel obstruction, and surgery will not help. Treatment of constipation involves enemas and disimpaction, not surgery. Paralytic ileus from many causes may also produce obstructive symptoms. It may lead to poor peristalsis and a slow transit time as seen on the small bowel follow-through. Case 8.6 Abdominal Pain in an Older Adult A 70-year-old presents to the emergency department with a 1-day history of nausea, vomiting, and increasingly severe abdominal pain. The patient has a low-grade fever as well as mild distention of the abdomen, which is nontympanitic and mildly ten- der. The pain seems much more severe than her abdominal findings. The abdominal radiograph shows a nonspecific ileus. SAMPLE