SGD 9 – Surgery Module 5: Surgical Diseases of the Digestive System

Lapoot, Legaspi, Lopez, Loquias, Lucman, Macabalang, Macabando, Macadato, Madrona

FN, 52-year old, Female, Businesswoman, Married,

RC, from Bulua CDOC 4 days PTA: PE Salient point:
-Bloatedness associated with two episodes of vomiting, Abdomen: distended abdomen, hypoactive bowel sounds,
PRESENTATION
Chief Complaint: Abdominal Distention non-bilous tense, tympanitic
- Passage of watery stools DRE: Collapsed Rectal Vault
CLINICAL

HISTORY OF PRESENT ILLNESS: 2 days PTA: Other salient points:

2 months PTA: -Bloatedness persisted, increasing abdominal discomfort
Noted decrease in caliber of stools noted Past Medical History: S/P CS-2001
(+) Obstipation, (+)Bilious vomiting with mild abdominal Personal History: Chronic Alcoholic Drinker
distention
Day of admission:
2 weeks PTA: -1 episode of vomiting
-Watery stools, yellow to brownish in character -Persistence of abdominal Distention prompted consult to
(-) Melena, (-) Hematochezia ER, and subsequently admitted

Decreased caliber to watery stools Abdominal distention

Complete obstruction Large Bowel Obstruction

Pencil-like stools LLQ pain S/P CS (2001) Bilious vomiting

Complete Bowel Obstruction Complete Bowel Obstruction Complete Bowel Obstruction Complete Bowel Obstruction
DIGANOSIS Secondary to Cancer secondary to Sigmoid Volvulus secondary to Adhesion secondary to Gallstone Ileus

CBC, BUN, electrolytes CBC, BUN, electrolytes, History of previous surgical procedure CBC, BUN, electrolytes
X-ray Abdomen Supine + Upright Abdominal X-ray and CT-scan CBC, BUN, electrolytes

DIAGNOSTIC
Chest X-ray PA Gastografin enema (Confirmatory) Diagnosed intraoperatively via Plain Abdominal X-ray
TESTS laparoscopy
CT scan of the Whole Abdomen with Contrast CT scan of the whole abdomen
Barium Enema
Colonoscopy

CBC Abdominal X-ray Laparoscopy Plain Abdominal X-ray

Assess anemia (Iron deficiency Inverted U-shaped, sausage- "Fat-bridging sign", Twisting Obstructive bowel gas pattern,
anemia common in Colon Cancer) like loop, "Omega sign", of the mesentery (-) Radiolucent stone
and elevated WBC with left shift "Coffee bean sign", Bent inner
tube sign

X-ray Abdomen Supine + Upright CT scan of the whole

Gas-dilated bowel loops, air-fluid Abdominal CT-scan abdomen
level seen, Whirl pattern, Bird's beak Rigler triad (Pneumobilia,
and no gas seen in the rectal vault. appearance Small bowel obstruction,
Impression: Ectopic gallstone); Site of
Large Bowel Obstruction fistulation often visible
Gastografin enema
(Confirmatory)
Bird's beak appearance
Chest X-ray PA
Atheromatous Aorta, Thoracic
Spondylosis
EXPECTED RESULTS

CT scan of the Whole Abdomen

with Contrast
Marked dilatation of the colon
particularly in the cecum,
ascending colon, hepatic
flexure,and transverse colon,
contrast and air-fluid level

Lesser degree of distention of the

descending colon with
circumferential wall thickening.

Proximal sigmoid colon is dilated

measuring 5cm with note of a
short segment (3cm) constricting
mass (2cm) diameter obliterating
the bowel lumen demonstrating
"Apple core deformity".

The sigmoid segment beyond the

mass and the rectum are well-
distended with retrogadely
introduced contrast with no
discrete lesion.

Impression: findings consistent

with distal large bowel obstruction
secondary to a short segment
constricting sigmoid mass with
malignant features.

Barium Enema
Detect small polyps even <=1cm;
large polyps >1cm

Pain control via IV medication Pain control via IV medication Pain control via IV medication Pain control via IV medication

IV fluid resuscitataion and electrolyte IV fluid resuscitation and electrolyte IV fluid resuscitation and IV fluid resuscitation and
PHARMACOLOGIC

replacement - Isotonic crystalloid replacement electrolyte replacement electrolyte replacement

PPI 40mg via IVTT Broad spectrum antibiotics with gram Broad spectrum antibiotics with Broad spectrum antibiotics with
negative, anaerobic coverage gram negative, anaerobic gram negative, anaerobic
Broad spectrum antibiotics with gram coverage coverage
negative, anaerobic coverage

Place bladder catheter to monitor Place bladder catheter to monitor Place bladder catheter to monitor
Place patient in NPO urine output urine output urine output
PHARMACOLOGIC

Perform bowel decompression via

Nasogastric tube placement and
NON-

NGT (Clear watery fluid- 50cc)

decompression
Insert Foley Catheter and Monitor
urine output

Pre-operative Diagnosis: Complete Initial Management: Detorsion via Laparoscopy or laparotomy Open/Laparoscopic
Bowel Obstruction secondary to Left rigid proctoscope; Hartmann's with adhesiolysis Enterolithotomy
sided Colonic new-growth procedure
Primary anastomoses of
remaining intestine
MANAGEMENT

4 to 6 weeks after
Exploratory Laparotomy, Subtotal Right hemicolectomy with a primary
Colectomy with end to end colorectal ileocolic anastomosis (for cecal
anastomosis. volvulus)
Repair of the choledochoenteric
Intra-operative findings: 3cm fistula + Cholecystectomy
constricting mass at sigmoid colon;
Emergent exploration and resection
markedly dilated proximal sigmoid
(for transverse colon volvulus)
colon up to the Cecum, multiple
serosal laceration with patchy
necrosis at the Cecum up to the
transverse colon. Liver is grossly
SURGICAL

normal, no palpable nodules, Minimal

clear intra-peritoneal fluid. No
carcinomatosis, No palpable pericolic
lymph node.

Post-operative Diagnosis: Closed

Loop Bowel Obstruction secondary to
Constrictive Sigmoid Colon Cancer
Stage IIB (cT4N0M0)

Histopathologic diagnosis: Well-

differentiated Adenocarcinoma of the
sigmoid with Infiltration up to the
Serosa. No lympho-vascular
invasion. Negative for tumor: 0/27
pericolic lymph node harvested. All
resection margins.

Pathologic Stage: Stage IIB

(pT4aN0M0)

Bowel Ischemia and perforation Risk for bowel strangulation Infection

Perforation
Recurrence Pancreatitis
Recurrence of symptoms
Recurrence of 20-40% to most Secondary peritonitis if there is Acute Renal Failure
common sites :local site within the perforation
abdomen, liver, and/or lung) Intraabdominal hematoma Biliary Fistula
Short bowel syndrome if a large
COMPLICATIONS

Metastasis part of the small bowel has to be Intra abdominal Abscess

removed due to necrosis
Lymph node involvement

Death (46%)

Metachronous disease (a secondary

primary tumor)

- Colonoscopy performed within 12 Follow-up after 6 months. Check Follow up after 11 months Follow-up visit 1 to 2 weeks after
months after the diagnosis of the patients exhibiting signs of (mean) to check for recurrence of surgery
FOLLOW-UP

original cancer; if normal, should be recurrence on physical or symptoms that may require
repeated every 3 to 5 yrs thereafter. radiological examination. repeat intra-abdominal surgery
- Endoscopic examinations (every 3-6
months for 3 years, then every 6
months for 2 years)
- Carcinoembryonic Antigen every 3-6
months for 2 years
- CT scans performed annually for 5yrs