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DRAMA INSIDE OPERATION THEATRE - III , (June, 2004)

Abdomen - the Magic Box & the Drama inside the O.T.
“Even when all the experts agree, they may well be mistaken” Bertrand Russel.

Even with clinical acumen and vast experience of highly skilled physicians and surgeons and with all the modern investigative techniques, it is not always possible to unravel the mysteries inside the “abdomen’ in a patient suffering from some abdominal disease. This is all the more difficult when there is an “acute abdomen” - an emergency situation. The goings on in an acute abdomen have been compared to a “drama” by Sir Zachary Cope in his book called “ Acute Abdomen in Rhymes”.

Main actors in the drama :
The main actors in the drama of acute abdominal problems are four in number. They are Pain, Distension, Vomiting and Rigidity. There are in addition, several minor characters in the drama, like fever, bowel or urinary disturbances, dehydration (loss of body fluids), alteration or deterioration of pulse, respiration and BP (collectively may be called as a state of “shock”) etc. Various permutations and combinations of these actors (symptoms) result in dramatic presentations which often defy interpretation even by experienced hands. Let me describe a recent dramatic presentation.

Seventy years old lady with “Acute Abdomen”.
She had repeated and continuous bouts of vomiting with severe pain in the upper abdomen and lower chest. Pain was very severe and excruciating. Her bowels had moved normally that morning and urination was normal. There was no fever. Previously she had a heart attack 2 years earlier and used to get anginal pain on and off ( due to heart disease) and was diagnosed to have “unstable angina”. She had undergone an abdominal operation 20 years earlier for removal of uterus. A senior physician and later a surgeon, who examined this patient suspected severe gastritis or gastroenteritis (food poisoning) . A fresh ECG and few other tests done were unremarkable. She was given appropriate medications and some I.V. drips and sent home. There was some improvement in her condition and she was again seen on the following two days and some more adjustments of her medications were done. Finally she was admitted into the Hospital for full evaluation and continuous observation. Some sort of highly resistant or unusual (like fungal) oesophagitis or gastritis or incomplete intestinal obstruction were suspected. A plain X-ray of abdomen in standing position did not show features of intestinal obstruction (like gas filled distended loops of intestines and multiple gas and fluid levels).

An upper G.I endoscopy did not show gastritis; but something unusual was there. The stomach contained faeces like material! This can happen either in very late stages of intestinal obstruction or if there is any abnormal communication (fistula) between the large bowel (which contains faecal matter) and the stomach. An intestinal obstruction did not seem likely because some of the typical features of this condition were not there; the type & location of pain, absence of distension of abdomen and X-ray features of obstruction. Also there was no other indications of the unlikely and rare possibility of fistula between stomach and colon.

What is the diagnosis?
At this stage, further investigations like a C.T scan and if still undiagnosed, a contrast X-ray of the large bowels (barium enema) were advised. A previously taken Ultrasound scan was not very helpful. However, at this juncture, the CT scan showed distended small bowels and completely collapsed large intestines suggestive of obstruction of terminal small intestines.

Some more rigorous non surgical measures for intestinal obstruction were then started. But the patient continued to have severe excruciating pain, did not pass out any motion or gas for over 4 days. The severe pain that she continued to have and on examination by the doctor, severe “tenderness” (pain induced by the doctor’s examining hand) in the right upper part of abdomen were quite ominous. Generally it indicated that some part of intestine was not only blocked but also being strangulated (deprived of its blood supply). Such a strangulating type of intestinal obstruction will sooner or later lead to "gangrene" or "death" of the affected loop of intestines. If not corrected by an operation, such a condition often ends in fatality. She needed urgent surgery as a life saving measure.

To do or not to do surgery?
She needed emergency surgery under anaesthesia; but her frail general health, poor heart condition and likelihood of getting another full fledged heart attack anytime, made it a highly risky proposition. The cardiologist’s opinion was sought once again to fine tune the cardiac medicines; a fresh ECG and Echocardiogram were taken. The team of doctors consisting of Consulting physician, Surgeon, Cardiologist and Anaesthesiologist reevaluated and discussed the situation. It was felt that doing surgery under any anaesthesia was very risky; she may go into a heart attack during or after surgery and this could be fatal. But, surgery had to be performed as a life saving measure, even though it was risky.

To complicate matters further, the lady was a close and dear relative of the surgeon and one of the other doctors. It was feared that the close emotional bonds may affect decision making and performance at surgery. Even the option of calling another professional colleague was considered.

The operation for the intestinal obstruction could be fairly simple or may turn out to be quite major and shocking, if “gangrene’ of intestines had occurred. The gangrenous intestines have to be cut out and the intestines rejoined.

And finally …
Taking all possible precautions and keeping ready two units of cross matched blood ready, surgery was performed under general anaesthesia. Fortunately there was no "gangrene". It was a relatively simple obstruction due to band of scar tissue, the result of abdominal hysterectomy performed 20 years earlier! After a somewhat stormy post operative period, the patient made complete recovery and discharged in about a week after surgery.

All the experts agreed; but they were all wrong !
All our strong suspicions about intestinal gangrene proved wrong ! All our fears about a further attack of M.I (myocardial Infarction or heart attack) during or after surgery were proved incorrect. Having thought of the worst and being prepared for the worst, we were very happy to be proved wrong! All these were due, to some extent, to the proactive steps and precautions taken. And fortunately all ended well in a happy note!

Some more dramatic real life stories in some future newsletters.

By healthy; be well informed!

Dr. M.Mohan Rao, MBBS,MS,FICS,MCH,

M.D. & Chief Surgeon, Dr. U Mohan Rau Memorial Hospital.
E-mail: mmr@mohanraohospital.com



 

Updated on 01.06.2004.
 

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