Case Presentation SIGMOID VOLVULUS By, Dr. ANSARI SANA AFREEN 1 yr PG Dept. of General Surgery KIMS Narketpally
Sathish a 18yr old male presented to the EMD on 10-06- 2015 COMPLAINTS AND DURATION: Pain in Abdomen since 3 days Not passing stools since 3 days 4 episodes of vomiting since 1 day
HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 3 days back then he developed Pain Abdomen sudden in onset, diffuse and colicky in nature associated with gradually increasing Abdominal distension. No aggravating /relieving factors H/o Obstipation since 3 days. H/o Nausea and vomiting 4 episodes since 1 day non projectile non bilious. There was no associated history of trauma/bleeding per rectum/ mucous discharge per rectum/ fever/ burning micturition No history of significant weight loss/ anorexia.
PAST HISTORY: No similar complaints in the Past. No history of Diabetes, Hypertension, TB, CAD, CVA, Bronchial Asthma, Epilepsy No history of previous abdominal surgeries. PERSONAL HISTORY: Appetite is Normal Consumes Mixed Diet Normal Bowel and Bladder habits No known Allergies No Addictions
FAMILY HISTORY: No h/o Diabetes, Hypertension, Heart Disease, Stroke, Cancers, tuberculosis or Asthma in Family. No other Hereditary Disease. DRUG HISTORY: Nil significant.
PHYSICAL EXAMINATION: GENERAL:- Patient is conscious, coherent, cooperative No signs of Pallor / Icterus / Cyanosis / Clubbing / Lymphadenopathy / Oedema of feet Patient is dehydrated. Temperature : 98.6F Pulse Rate : 100/ min BP : 110/80 mm of Hg Respiratory Rate : 20/ min
SYSTEMIC EXAMINATION:- CVS- S1 S2 heard No Murmurs RESPIRATORY SYSTEM- BAE + NVBS No Adventitious sounds CNS- No focal neurological deficit
ABDOMEN: INSPECTION: Abdomen is Distended No visible Peristalsis No visible mass No scars or sinuses Hernial orifices are normal PALPATION: Tense Generalized Tenderness is present no guarding no rigidity no organomegaly no signs of free fluid in the peritoneal cavity. PERCUSSION : tympanic note found all over abdomen. AUSCULTATION: Bowel sounds absent
INVESTIGATIONS: X-RAY ERECT ABDOMEN Evidence of large dilated bowel loop showing Coffee-Bean Appearance is seen in left side of Abdomen extending into right side inferiorly No evidence of Air under Diaphragm. Few Air-fluid levels noted. Visualized bone and soft tissues appear normal Impression: D/D 1. sigmoid volvulus 2. caecal volvulus
INVESTIGATIONS: USG ABDOMEN Impression: free fluid noted in Peri-hepatic,RIF and Inter-Bowel spaces no evidence of internal echoes correlate with erect X-ray Abdomen.
BLOOD GROUP: AB positive CBP: Hb : 13gm% TLC : 8,600/cu. mm Platelets : 2.4 lakh/ cu.mm Smear : Normocytic Normochromic Bleeding Time : 2min Clotting time : 3min 30sec RBS : 92 mg/dl ECG : normal findings Chest X-RAY : normal findings
PROVISIONAL DIAGNOSIS : SIGMOID VOLVULUS Initial treatment : NBM Ryles tube aspiration foleys catherisation IV fluids Inj cefotaxim 1gm iv Inj metronidazole 100ml iv Inj pantoprazole 40mg iv Inj tramadol 50mg slow iv
OPERATIVE PROCEDURE: Detorsion of volvulus and procedure Surgery Starting time: 10.15pm Ending Time: 11.30pm Under GA abdomen was prepared with Betadine and Spirit and draped. Abdomen opened with Left Para Median Incision. Sigmoid Colon deflated and detorsion done. Resection of Volvulus Segment done sigmoid colectomy. End to end anastomosis of descending colon to rectum done. Rent in sigmoid mesocolon is closed. Hemostasis is secured. Flatus tube passed beyond anastomosis. Wound closed in layers with Abdominal drain in pelvis. Final DIAGNOSIS: SIGMOID VOLVULUS
Sigmoid volvulus
Ligation of arterial arcades in sigmoid mesocolon Resected sigmoid colon
Anastomosis of bowel
Post Operative Management: POD-1 NBM for 48 hrs with RTA 2 nd hrly IV fluids, Antibiotic, Analgesic Flatus tube continued I/O charting Care of catheters Drain-20ml POD-2 Patients General condition is stable continued IV fluids, Antibiotics, and other treatment as on 1st POD Drain-150ml POD-3 Bowel sounds present Ryles tube removed IV fluids discontinued liquid diet started, Drain-100ml
POD-4 Flatus tube removed, Drain-minimal POD-5 Soft diet started, Oral antibiotics instituted, passed stools, Abdominal Drain removed. POD-8 Suture removal done, wound healthy. POD-12 Post-operative period is uneventfull. Patient is Discharged
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