Presentation
Two days post lower segment cesarean section and bilateral tubal ligation. She was tachycardic, febrile with a tender abdomen especially in the right iliac fossa.
Patient Data
The cecum is gaseously distended up to 9 cm as is the ascending and proximal transverse colon with a relative transition point at the splenic flexure. Findings are suggestive of colonic pseudo-obstruction.
A small amount of rectal gas is noted. A large dense rounded opacity is noted in the pelvis, which may represent the bladder or postpartum uterus. No evidence of pneumoperitoneum allowing for supine projection. Tubal ligation clips noted. No destructive osseous lesions.
She remained tachycardic with new post-operative anemia of Hb 77. There was a concern of a right-sided rectus sheath hematoma. She proceeded to have a multi-phase CT Abdomen Pelvis.
Mild asymmetrical thickening of the right rectus abdominis muscle which measures up to 13 mm in depth, when compared to the contralateral side. There is overlying inflammatory stranding with locules of free gas. Within the intra abdominal cavity, deep to the rectus abdominis muscle, there is small volume free fluid and locules of free gas. These findings are presumably within the normal postoperative limits. There is no evidence of active arterial extravasation or delayed enhancement, particularly within the region of the right rectus abdominis muscle.
Bulky postpartum appearance of the uterus. No significant free fluid within the pouch of Douglas. Non distended urinary with bladder catheter in situ.
Small volume fecal material within the distal sigmoid colon. Mildly prominent gas and fecal filled cecum and ascending colon. Mixed gas and fluid filled small bowel is normal in caliber.
Impression:
No evidence of active hemorrhage within the right rectus abdominis muscle.
The CT confirmed a dilated cecum of 9 cm. She had worsening abdominal pain and raised inflammatory markers with a white cell count of 26.4 x 109/L and CRP 267 mg/L. She proceeded to have an emergency colonoscopy and decompression.
Colonoscopy demonstrated that the right colon was very distended. Cecum was intubated with large area of mucosal ischemia. No signs of full thickness necrosis. Impression was that it was pseudo-obstruction with cecal partial thickness ischemia. Entire colon decompressed as much as possible.
Case Discussion
Her diet was slowly upgraded. Bowels were opened. She made an unremarkable post colonoscopy decompression recovery and was discharged home day 5 with her newborn.
Cesarean section and pelvic surgery precede acute colonic pseudo-obstruction in 10% of all cases 1. Colonoscopy decompression is effective and safe for acute colonic pseudo-obstruction, in one study of 50 patients 88% demonstrated sustained clinical success 2.
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