Indexing Title: HTURINGAN's Medical Anecdotal Report [04-1]

MAR Title: Patient presenting with complete intestinal obstruction due to appendicitis

Date of Medical Observation: April 12, 2004

Narration:

M. Atienza was admitted under the service of internal medicine with an impression of complete intestinal obstruction without prior history of abdominal pain only noting gradual abdominal distension and absence of flatus and bowel movement for 5 days.
Plain abdominal radiographs only demonstrated dilatation of the large and small intestines with interserosal thickening.
There was no evidenceof pneumoperitonuem on chest upright.
She was then referred to surgery for evaluation.
The abdomen although soft, showed evidence of peritoneal irritation with the presence of tenderness and guarding on all quadrants.
Patient underwent exploratory laparotomy
Multiple loculated abscess were located on the right and left pericolic gutters with the cecum and appendix enveloped by the omentum impinging and kinking the sigmoid colon, causing complete proximal bowel obstruction.
The appendix was gangrenous and appendectomy was done followed by peritoneal lavage.
Although the bowels were distended we did not attempt to milk the bowel as this will only lead to delay in the normal bowel function.
Post-operatively the patient’s general condition dramatically improved with return of bowel function on the second post-op day and gradual decrease of the abdominal distention
The patient was discharged recovered on the fourth post-op day.
Interviewing the patient again, she vaguely recalled an episode of hypogastric pain prior to the obstipation and abdominal distention.
 

Insights (Discovery, Stimulus, REINFORCEMENT):

Atypical presentation of appendicitis may at times be encountered by the general surgeon. And prompt decision should be made once an acute surgical abdomen is suspected.
Once the pathology is addressed, it is important for the surgeon to be reminded not to do anything that might eventually harm the patient. Such as the urge to milk the bowel to decrease the bowel distention and in so doing, close the abdomen with ease. However, this would only cause further problems like serosal tear and in the least would cause further delay in the return of bowel function.