Case 97: Abdominal distension and vomiting
A 43 year old man presents with central coloicky abdominal pain, distension and vomiting. He has a history of appendicectomy but no other abdominal operations. A radiologic study is shown below.
1. What is the study and diagnosis?
The study is a contrast meal and follow through. Water soluble contrast such as gastrografin is used in the setting of suspected obstruction in preference to barium. Small bowel obstruction due to post operative adhesions is the most likely diagnosis.
2. What is the potential role of this study in the management of this man?
Gastrografin meal is a useful diagnostic tool to confirm the diagnosis of SBO. It has also been shown to reliably differentiate between complete obstruction that will require operative intervention versus incomplete obstruction that will be successfully managed conservatively.
There may be a potential therapeutic benefit of the osmotic load of Gastrografin and studies are underway to investigate this. At present anecdotal evidence supports a therapeutic benefit but there is little data in the literature to support this view.
3. If conservative management is successful what other options would you consider in future?
Post operative adhesions are a major cause of morbidity and even mortality. Extensive investigation contiues into techniques to prevent adhesion formation. At present elective surgery to divide adhesions is controversial becuase the further surgery is likely to result in recurrent adhesion formation. The one instance in general surgery where this is not the case is following appendicectomy.
There is a significant chance of finding a single band adhesion in a patient with SBO following appendicectomy alone. In this circumstance it is justified to perform laparoscopic division of adhesions in the elective setting following resolution of the obstruction.