A 20-year-old male patient presented to Nefas Mewcha primary hospital Emergency department in January 2020 with the main complaint of crampy abdominal pain and distention of 14 hours duration. Associated with this, he also had nausea and frequent bilious vomiting of eight times. He had passed feces 24 hours ago. He had no fever, cough, chest pain or night sweating. He had no history of similar illness before, no history of previous abdominal surgery.
H is a not married and claims to be not sexually active. Lives with his parents has 3 sisters and 2 brothers. He makes a living as a farmer. There are no medical illnesses that run in the family. There was no history of tobacco smoking or substance abuse. He consumes a local alcohol made of sorghum occasionally.
At presentation, his blood pressure was 105/60 mmHg, pulse rate was 68 beats per minute (bpm), respiratory rate was 18 per minute, and temperature was 36.2 °C axillary. Physical examination of the patient at presentation, the patient was acutely sick looking in pain; not in cardio respiratory distress. He had a dry tongue and buccal mucosa. No palpable lymph adenopathy in all accessible areas. Chest was clear and resonant. S1 and S2 cardiac sounds were well heard and there were no added cardiac sounds. Abdomen was slightly distended, moves with respiration, flanks were full, there were no scars, no distended veins and hernia sites were free. Palpation revealed a tense abdomen with no area of tenderness, no shifting dullness, hyper tympanic percussion note, bowel sounds were 35 per minute. There is scanty stool on the examining finger, with no blood on it from digital rectal examination, no palpable mass was detected. The patient was conscious and neurological examination was intact.
A complete blood count of our patient showed: white blood cells (WBC) 12500 mcL, red blood cells (RBC) 4.6 mcL, hemoglobin (Hgb) 16 gm/dL, hematocrit (Hct) 48%, mean corpuscular volume (MCV) 89.1fL, platelets 470 × 103, creatinine 0.6, blood urea nitrogen (BUN) 30, alanine aminotransferase (ALT) 28, aspartate aminotransferase (AST) 24, alkaline phosphatase (ALP) 48, albumin 4.3, total bilirubin 1.1, and direct bilirubin 0.4.
Plain abdominal X-Ray showed centrally distributed, distended small bowel loops and rectal gas shadow (Fig. 1). CT scan is not available at this setup so it was not possible to do one.
Management and outcomes
The diagnosis of acute abdomen secondary to small bowel obstruction secondary to primary small bowel volvulus plus stage I shock was entertained, Double intravenous line was inserted, and Trans-urethral catheter inserted, Naso-gastric tube was inserted. Three Liters of normal saline was given over a course of 2 hours, at emergency department. The patient was admitted to the ward was advised on the possible options of management, consented on conservative management, associated risks and the possibility of surgical intervention at any time in the course of the management.
The patient was kept Nil per oral, put on maintenance fluid and replacement of ongoing losses. Nasogastric tube produced 600 ml of bilious content during the first 6 hours; which was replaced with equal amount of ringer lactate. The abdominal cramp subsided after 4 hours of inpatient admission.
After 12 hours of admission, the Blood pressure was 100/70 mmHg, pulse rate 68per minute and the abdominal distension decreased significantly and the bowel sounds were 26 per minute, there was no area of tenderness and the patient passed flatus. Following 24 hours of admission the patient passed feces and vital signs were within normal range. Naso-gastric was removed and patient was initiated with sips. The patient tolerated sips very well and was observed for 24 more hours and discharged on next day. He was appointed to the surgical referral clinic after a week. On subsequent week the patient was seen at referral clinic; he had no change in bowel habit or any other complaint. His vital signs were stable and physical examination was detected no abnormality.
He has been followed every month for 3 consecutive months and has reported no recurrence of symptoms.