When the Stomach Takes Over the Abdominal Space
CCCF ePoster library. Mohamed A. Nov 8, 2018; 233368
Amira Mohamed
Amira Mohamed
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Abstract
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Introduction: Emergent surgery happens infrequently however there are several indications that help guide the decision to take certain patients to the OR. Uncomplicated small bowel obstruction however is not an indication of acute intervention. In these patients, nasogastric tube decompression and watchful waiting is usually successful. Here we present a case of a seemingly uncomplicated obstruction and stomach dilation with extraordinary CT scan images.

Case Presentation: A 32 year old female with ulcerative colitis with a complicated previous surgical history underwent an uneventful diverting loop ileostomy and was subsequently discharged in 2 days.  She presented one week post-op with complaints of nausea and vomiting yet her ostomy output remained within normal. A CT done in the emergency room showed a distended stomach however several CT scans in the past had showed a similarly distended stomach thought to be secondary to reduced peristalsis.  Given that the patient was still tolerating PO diet with a benign physical exam she was sent home with outpatient follow up. Two days later, at around 9pm, the patient presents with worsening nausea and vomiting, this time unable to tolerate a PO diet. Labs at the time remained normal including liver enzymes and creatinine.  A repeat CT scan with oral and IV contrast was done which showed a massively distended stomach compressing bowel and other abdominal organs with the oral contrast lingering in the stomach. She was admitted and an NG tube was placed in an attempt to decompress the stomach. At the time there was no indication for any acute surgical intervention so the patient was admitted to the general floor. Overnight the patient had worsening emesis and severe retching. She then acutely deteriorated becoming hypotensive and hypoxic requiring intubation. Her physical exam showed signs of peritonitis and she was taken to surgery emergently where an ex-lap revealed two large tears in the esophagus with two liters of enteric and feculent fluid in the left chest and three liters in the abdomen. During the procedure, ischemic appearing bowels and liver were noted. The esophageal tears were repaired and an NG tube was placed past the area of anastomosis. The patient remained intubated requiring vasopressors for several days before making a full recovery.

Conclusion: In this case we document severe stomach dilation causing small bowel compression ultimately resulting in small bowel obstruction. Despite the appearance of compressed liver and bowels on imaging and in the OR, signally abdominal compartment syndrome, creatinine remained normal.  Whether a massive stomach on imaging with any signs of perforation or abdominal compartment syndrome warrants emergent surgical intervention before nasogastric tube decompression is attempted remains controversial but in such a case with dramatic CT scan findings, surgery would have been a reasonable option.

 


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