By Tedler D. Depaynos, MD
The 58 year old male patient has been complaining of on and off abdominal pain accompanied by abdominal distension since 2 weeks ago. It was, however, occasionally relieved by the passing out of small amounts of liquid stools and flatus. Thinking it was just plain “gastroenteritis” he started taking plain water and “anti-diarrheal drugs”.
After one week, the abdominal pain although tolerable, became constant and the abdominal distension worsened. He was then forced to seek admission. Because of the history of “diarrhea”, the initial impression was paralytic ileus where both the small and large intestines are dilated due probably to electrolyte imbalance.
The electrolyte imbalance was confirmed in the laboratory but the abdominal plain x-rays revealed only a portion of the large colon is distended specifically the transverse and descending parts only. In the small intestines, only a small non-specific portion is dilated. In paralytic ileus, all the small and large intestines should be dilated, hence the possibility of partial obstruction was considered. It was partial, because the patient was still passing out stools and flatus.
A routine chest x-ray was also done because in abdominal distension, the diaphragm may also be pushed upwards compressing the lower parts of the lungs which may be prone to pneumonia. Fortunately, the chest x-rays were normal. In interesting cases like this, the possible complications are monitored and must be prevented.
Hoping to see an obstructive lesion, an abdominal ultrasound (UTZ) was done. Except for probable stones in the gall bladder, nothing was seen in the intestines. A CT Scan was then requested which revealed thickening of the dilated portions of the colon. A dilated intestine should appear thin walled but when they are thickened, a probable swelling is initially thought of probably due to infection or “colitis”. An aggressive conservative management was then done with the correction of the electrolyte imbalance and giving of massive antibiotics hoping to control the infection followed by reduction of the swelling. Sepsis or in layman’s term, infection going into the blood stream must be prevented.
After 4 days, however, no significant clinical improvement was appreciated. Repeat abdominal x-rays were done to monitor the dilatation because with severe dilatation the danger of the wall of the intestines becoming ischemic may lead to perforation. The results were more or less the same. The patient was then referred to a young Gastroenterologist for possible gastro-endoscopy and colonoscopy.
The gastro-endoscopy just revealed a slight swelling of the gastric lining interpreted as Acute Gastritis. Probably due to stress and nothing per orem was taken for quite some time. The colonoscopy however revealed a mass at the distal colon called sigmoid causing partial obstruction which the young Gastroenterologist from experience opined that it is probably malignant. A biopsy was taken and true enough the tumor was malignant.
The patient eventually underwent surgery removing the tumor together with the segment of the colon where it was located. The surgery was uneventful and the patient was discharged although looking obviously thinner but alright. The pathologist would study the specimen and give the stage of the malignancy which would be the basis of the treatment of the Oncologist where the patient would be referred to eventually.
In training hospitals, each department is required to have regular weekly conferences where interesting and even problematic cases are presented and discussed. Opinions from the different participants are encouraged. Participants especially the young doctors and students learn from them. Exposure and experience is a must in the learning process. This case is one of those presented. It may be simple but was interesting.
An elderly retired surgeon who happened to drop by commented that during their time when there was not yet an UTZ, CT Scan and trained Gastroenterologist around, his preceptors just based on their clinical findings and x-rays could have opened up the patient earlier. A medical intern innocently asked how many cases they opened just to find out that surgery was not required. The elderly pretended not to hear so that when he did not reply one of the young doctors commented, “Jurassic”!. Although it took time for the attending MDs to open up the patient, the diagnosis was clear and there was no guessing game! Possible complications were also closely monitored and prevented.**