Closed loop small bowel obstruction

Case contributed by Dr Hoe Han Guan

Presentation

Severe abdominal pain and distension for 4 days with a history of abdominal surgery.

Patient Data

Age: 12 years
Gender: Male

Most left-sided colon is absent due to previous surgical resection. The right-sided colon and rectum are grossly dilated and filled with a large amount of impacted feces. The largest diameter of the colon measures up to 10.3 cm. 

Abnormal U and C-shape small bowel loops dilatation at the left lumbar region, with a diameter up to 4.0cm. These segments of dilated ileum have reduced bowel wall enhancement compared to the normal caliber and well-enhanced jejunum.
No intramural gas, pneumoperitoneum or portal venous gas. Moderate ascites.

Mesenteric infiltration/fluid with mesentery lymphadenopathy noted.

Case Discussion

This a case of a closed-loop small bowel obstruction. The reduced bowel wall enhancement at this segment of small bowel segments and ascites are suspicious of bowel ischemia.

Chronic rectal fecal impaction and gross distension, the diagnosis of stercoral colitis should be considered (although it is commonly encountered in elderly patients, it can present in young patients who have neurologic or muscular disorders).

This patient has a history of extended left hemicolectomy during infancy with primary anastomosis. The intestinal obstruction is likely due to adhesion. Intra-operatively a closed-loop obstruction secondary to adhesion bands with a short segment of small bowel ischemia resected and an ileostomy created.

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