By Tedler D. Depaynos, MD
The male patient has been complaining of on and off epigastric pain and although he was diagnosed to have “hyperacidity”, he underwent extensive work –up mainly for peace of mind. A young Gastroenterologist MD did an Esophago-Gastro-Doudenoscopy and Colonoscopy visualizing all those organs and his final finding was just “hyperacidity”. With medications as well as the thought that he is not suffering from any serious ailment, the patient was much relieved.
It was after a year when on one late afternoon, the patient suddenly felt a different abdominal pain. The pain was “generalized” and gradually worsening and he felt his abdomen getting “bloated”. He felt that air seems to be accumulating and was causing his abdominal distension so that he went to the comfort room several times trying to relieve himself but to no avail. Because of the severe pain, he was rushed to a nearby hospital.
After a brief evaluation at the emergency room (ER), his condition was diagnosed to be an “acute abdomen” implying that an emergency surgery might be needed. Hence, despite the Covid 19 priorities and precautions he underwent an x-ray and ultrasound of his abdomen and other laboratory work-ups. Initial impression was “small bowel obstruction”. His Gastroenterologist MD was called and he was immediately referred to his colleague surgeon.
On closer study, the patient appeared to have “volvulus” or twisting of the intestines over its mesentery which seem to involve the small ones. The twisting usually involves the large intestines specifically the ceacum, the sigmoid or even the transverse colon. In elderlies like this patient who has been a senior already for just less than a decade already, a malignant tumor initiating the twisting would be a major consideration.
Malignancy in the small intestines is not very common, however, in contrast to the large ones. In this patient where the small intestines appear to be involved, a concomitant cause is not obvious. Perhaps, the mesentery is more than redundant than usual. Further work-up was thought of to confirm the exact diagnosis and the cause of the “volvulus” but because of the very uncomfortable condition and age of the patient, emergency surgery was prioritized.
Twisting of the intestines over its mesentery which carries its blood supply may cause sudden ischemia to the affected intestines. The twisting would also result in intestinal obstruction causing dilatation which would explain the abdominal distension. The distension would also compress the minor blood vessels on the walls of the intestines worsening the ischemia so that gangrene may eventually occur. The occurrence of this unfortunate process would cause the severe pain.
With intestinal dilatation, the bacteria together with its toxins inside the intestinal lumen may seep outside and circulate inside the entire body causing sepsis which is a dangerous complication. To prevent this occurring in this patient, an emergency intervention was opted especially so because his laboratory results appear to imply the inevitable occurrence of this septic complication. Besides, an early surgery may prevent the occurrence of gangrene. Meanwhile, massive antibiotics were started.
With careful Covid 19 precautions, the patient underwent emergency surgery. True enough, the patient had intestinal “volvulus”. It was the small intestines that twisted on its mesentery and they looked severely swollen and edematous with very poor blood supply. Most of it appeared grayish and in some areas, they are already dark. Resection of the twisted intestines was done and unfortunately a long portion was resected despite the conservative attempts of the surgeons. The distal part of the remaining small intestine was exteriorized ((jejunostomy) together with the proximal end of the large colon (colonostomy) because direct anastomosis may not be feasible due to the swelling and unsure blood supply. The emergency surgery was uneventful.
After a week, the exteriorized end of the small as well as the large intestines where returned into the intestinal cavity and were anastomosed.
During the patient’s confinement, he was on NPO (nothing per orem) and was given hyper alimentation thru his IV (intravenous) fluids. Although he could now return to be on diet, food absorption would be limited because of the shortened intestines. He would be advised to take in easily absorbed diet and probably would be given hyper alimentation thru IV from time to time. His Gastroenterologist MD would surely make plans with regards to this.
In retrospect, the surgeons could not definitely conclude the cause of the “volvulus”. They were just cheerful it was not due to the big C. **