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HOPC: Debbie Winter presented a week ago with colicky severe abdominal pain, nausea
and vomiting. The pain was sharp and tight over the upper abdomen and the RIF, worse
on eating and when lying flat. The physical examination was equivolcal. She underwent a
diagnostic laparoscopy and appendicectomy ( some blood in the pelvis, normal appearing
appendix with only mildly inflamed appendix on pathology report, ?retrograde
menstruation) with uncomplicated post-operative recovery and she was discharged on day
3. Over the last 2 days the nausea, vomiting and abdominal pains have reoccurred, now
becoming quite severe and colicky. She has not opened her bowels for 3 days.
O+G Hx: unremarkable, LMP 9 days ago, no intercourse.
PHx. + FHx: unremarkable
SHx: single shop assistant, shares a house with 2 friends, non smoker, little alcohol,
NKA, no medication.
EXAMINATION: HR 110, BP 105/75, RR 20, SaO2 95% on RA, T 36.8.
Distended abdomen, lower abdomen and right flank tenderness, bowel sounds high
pitched, and they occur in frequent runs at the same time as her colicky pains.
INVESTIGATIONS:
Hb 115/WCC 6.7/CRP 370/Creatinine 59/Lipase 13
AXRAbdominal X ray revealed Marked gaseous distension of numerous loops
of small bowel and large bowel
1. Diet may be a factor as their patients had eaten large quantities of fibre
after prolonged fasting.
2. Gut motility: there must be a combination of a long small bowel ,very
firm abdominal muscles (restricting bowel movement to the coronal
plane) and a diet with an exceptionally high bulk, eaten rapidly on an
empty stomach.
SBV presents with the classical features of intestinal obstruction. Typical symptoms are
sudden abdominal pain followed by nausea, vomiting and abdominal distension. The
vomitus begins with gastric content, bile stained fluid and later even faeculent smelling
material!
A white blood cell count over 18 has been associated with the presence of necrotic bowel
loops, hyperamylasaemia and abnormal serum lactate levels in 86% of patients with
gangrenous small bowel, in contrast with 5% and 4%, respectively, in those with other
causes of small bowel obstruction.
Metabolic acidosis can be present in three-quarters of those with strangulated bowel.
Plain films usually show nonspecific features, ultrasonography is also a low-accuracy test
in bowel obstruction cases as a result of bowel distension and gas interposition.
The imaging test of choice for the diagnosis of small bowel volvulus is the CT scan;
characteristic findings include the "whirl" sign of the rotated mesentery and "peacock's
tail" sign resulting from torsion of the bowel around the mesenteric axis.
Small bowel ischemia is suggested on CT scan by the presence of bowel wall thickening,
intramucosal air, and intraperitoneal fluid.
The outcome of SBV is dependent on the speed of diagnosis leading to surgical
intervention
MANAGEMENT:
NBM
IV Abx
Analgesia PRN
The surgical options for SBV consist of de-rotation, with or without fixation, and
resection with anastomosis.