Small bowel injury
Note: an injury of the small bowel… not a small injury of the bowel.
A man was involved in a head-on collision between his car and an on-coming lorry at 6 pm. His abdomen struck the steering wheel. He had received outpatient treatment and went home. He came to hospital the next morning with severe abdominal pain. Examination revealed a septic, dehydrated man with signs of peritonitis. He was given lots of fluids and a laparotomy was performed.
These were what I found:
1. A hole in the intestine.
2. A hole in the “mesentery”, that layer of membrane and fat attached to the intestine.
Bad news: multiple bowel injuries. I wonder which injury will be more likely to give me sleepless nights post-op.
The hole in the intestine (number 1) was pouring intestinal contents into the peritoneal cavity. That’s bad. It’s very contaminated. That causes a life-threatening infection in the abdomen. The hole was repaired with stitches. Ok… looks good. There’s a risk of stitches breaking down and spilling the intestinal contents again but small bowel heals fairly well compared to large bowel.
Now, the hole in the mesentery (number 2) is a bigger problem… the mesentery carries the blood supply to the particular segment of intestine it’s attached to. If there’s a big tear like this one, the bowel’s blood supply is cut of. That’s bad too. Soon, that segment of bowel will die and an even bigger source of infection will open up. The dying segment was removed (segmental resection), the open ends were brought together, and joined with stitiches (primary anastomosis). This is going to be the bigger headache… because the risk of it leaking is higher than no. 1.
When will he pass wind? The longer he takes, the more anxious we’ll be getting.
Only by clicking “comments” am I able to “read more”, just to let you know.
Let us know the patient’s progress, ok? This is “ken cheong” post!
just me.. oh, you’re right.. thanks.. got that sorted out :-).. Yes, this is kan cheong.
Aiyo..anything to do with bowel has got my attention! Pls update if he can kentut. Also..can one still eat solids during this recovery time? How did the accident cause this? Via impact? How?
I had the same problem with “just me” again just to inform!
Wow interesting, how far apart were the 2 injuries?
Wah, sure susah tidur especially in private practice!
Young or old? The abdominal wall looks like a muscular young man!
Well if you have lavaged the abdomen well, all will go well. I am sure. I am a bit worried with the first hole as it appears big and a primary repair is definitely worrying this my first question?
Keep us posted!
Yup. Definitely something to loss sleep over.
Sigh.
Just wondering, did he put on the seat-belt?
err…my qestion will be..when he first consulted ur OPD , is there any way u can know that he has already preforated his bowels?..i mean , if he had come to a GP like me , i might have missed something…even if i do an ultrasound , would i have found anything?..
wah .. got lotsa holes. Is he ok?
ya, the kentut will be music to the ears.
hope he cepat-cepat kentut lor.
I never realised that Small Bowel Injury might be mistaken as small injury of the bowel..
How long u take to perform the surgery?
Dang, seeing the pictures reminds me of nice fat juicy chinese sausages. I feel like a cannibal… HA HA HA HA HA.. or is it just the fact i skipped breakfast.
Sorry for the absence… couldn’t get online. Thanks for sharing the concern. Really kan cheong.
Update: post-op day 2: my patient hasn’t passed flatus yet. But sepsis under control. No fever, heart rate slowing down, urine output improving.
mott, no he can’t eat or drink anything when the bowel is not functioning.
George, he’s 40. The two injuries were fairly far apart. The perforation was 80 cm from the DJ junction. The mesenteric tear was 60 cm from the ileo-colic junction. The hole is not that big, about 10% of the circumference of the bowel. But still worrisome.
Aren’t you glad you have a whole team to share the anxiety with??
yenjai, i should say that the steering wheel struck his abdomen rather than the other way around. He was wearing the safety belt. He was involved in a head-on collision and the incursion of the dashboard had caused the steering wheel to impact upon the abdomen.
eve, he went to another hospital (that’s usually the case, right?). The suspicion should arise if there was abdominal pain. The sign to look for is tenderness and guarding.
Ulrasound is not sensitive for intra-abdominal injuries, particularly hollow organ injuries. The only time ulrasound is used is in a hypotensive patient, to confirm the presence of intra-abdominal free fluid and the patient brought immediately to OT for laparotomy.
In short, go by clinical signs. If you performed an ultrasound examination, you might find free-fluids. But the absence of such findings does not rule out an injury.
If any patient comes with abdominal pain but no local or general signs of blood loss or peritonitis, it’s better to cover yourself by advising the patient and the accompanying person to bring the patient back to a hospital if pain gets worse or is persistent. And document it in the notes.
cibol, he’s on the road to recovery but not quite ok yet. thanks.
nyonya, yes general surgeons are usually very happy to hear kentut. It means that the bowel is functioning.
Chen, took one and a half hours. There was a lot of wash-out to do.
jonzz, you must be very hypoglycaemic already.
Well,that is true. We work as a team and thus it feels better but the responsibility is still yours to face. Don’t worry. With so badly contaminated abdomen, and if the lavage was good it would take more than a while for the bowel sounds to return. While waiting, prayer and possibly TPN may help if necessary. Good luck.
Hope the patient recovers quickly.
separately.. no worries bernard, your photos dont seem to put me or jonzz off. They are of really fresh meat! oops. ;P
Thanks for the update.Keep us posted.
Your statement “couldn’t get online”..did it mean you were busy or you had internet problem. If it is the latter, I thought only my pc server is playing games with me, on and off without warning!
Update: started passing flatus this morning! He was so unsure that he asked his neighbour who said, ‘Yes!’ Anyway he passed a lot of it today. That’s not the end yet… got a load of other complications to look out for.
George, thanks. Patience
must i have. Watchful must i be.
LM, i have no doubt whatsoever that you will not be put off by fresh meat.
just me, it was funny… i couldn’t open my own blog for a whole day. Puzzling. But i didn’t have time to fiddle and see what was wrong. This morning too. Then, suddenly, it’s behaving itself. It’s got a mind of its own… hehe.
only one word comes to mind.
PHEW!!!!!!!!!!!!!!!
Nvr thought I’d be so glad to hear someone able to flatulate! Hope he’ll pull through this!!!!
mott, haha! thanks for rooting for him!!
imagine what other bodily functions we take for granted.
Bernard, yes, your site seemed to be … less than stable these few days. If it happened again, I guess we have to write in a letter
OMG, this is so gross can die!
yenjai, thanks. it’s ok now, i think. good thing your site wasn’t affected.
Titoki, this is one time that “can die” can be literal one. Welcome to my world!
Update: The patient has started oral intake, phew!
This message is for everyone: Drive carefully and defensively.
Can’t figure out how a accident can cause a hole in the intestine. Very not logic right?
Good to know the positive progress of patient. Yes,your world…where “can die “is real….it can either make you docs appreciate life so much more or numb you to death itself!
Queen, the hole is due to direct trauma. The steering wheel strikes the front abdominal wall and compresses it (plus the contents of the abdomen) against the back wall.Most of the time, the mobile parts (such as the small bowel) slip away when they are compressed.
But sometimes, they get caught and the pressure causes a tear.
just me, life is always precious but death is inevitable. It’s a balance between enthusiastic optimism and gloomy hopelessness.
Clap! Clap! Clap! Yeah!
The major problem is out of the way, the rest is a walk in the park!
Such a dramatic post, I must say!
George, too much drama is not good for the heart. Anyway, today he’s starting solid diet. Going home soon.
Good to know that.
Life is precious (but fragile) and death is inevitable( but sometimes it is sudden)
your blog is pretty special cos we can see the inner side of human body.it’s interesting n informative.really learn a lot from here.but i cant read it while i m eating,very wat tat sometimes..(unlike Jonzz can take it as chinese sausages….yiaakkkk)…hehhee
it’s good to hear tat the patient is recovering
Joycelyn, welcome. True that some people find it rather unsettling, to put it mildly. Anyway… do come back when you’re not having a meal
Guess the episode gave the family members cold sweat for fear losing him. Good to know he is getting on fine. :)Great job, doc!
hoiling, his mother didn’t go home until he was discharged. And he’s 41 liao.
We’re always a baby in mama’s eyes. So, age is immaterial here.
Bernard Chan, FRCS
RESPECT!
Aiyah, this is nothing la. To Dr. Bernard is like slaughter chicken only. haha…. ya hor. Have you slaughter a chicken before?
Err… shhh… Queen, no worr, i’ve never slaughtered one… never even cut dead chicken pieces. Hehe.