A Catastrophic Small Bowel Obstruction Dr Zoe D Scounos Thoracic and Sleep Physician The Prince Charles Hospital Holy Spirit Northside Hospital Brisbane, Queensland, Australia

Case Presentation 76 yr old male (father of presenter) presented 21 May 2013 with: Vomiting, diarrhoea, along with haematezia for 4 days, intermittent fevers, and eventual abdominal pain, with distension necessitating presentation to the emergency department. Relevant background includes; Ischaemic heart disease- MI 25 yrs ago, thrombolysed Cerebrovascular Accident, left ACA territory, 10 yrs ago, no residual neurological deficit Former smoker (at least 30 pack yr history) Therapeutic regime: Aspirin, Clopidogrel, Simvastatin

Clinical Evaluation Clinically , appeared unwell, afebrile, haemodynamically stable, with mild tachycardia (110bpm), tachypnoeic (28), poor peripheral perfusion with SpO2 90% on room air. Rest of cardiovascular examination unremarkable, and chest was clear. Abdomen distended , mottled, and absent bowel sounds. Further evaluation revealed a leucocytosis, with a neutrophilia (22.3, and 17.6, respectively), mild acute renal impairment, cr 146, ur 13.5, along with abnormal LFT’s, lipase normal. ECG revealed sinus tachycardia and poor r wave progression anteriorly. AXR confirmed multiple loops of dilated fluid filled small bowel in keeping with a small bowel obstruction. Abdominal & Pelvic CT scan with IV contrast revealed moderate to marked dilatation of the stomach, proximal and mid small bowel in keeping with distal small bowel obstruction. A thick walled distal ileum was noted in the right iliac fossa. At least 70% stenosis of the origin of the coeliac axis and superior mesenteric artery.

AXR SUPINE

AXR ERECT

CT ABDOMEN WITH CONTRAST PRE SX

Provisional diagnosis Distal small bowel obstruction: - cause unclear, with high index of suspicion for ischaemic bowel until proven otherwise.

Immediate treatment of acute abdomen Fluid replacement, nil by mouth Nasogastric tube insertion, with adequate drainage Low flow oxygen therapy Close clinical monitoring in general and of fluid balance Surgical opinion sought, supportive treatment continued as was found clinically stable post admission Follow up blood tests confirmed normalization of renal function (cr 98), an improvement in the neutrophilic leucocytosis, despite a shift to the left and an improvement to the liver function tests.

Progress –a turn for the worst Within hours of surgical review after being deemed clinically stable, progressive deterioration ensued Worsening tachycardia, up to 130bpm, haemodynamics maintained Worsening hypoxemia, requiring high flow oxygen Fever ensued Thus transferred within hours to ICU for appropriate monitoring and treatment Urgent re-evaluation confirmed early sepsis with ischaemia being the likely cause given an elevated lactate level. Broad spectrum antibiotics commenced. Emergent exploratory laparotomy performed with intubation and ventilation had in theatre. This confirmed suspicion of an infarcted bowel. A right hemi-colectomy was required along with resection of part of the ileum. Inotropic support commenced with noreadrenaline.

Continued precarious state Repeat laparotomy had within 12-24 hours as per standard; Rest of ileum required resection, and 20cm of jejunum as it appeared ischaemic. The concern was that the jejunostomy created proved that the inner lining appeared ischaemic, hence remaining bowel likely also ischaemic. A mucous fistula created for the redundant colon. Deemed limited chance of survival. Family meeting had as prognosis was poor, and guarded. Supportive care continued, including the commencement of TPN. Mean arterial pressure was aimed at 65-70mmHg.

Pathological Diagnosis Histopathological report of the right hemicoletomy revealed extensive mucosal ulceration consistent with an ischaemic aetiology. Further examination had with further tissue submitted of involved areas confirmed the presence of partial thickness necrosis, consistent with the diagnosis of ischaemic colitis. Further resection of ileum, confirmed ischaemic ileitis.

The Prayer At completion of family meeting we were faced with an impossible situation medically. A unanimous prayer had with mother (wife) and younger sister, with joining of hands: “Father God, your Word says when 2 or more people gather together in prayer you are present. Please restore the circulation through the rest of the bowel and restore Dad completely.”

Praise God – Prayer answered expediently The following day after the prayer, the surgical team decided to repeat the CT abdominal angiogram to determine whether revascularisation was suitable to provide a chance of survival. The result was astounding: No evidence of vascular disease was identified intra-abdominally. (vasculature was divinely restored) Within further 24 hours inotropic support was begun to be weaned as was clinically appropriate. Active treatment continued. 5 days later successfully weaned off mechanical ventilation.

CT ABDOMINAL ANGIOGRAM POST SURGERY

Ongoing clinical progress Critical illness proximal myopathy ensued After 9 days in ICU transferred to acute surgical ward. Within 2 days TPN no longer required. Oral nutrition encouraged, however the NGT which was in-situ from outset had caused local trauma impeding natural swallow hence a finer one was inserted and oral hydration a nutritional intake were commenced. Due to a high output stoma, high dose Loperamide was commenced and ongoing close monitoring of biochemical profile was had and maintained to adequate avail.

Continued progress NG feeding commenced and continued until oral nutrition was achieved, including St Mark’s solution. Week 2 on acute surgical ward, fever developed and septic screen, including CT abdomen confirmed an intra-abdominal collection (para-colic gutter collection) of which was loculated and not amenable to percutaneous drainage. Maximum diameter 10.4cm x 7.4cm x 6.4cm. IV Piperacillin/Tazobactim course had for 2 weeks followed by Augmentin duo forte for a few weeks only as this contributed to increased stoma output. Follow-up abdominal u/s within weeks confirmed marginal reduction in size of collection. Clinical status improved slowly but surely. Functional capacity included. As nutritional status improved within weeks NG feeding no longer required. Two weeks were spent in rehabilitation as full independence was achieved along with maintenance of the care and dressing of the jejunostoma, and mucous fistula. After 7 weeks in hospital, discharged home, on multi-vitamins,, low dose aspirin, and St Mark’s solution. Post –operative anaemia resolved within weeks along with normalisation of the albumin which had reached a nadir of 19 during hospitalisation. Hydration and nutrition remained optimal at all times, in the absence of complications.

Complete restoration attained Within 2 months decision made given excellent recovery for the reversal of jejunostomy and mucous large bowel fistula. This was had with a laparotomy restoration of bowel continuity to adequate avail. Within a week post-operatively an entero-cutaneous fistula was identified having complicated the surgery. Treated with IV broad spectrum antibiotics prophylactically along with TPN, and hence nil by mouth, conservatively for 4 weeks to adequate avail. Discharged thereafter with maintenance of nutrition and complete healing of abdominal wound within 3 months. Healed by the grace of god

The Power of the Word Matthew 18:19-20 “Again I say to you that if two of you agree on earth concerning anything that they ask, it will be done for them by My Father in heaven. “For where two or three are gathered together in My name, I am there in the midst of them.” Mark 10:27 “with God all things are possible” Mark 9:23 “all things are possible to him that believeth”

My Father’s Testimony An example of healing by the Grace of God Restoration of the vasculature of the bowel, with healing of an ischaemic organ to normality, and complete restoration of functional/physical capacity. My Father’s Faith made him well Request of prayer prior to presenting to hospital with an abdominal catastrophe in the outset.