By Tedler D. Depaynos, MD
It was just incidental when I met a male town mate at the Emergency Room who migrated and settled in a nearby province because of a wider and more irrigated farm land. They came to enjoy the festivities of the city when he developed a bloated abdomen accompanied by severe pain which started 3 days before. Because of the worsening condition, he was brought to the hospital.
There was a mid lower abdominal scar and the abdomen is obviously distended. No bowel sounds were appreciated. Tenderness could be elicited specially on the left lower quadrant of the abdomen even with very slight palpation. Because the patient has not been moving his bowels or even passing out flatus, Intestinal Obstruction was entertained. This was confirmed by plain abdominal x-rays.
From his history, the patient underwent emergency appendectomy 17 years ago in their province due to “ruptured appendicitis”. After 3 years he underwent another abdominal surgery or “explore lap” due to “Intestinal Obstruction” secondary to “postoperative (post-op) intestinal adhesions”. The adhesions were “released” and he recovered well. No wonder his mid abdominal scar is quite big. Usually the incision of a simple appendectomy is 3-4 inches long located at the right lower quadrant of the abdomen where the appendix is located.
Adhesions in the intestines are due to scarring. Some individuals are prone to scarring which cannot be predicted or avoided. Some factors may contribute to the “scarring” however, and most common is abdominal infection resulting in bowel inflammation and later adhesions like in ruptured appendicitis. With the rupture, the pus is leaked into the abdominal cavity and this is the main reason why emergency appendectomy is done when diagnosed clinically. Ideally, surgery is done before the rupture to prevent pus leakage and other possible complications. A portion of the leaked pus may be absorbed into the blood vessels and then distributed into the whole body causing “sepsis” which is dangerous. Complications must then be avoided if possible!
With the adhesions, the intestines maybe constricted narrowing their lumen resulting in partial or complete obstruction. In more unfortunate circumstances, the narrowing may be located in several areas so that obstruction may be found in several sections of the intestines. These are diligently released to relieve the obstruction and if raw areas of the intestines due to tearing occur, they are sutured and not exposed because it may become sites of adhesions again. Some surgeons may decide to by-pass the obstruction if the adhesions cannot be released.
Recurrence of Intestinal Obstruction due to adhesions must be prevented. What is unfortunate to some patients is that they may experience the same problem in the future just like in this patient. What is just fortunate for this patient is that his obstruction due to intestinal adhesions took years to occur. There were patients that took only several months.
Although the patient has not been passing out flatus, the abdominal x-rays revealed air in the distal large intestines so that “partial obstruction” was entertained. Hence, a conservative approach was first done. The patient was placed under NPO (nothing per orem) and an NGT (nasogatric tube) was inserted to drain the gastric contents. Intravenous fluids (IVF) were placed and his electrolytes were corrected specially the potassium (K+) level which may paralyze the intestines when low. Antibiotics were injected and rectal suppositories inserted to stimulate his bowel movement.
After several days, he started passing out flatus and his abdominal distension reduced. Probably a part of his intestinal lumen just narrowed and with solid fecal material, obstruction occurred. He was advised then to make sure that his stools would be soft to prevent recurrence of his condition. **