A 34 year old woman with Vomiting and abdominal pain

A 34 year old woman with Vomiting and abdominal pain

The patient was a 34 y/o woman admitted because of epigastric pain developed from 2 months ago. It was a crampy pain without radiation that became better with vomiting. She didn t have any history of hematemesis, melena, jaundice, weight loss, headache and fever. No history of constipation, diarrhea and obstipation.

BP=120/70 PR=80 RR=14 T=37.2

No history of: PUD Renal disorders Chronic liver disease DM HTN Recent surgery (cesarean section 7 years ago)

Drug history: Negative Familial history: Negative

Head and Neck: No paleness No icter No lymphadenopathy JVP=Nl Thyroid=Nl

Chest: Lung=Bilateral clear Heart=Nl Abdomen: Skin=Nl Obese No distention Slightly tenderness in epigastr No rebound tenderness No organomegally Bowel sound= Nl Extremities: Nl

2 months ago was admitted for the first time at ER because of the same complaint. Some work up such as lab tests and abdominopelvic sonography was performed that were normal and she was discharged.

1 month ago because of abdominal pain, vomiting and rise in Cr was admitted in nephrology ward for rule out of the cause of ARF.

CBC: WBC=5600 Hb=12 MCV=87 Plt=121000

Urea:104 Cr=2.1(reduced to 1.3) Na=138 K=4 AST=45 ALT=40 ALKP=140 ESR=12

U/A: Ph=5 Pro=1+ WBC=2-4 RBC=1-2 Bact=Negative

HBS Ag=Negative ANA=Negative Anti ds DNA=26 C3=1.2 C4=0.16

Abdominopelvic Sonography: Nl

1 weeks ago the patient was admitted in surgery ward because of the same complaint for rule out of pancreatitis.

Abdominopelvic CT with IV and Oral contrast: Liver, spleen, pancreas are normal Enlarged gall bladder Both kidneys have normal size and paranchymal thickness No evidence of hydronephrosis Upper GI Endoscopy: Nl

Some lab tests (Amylase,Lipase) was performed for her that were normal and then she was discharged.

Disorders of the gut and peritoneum Mechanical obstruction Functional gastrointestinal disorders IBS Dyspepsia Gastroparesis Organic gastrointestinal disorders (Cholecystitis, Pancreatitis, PUD, Hepatitis, Crohn's disease, Mesenteric ischemia, Inflammatory intraperitoneal disease )

Infectious causes Gastroenteritis( Viral, Bacterial ) Nongastrointestinal infections( Otitis media)

CNS causes Migraine Increased intracranial pressure (Malignancy, Hemorrhage, Infarction, Abscess, Meningitis, Pseudotumor cerebri ) Seizure disorders Psychiatric disease (Psychogenic vomiting, Anxiety disorders, Depression, Anorexia nervosa, Bulimia nervosa ) Labyrinthine disorders(motion sickness, Labyrinthitis, Tumors, Meniere's disease )

Medications Cancer chemotherapy Analgesics Cardiovascular medications (Digoxin, Antiarrhythmics, Antihypertensives, β-blockers, Calcium channel antagonists ) Diuretics Oral antidiabetics Oral contraceptives Antibiotics/antivirals Gastrointestinal medications (Sulfasalazine, Azathioprine ) Antiasthmatics (Theophylline )) CNS medication(anticonvulsants, Antiparkinsonian )

Endocrinologic and metabolic causes Pregnancy Uremia Diabetic ketoacidosis Hyperparathyroidism Hypoparathyroidism Hyperthyroidism Addison's disease Acute intermittent porphyria

Postoperative nausea and vomiting Cyclic vomiting syndrome Miscellaneous causes Myocardial infarction Heart failure Starvation

CBC: WBC=8500 Hb=13 MCV=80 Plt=235000

BS:86 Urea:62 Cr:1.4 Na:144 K:4.3 Ca:4 Ast:123 Alt:113 Alkp:190 Bili (T=1.1, D=0.8) INR:1

U/A: PH=5 Pro=Negative RBC=0-1 WBC=0-1 Bact=Negative VBG: PH=7.40 PCO2=35 HCO3=24

Abdominopelvic Sonography: Nl Bowel series: Dilation in stomach and duodenum and proximal of jejunum are evident in favor of obstruction Small passage of barium toward distal part of small bowel

Small bowel obstruction (SBO) occurs when the normal flow of intestinal contents is interrupted. The most frequent causes are postoperative adhesions and hernias, which cause extrinsic compression of the intestine. Less frequently, tumors or strictures of the small bowel can cause intrinsic blockage.

The most common symptoms of SBO are abdominal distention, vomiting, crampy abdominal pain, and inability to pass flatus. In proximal obstruction, nausea and vomiting can be relatively severe compared to distal obstruction, but distention of the abdomen is somewhat less since the proximal intestine acts as a reservoir as it dilates.

Adhesions Postoperative adhesions cause the majority of small bowel obstructions. Malignancy Malignant tumors are the second most common cause of SBO. Hernias the third leading cause of intestinal obstruction. Strictures Intraluminal stricture can be caused by a number of disorders including Crohn's disease, certain drugs such as entericcoated potassium chloride solutions and NSAIDs, radiation therapy, ischemia, and tumors.

Trauma Traumatic small bowel obstruction caused by intramural hematoma results in nausea, vomiting, and upper abdominal tenderness. Intussusception is rare in adults Gallstone ileus results from erosion and fistulization between the biliary and intestinal tracts. Bezoars Superior mesenteric artery syndrome The syndrome is characterized by compression of the third portion of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta and is primarily attributed to loss of the intervening mesenteric fat pad.

The diagnosis of SBO can be made by history and physical examination in the majority of patients. While imaging is potentially helpful in establishing the diagnosis, in most cases a laparotomy will be needed to make a definitive diagnosis and for treatment if a patient does not respond to nonoperative management. Laboratory studies are generally not helpful in determining the presence of small bowel obstruction, but can help in the assessment of the degree of dehydration.

Plain abdominal radiography Multiple air-fluid levels with distended loops of small bowel. Small bowel series These studies are highly sensitive and are the gold standard for determining whether an obstruction is partial or complete. Computerized tomography More recently, CT has been replacing the small bowel series as the adjunctive study of choice since it can simultaneously provide information about the presence, level, severity, and cause of obstruction. Ultrasonography ultrasound may be appropriate for pregnant patients or as a bedside test for the critically ill.

INITIAL MANAGEMENT The primary goals in the initial management of patients with SBO are to determine: The degree of volume depletion and metabolic derangement. The severity, cause, extent and location of the obstruction. Whether nonoperative management can be considered The need for and timing of operative intervention

NONOPERATIVE MANAGEMENT can sometimes be successful in patients with partial SBO. IV fluid Nasogastric tube Water soluble contrast- Hypertonic water soluble contrast agents (eg, Gastrografin) can be used for both diagnostic and therapeutic purposes in the setting of partial small bowel obstruction.

OPERATIVE MANAGEMENT Approximately one-quarter of patients admitted for small bowel obstruction will require operation. Patients suspected of having complete or closed-loop obstruction with fever, leukocytosis, tachycardia, metabolic acidosis, continuous pain or peritonitis warrant prompt exploration.

Surgery consult was done and the patient referred for laparatomy.

Laparatomy was performed: A nodule and stricture was found in 30cm from treits ligament in jejunum that was resected.

Pathologic report: Pneumatosis cystoides Intestinalis