Last week was a pretty hectic one for me here on the general surgery service. Now, I’m sure it’s nothing compared to what the clerks in St. John’s are dealing with, but for a rural surgery rotation, it was busy!
I was on call for a few days last week, since it was my preceptors’ week on call, and I wanted to do their call with them. There were two cases that were particularly interesting, and great learning experiences for me. Here’s the first one.
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An older woman presents to the emergency department on Tuesday evening with abdominal pain, nausea, and vomiting. Anything she tried to eat or drink came back up. The last time she’d had a bowel movement was that morning (it was normal), and she wasn’t passing any gas. The next morning, she had a CT scan that showed a complete small bowel obstruction.
Two of the most common causes for an obstruction of the small intestine are (1) adhesions and (2) hernias.
(1) Adhesions are a common result of surgery, kind of like bands of scar tissue that connect stuff that’s not supposed to be connected. Take this picture (stolen from Google) as further explanation:
What can happen is that the intestine gets caught up in an adhesion and kinked off. I don’t think we really know exactly how it happens, but I guess it’s enough to know that it does.
If you have a patient with a small bowel obstruction who’s had a bunch of open surgeries, you can be relatively confident that it’s caused by an adhesion. These are generally treated conservatively (non-operatively).
(2) Hernias are another, less common, cause of bowel obstruction. A hernia happens when there’s a defect in some kind of wall in the body, causing a little hole, and a part of an organ squeezes through. How does this relate to a bowel obstruction? Well, say you’ve got a defect in the abdominal wall that creates a little hole, and some intestine pokes its pesky little way through. Well, then you’ve kind of got your bowel kinked off, and it’s just like if you kinked off your garden hose: no more water can get through. And voila! Obstructed bowel.
Small bowel obstructions due to a hernia of some sort are generally NOT treated conservatively. They need surgery.
In this case, my attending wasn’t convinced that the bowel obstruction was caused by adhesions (there wasn’t any way to tell for sure without having a look inside), and so he decided to go ahead with laparoscopic surgery (using all sorts of fancy equipment and cameras to do surgery instead of cutting them wide open). We scheduled the patient for emergency surgery late that afternoon.
The offending hernia was easy to find on laparoscopy; it was an internal hernia. Basically, a small hole had formed in some tissue where she’d had a hysterectomy many years earlier, and some of her bowel had gotten stuck in it. The surgery was super quick – the doctor basically pulled the bowel out of the hole and made a snip in the tissue. No more hole and no more bowel obstruction!
I saw the patient the next day, and she was looking and feeling a 100% percent better. It’s pretty amazing what a huge difference such an easy surgery made.
It was also a good learning opportunity for me since I saw a classic small bowel obstruction presentation, but I learned an important lesson – don’t leave the patient under observation unless you’re very confident the obstruction is due to adhesions. If we had left this patient alone, it would’ve been bad news bears.
Hope that made some sense!