INDEXING TITLE: RCHAN’S MAR [5-01]
TITLE: “The Abdomen is a Temple of Surprises”
PERIOD OF MEDICAL OBSERVATION: January 15, 2005
NARRATION:
A 69-year-old male was referred to our department by Internal Medicine. He had a three-week history of constipation alternating with watery stools accompanied by abdominal pain. Three days prior to consult he had persistence of his signs and symptoms and progressive abdominal distention. On physical examination, abdomen was distended with hypoactive bowel sounds, was distended with muscle guarding and tenderness on all quadrants of the abdomen. Rectal exam revealed a collapsed rectal vault with no feces on tactating finger. NGT was inserted. Bilous output was noted. Plain abdominal xrays revealed “step ladder” and “stack of coins” appearance of the small and large intestines with minimal presacral gas. We had an initial impression of “Complete Intestinal Obstruction Secondary to Malignancy”. We booked the patient for explor lap optimized his condition, and prepared the materials and consent for operation.
Upon opening up, both the small and large intestines were dilated. There was no peritonitis noted. We began exploring the abdomen from proximal to distal. No pathology was noted in the small intestines. However, we noted dense adhesions between the hepatic flexure of the transverse colon and the gallbladder area. It did not cause any significant obstruction and we just dismissed it as due to previous cholecystitis attacks in the past. As we were running the large colon, we palpated a hard, non-movable, intraluminal mass in the distal sigmoid area completely obstructing the lumen.There were no enlarged lymph nodes in the area too. Liver was smooth with no palpable nodes.
I then surmised that the mass was still a malignant lesion that needed to be addressed to properly. I had two options: to resect and anastomose or to do a sigmoidectomy and proceed with a Hartmann’s procedure. I referred the patient to our service consultant. I was adamant to do resection and anastomosis because of the fecal load of the patient. I proceeded to do Sigmoidectomy, and did the Hartmann’s procedure. We were about to close the skin when I decided to let my junior resident finish the closure. I took the resected sigmoid, palpated the mass and started opening up the specimen over the mass. Lo and behold the shock of my life! It was not a malignant tumor that was causing the obstruction, it was a STONE impacted at the narrowest portion of the sigmoid colon! It measured 3 x 4 cm hard, blackish brown in color. So that was the culprit!
In retrospect, the dense adhesions were actually due to the presence of an cholecystocolonic fistula. The stone came from this fistula and eventually migrated to the sigmoid and caused the obstruction.
INSIGHTS: (DISCOVERY, stimulus, REINFORCEMENT) (PHYSICAL, psychosocial, ethical)
We encounter a lot of patients as surgeons. No two patients are alike. No matter how you may know a procedure like the back of your hand, when you’re faced with a patient who deviated from the usual presentation, you will take one step back and rethink everything. You’d have to map out a new plan, a new approach to this new unexpected event that you have come face to face with. Decision making is very crucial to any surgeon, it may or may mean giving the patient a better fighting chance or getting that fighting chance away from him.
Admittedly, it was an overkill of a procedure that took place. Had I put significance on the presence of the dense adhesions at the gall bladder area, maybe I would’ve had an inkling that the patient had passed out a stone from the fistula. I would’ve just done an simple enterotomy to get the stone out. I should’ve opened the specimen while the operation was ongoing.
Well, too late to be pointing fingers at anybody huh?