CASE PRESENTATION

FIRM 1

PRESENTORS:
DR FALGUN ASAWLA
DR ANTHONY MAPANDE

FACILITATOR: DR RINGO
 INTRODUCTION
• Hospital number : M32-66-74
• Name: E. M.
• Residence: Morogoro
• Age: 73 years
• Informant: Wife
• Referal from : Sokoine hospital
 MAIN COMPLAINTS

– Altered Mental Status – 10/7

– Abdominal Distension – 3/7
 HPI
• The patient was apparently well until 10 days ago,
when he present with altered mental status
characterised by confusion, loss of memories,
disorientation to place, weakness, lethargy, headache
on the right side of the forehead after a fall and the
loss of consciousness for about a minute.

• It has been an intermittent presentation but

gradually increasing in intensity, no history of
hallucinations, no agitation, no seizures, no visual
disturbances, no mouth deviation no loss of strength
in the limbs no tongue deviation
 HPI...
• In the course of this illness he had attended at
sokoine hospital was given IV fluid and medication
can’t be remembered by the informer (Wife) with
insignificant success.
• However; this was followed by gradual onset of
progressive abdominal distension, associated with
mild to moderate pain and inability to pass stool and
flatus with no history of vomiting for three days
prior index admission.
• Patient’s previous history of changes in bowel habits
e.g. constipation, vomiting or passing blood in/with
stool and recurrent abdominal pain was not
ascertained because of patients condition.
 HPI...
• The patient had history chronic use of prednisone and
aminophylline due to asthma
• No hx of fever,
• No hx of chest pain, no hx of awareness of heart
beat, no history of bluish discoloration of lips
• No hx of difficulty in breathing when lying flat, no hx
of cough, no hx of night sweats, no hx of air hunger,
no hx of TB exposure
 HPI...
ROS
• As per HPI
FSH
• Married with 5 children
• Manager at security company
• No history of smoking or alcohol use
PMHX
• No hx of known food or drug allergy
• No hx of BT
 GENERAL EXAMINATION
• Fully conscious, afebrile, not cyanosed, not jaundiced,
not pale, no palpable peripheral lymphadenopathy, mild
lower limb oedema pitting; Dehydrated
• He has a bruise on the right side of the lateral
forehead
• NGT in situ draining brownish material 100mls, 20G
IV cannula in right arm and urinary catheter insitu
(700mls - duration??)
• Vitals: Stable
BP 149/92 PR 117 Temp 37⁰C RR 18
Sat O2 97% RA
 P/A
• Grossly distended abdomen, movable with respiratory
rhythm, no traditional or surgical scar, no visible
peristalsis, soft, non tender, no masses palpated, no
shifting dullness, hyper tympanic percussion bowel
sounds were exaggerated

DRE: Normal findings

• Normal anal verge and sphincter tone
• Rectal mucosa filled with some faecal material, no
prostrate enlargement
• Gloved finger stained with brownish faecal material.
 CNS
• GCS – 14/15 (E4V4M6)
• Oriented to time place not person
• Cranial Nerves intact
• Bulk - normal (all limbs)
• No irregular movements
• Gait - not assessed
• Tone – normal (all limbs)
• Power – 5/5 (all limbs)
• Sensations – not assesed
 SE

• CVS Essentially
• RS Normal
 PDX

• Intestinal Obstruction secondary to

??Sigmoid Volvulus
• CVA?

• Electrolyte imbalance
– Hyponatremia
 INVESTIGATIONS
• Full blood count, malaria rapid test were
normal
• ABG revealed pH – 7.49, pCO2 – 34.3, HCO3 –
26.6 (mild metabolic alkalosis)
• Na- 106 mmol/l ↓ (138 – 146)
• K – 3.9 mmol/l (3.5 – 4.9)
• Cl – 67 mmol/l ↓ (98 – 109)
• Creatinine – 100 umol/l (53 – 115)
• Urea – 5.3 mmol/l (2.9 – 9.4)
 INVESTIGATIONS...
• Abdominal X-ray (LD and supine)
 INVESTIGATIONS...
• Chest x-ray was done
 INVESTIGATION...
• Brain CT Scan
 TREATMENT
• Prepared for emergency exploration
• IV Ceftriaxzone 1gm od
• IV Metronidazole 500mg tds
• IV Pantoprazole 40mg od
• IV Paracetamol 1gm tds
• IV Fluids (DNS ↔ RL) 3 litres
• IV 3% NS 1 litre for 12 hours
• Retain catheter and ngt drain
 TREATMENT
• Patient was taken for Exploratory Laparotomy
• Intra operative finding
– Grossly distended transverse colon having being
twisted once with long mesentery, after untwisting
there was found a sigmoid volvulus likewise twisted
once which also had long mesentery and both
segment were excessively long (Redundant)
– Bowels were viable, no Peritonism, no perforation
– Rectal polyp seen (from the rectal mucosa when
sigmoid was resected)
– No mass was palpated, otherwise the rest of the
viscera was normal.
 TREATMENT...
• Done
– Mobilization of the colon from its lateral
peritoneal reflections, splenic flecture to
the mid transverse colon followed opening
of the mesenteries to identify the
supplying vessels ligation and dissection.
Left hemicolectomy done followed by EEA
of the Transverse with the Remnant rectal
stump.
– Resected colon which measured about a
metre and rectal polyp sent for
histopathological analysis
INTRA - OP
INTRA - OP
POST OPERATION ORDERS
– Admitted patient to ICU
– IV metronidazole 500mg 8hrly
– IV ceftriaxzone 1gm od
– IV pantoprazole 40mg od
– IV paracetamol 1gm 8hrly
– IV pethedine 100mg 6hrly
– IV NS 2 litres 24 hours
– Transfuse 2 units of PRBC
 Operation Day 1 Day 2 Day 3 Day 4
Day
BP 129/78 153/74 116/68 163/85 148/88
PR 80 101 84 101 109
SAT 02% 97% RA 100% 100% 100% RA 98% RA
Intubated Intubated
TEMP 37⁰C 36.8⁰C 36.7⁰C 36.7 37,8
GCS 14/15 11T/15 11T/15 11T/15 7T/15
RR 20 10 12 16 17
WBC 6.97 4.85 5.42 5.84
Hb 14.6 14 12.2 11.4 12.5
Platelets 176 70.2 84.5 136
Na 106 Sample Sample Not Reported 128
accepted Accepted
K 3.9 Sample Sample 3.2 2.5
accepted Accepted
Cl 67 Sample Sample 81 88
accepted Accepted
Creatinine 100 - 80.4 62.6 60.5
Urea 5.3 - 3.6 2.8 2.2
 FOLLOW UP
• Patient is in ICU and was on ventilator
machine, on the 3rd day post op, he pulled out
his ETT but oxygen saturation was maintained
and was left on oxygen mask
• 1 day later patient had an episode of apnoea
and convulsion and bag ventilation was done
which resulted into burst abdomen and
currently awaiting
 POINTS TO LEARN
• Management of Hyponatremia
• Sigmoid volvulus coexisting with Transverse
volvulus (Double volvulus)
 INTRODUCTION
• Volvulus refers to torsion of a segment of of
the alimentary tract, which often leads to
bowel obstruction.

• A volvulus may reduce spontaneously, but

more commonly produces bowel obstruction,
which can progress to strangulation, gangrene,
and perforation
 INTRODUCTION...

• 1-5% of large bowel obstructions

• Sigmoid colon (anticlockwise) ~65%.
• Caecum (clockwise) ~30%.
• Transverse colon ~ 4%
• Splenic flexure
 RISKS FACTORS
No known precise etiological factors
• Adhesions
• Peridiverticulitis
• Overloaded redundant colon
• Long mesocolon
• Narrow attachment of sigmoid
mesocolon
• Bowel dysmotility disorders
 TYPES OF VOLVULUS
• Duration – Acute
- Chronic
• Organs involved
-Volvulus of small intestine
-Ceacal Volvulus
-Sigmoid Volvulus
-Transverse Colon Volvulus
-Gastric Volvulus
-Gall bladder Volvulus
CLINICAL PRESENTATION
• Pain in the abdomen
• Absolute constipation (obstipation—no
faeces, no flatus).
• Enormous distension of abdomen
• Late vomiting, and eventually
dehydration.
• Features of peritonitis.
• Hiccough and retching can occur.
 DOUBLE VOLVULUS
Rarely seen clinical feature
• Ceacum and Sigmoid Colon
• Transverse and Sigmoid Colon
 RADIOLOGICAL FINDINGS
Plain Erect Abdominal
Xray
– Coffee bean sign/
– Kidney bean sign/
– Bent inner tube sign
 RADIOLOGICAL FINDINGS
Contrast Enema
• Bird beak sign
RADIOLOGICAL FINDINGS
CT Scan
– motorcycle sign
TREATMENT
 TREATMENT...
• Laparoscopic derotation
-Sigmoid and Transverse Colon Volvulus
-Not advised in Ceacal Volvulus
 TREATMENT...
Surgical Management
• Ceacal Volvulus
- Cecopexy
- Right Hemicolectomy with ileostomy or Ileal-
colic Anastomosis

• Transverse Colon Volvulus

- Colectomy with Colostomy or Colo-Colic
Anastomosis
 TREATMENT...
• Sigmoid Colon Volvulus
-Sigmoidopexy
-Sigmoidectomy with Colostomy and distal end is
brought out as mucus fistula from the rectum or
with
Hartmann’s operation
 REFERENCES
• Schwartz's 11th Edition
• Sabiston 19th Edition
• SRB 5th Edition
• Mpapho Joseph et al . Synchronous
volvulus of sigmoid and trasverse colon-
University of Bostwana; Nov 2018
• Ming-Pin Lin et al. Diagnosis of Sigmoid
volvulus using the coffee bean…Chen
Shiu University; June 2011
 REFERENCES
• UpToDate