#4: LARGE BOWEL OBSTRUCTION SECONDARY TO COLONIC MASS

A.S., a 75-year old, male, single, from Makati City, came at the Emergency Room due to severe abdominal pain,
associated with vomiting episodes of fecaloid matter. Patient’s symptoms started with a 2-week history of
constipation and intermittent epigastric pain. No consult done and symptoms subsided spontaneously. 1 day
prior to consult, patient experienced severe, diffused abdominal pain with a scale of 10/10. Patient selfmedicated
with Buscopan 1 tab every 6hrs which provided temporary relief. Few hours prior to consult, patient experienced
severe abdominal pain, associated with anorexia, and projectile vomiting with fecaloid matter. Last BM noted
was 2 days ago (Bristol 1). This prompted patient to seek consult. Upon physical examination, patient was noted
to have globular, tensed abdomen with tenderness on periumbilical area. Vital signs: 180/100 mmHg, 120 bpm,
22 cpm, 39C, 96% O2 saturation. Height: 5’6” Weight: 97kg. The ER nurse noted the patient to be weak looking,
in severe pain, nausea, chills and with guarding behavior. During the interview, patient is hypertensive for 5yrs
with Losartan 50 mg OD in AM and Amlodipine 5mg OD in PM as maintenance medications. Patient is a call-
center agent and had history of MSM. Patient was previously treated for Syphilis last year. His father also had
hypertension and died of CVA. His mother also had hypertension and died due to Breast Cancer. He also had one
of his maternal aunts died due to Gastric Cancer. The patient admittedly loves to eat pork and smokes everyday
(1 pack per day for 8 years). He is allergic to nuts and egg.
Admitting Doctor’s Orders:
- Place patient on NPO - IVF: D5LR 1L x 80 cc/hr

- Diagnostics:

o CBC w/ PC
Hemoglobin 115 g/L Eosinophils
Hematocrit 0.41 Monocytes 0.10
RBC 3.08 x1012/L Platelets 410
WBC 20.3 x109/L
Neutrophils 0.95
Lymphocytes 0.05

o UA
Color yellow Blood Negative
Clarity Amber Protein Negative
pH 7.0 RBC 0-1
Specific gravity 1.010 WBC 0-1
Glucose Negative Epithelial cells Rare
 o Electrolytes
Sodium 130 mmol/L
Potassium 3.3 mmol/L

o Creatinine – 0.9 mg/dl

o Prothrombin time, Partial Thromboplastin time, INR
o SGPT = 132 U/L, SGOT = 102 U/L
o Total Protein – 55 g/L, Albumin – 28 g/L, Globulin – 23 g/L
o CEA – 10 ug/L
o CA 125 – 10 kU/L
o AFP – 8 ug/L
o CXR : Hazy opacities on R lower lung field
o RT-PCR SARS COV2 – viral RNA not detected
o WAB CT Scan with Triple Contrast - CT scout image shows air-filled dilated colon
terminating in the left upper quadrant; Midline coronal reformatted CT image of the
abdomen and pelvis after administration of intravenous contrast material shows obstructing
left colonic adenocarcinoma with adjacent perforation and abscess
o 12L ECG – Sinus Arrhythmia

o CBG – 70mg/dl

Therapeutics:

1) Pantoprazole 40 mg IV now then OD

2) Metoclopromide 10mg IV now then PRN for nausea or vomiting
3) Fleet enema now
4) Ceftriaxone 1g IV OD
5) Metronidazole 500 mg IV Q8
6) Ketorolac 30mg IV now then PRN for pain
7) Buscopan 1 amp IV Q6
8) Paracetamol (Aeknil) 300 mg IV Q4 PRN for temp >37.8
9) Nicardipine drip: Nicardipine 10mg + D5W 90 cc to start at 10 cc/hr, may titrate 5cc/hr to achieve SBP
120/80.
10) Kabiven 1400kcal x 24hrs

- Insert NGT and keep open to bedside bottle

- Replace NGT losses w/ PLRS volume per volume
- Insert IFC and monitor UO Q1; Refer if UO <30cc/hr
- Schedule for Exploratory Laparotomy possible Sigmoidectomy with Colostomy creation and Appendectomy -
Secure 1U PRBC properly typed and crossmatched

Patient A.S. underwent Exploratory Laparotomy with Hartmann’s Procedure; Appendectomy under General
Anesthesia. Patient tolerated the procedure well and was transferred to Recovery Room after 5 hours. Post-Op
orders were the ff:

- Monitor VS Q15mins until fully awake and stable VS

- Hook to O2 via nasal cannula at 2-3lpm

- NGT to drain
- Maintain moderate to high back rest.
- Deep breathing exercises
- Gargle with Bactidol once at room
- Maintain on NPO

- IVF: PNSS 1L x 8hrs; IVF TF: D5NSS 1L x 8hrs

- Continue Kabiven as ordered

- Continue Pantoprazole, Ceftriaxone and Metronidazole as ordered

- Start Tramadol 50mg IV Q8

- Ketorolac 30mg IV Q8 ANST to alternate with Tramadol

- Nubain 10mg IV Q6 PRN for breakthrough pain; Do not give if SBP <90mmHg

- Check for patency of NGT, IFC, JP drain and colostomy qshift

- Refer accordingl