Thursday, June 7, 2007

unusual cause of bowel obstruction

Very interesting case from over the weekend. This was a 65 year old guy I was called about on a Sunday. He started having crampy abdominal pain on the previous Thursday that seemed to progressively worsen as Friday dinner time rolled around. After picking at his plate, nausea ensued with multiple episodes of emesis. He finally came into the hospital Saturday morning, and after waiting 6 hrs in the ER waiting room, a CT scan suggested "small bowel thickening" and he was admitted to the hospitalist service. When I evaluated him, he clearly had diffuse peritoneal signs with a WBC count of 16k. My impression of the CT scan was that of a high grade small bowel obstruction with massive gastric dilatation. In the LUQ, there was a segment of SB with mural thickening and mesenteric inflammatory changes. Complicating matters, this man had been started on coumadin about a month ago for atrial fibrillation and his INR was 6.9. We placed a nasogastric tube and commenced IV fluid resuscitation with saline. I also quickly gave him 7 units of FFP to try and correct the coagulopathy. Ultimately, I took him for exploration later that day. Findings: 15 cm segment of indurated, hemorrhagic proximal jejunum with obvious hemorrhage into the mesentery. The SMA was palpable and strong. The rest of the bowel looked completely viable and healthy. I resected the involved segment and performed a hand sewn side to side anastomosis. The final path showed hemorrhagic transmural infarction of the bowel with gangrenous changes.

The question: what was the underlying etiology? It clearly wasn't mesenteric ischemia. His only previous abdominal surgery was a lap chole ten years prior, and there weren't any significant intra-abdominal adhesions. Then I did some digging on Pubmed re: bowel obstructions and anti-coagulation. I think he had a spontaneous transmural intestinal bleed that ultimately led to the ischemic changes. The guy is now post-op day 3 and he's making good progress. Will probably start clears tomorrow.


Coffee Addict said...

thanks for sharing. will keep this story in mind when similar patients roll along. :)

Sid Schwab said...

I think your diagnosis is correct. I saw a couple of cases of the exact same thing over the years. Like a blood sausage.

Unknown said...
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Unknown said...

Question from a floatpool RN,

Would you give him Vitamin K to reverse the INR? Does it work faster than FFP? or did you give FFP to also support him fluid wise since he looked to be bleeding?

I remember hearing a oncologist who specialty was hematology tell me Oral vitamin K works as fast as IV vit K and I thought our rapid INR reversal protocol said to use vit K IV ONLY If oral route contraindicated( Obviously it would be in your patient. ) but I see hospitalists routinely order VIT K IV for surgery in the AM for cases where they can still take PO the night before.

I worry as I always closely monitor the Vit K when given IV like sit in room for the start of the infusion to make sure the 15 minute vitals are fine no reactions etc as I heard if they do have a reaction to the IV vit K it should happen pretty quickly. After the start of the infusion it decreases chance of bad outcome.