Case Presentation

I.D, a 56 year old male who presented to the A and E on

the 8th of May, 2022 with complaint of:
● Abdominal Pain ✕ 1/52
● Constipation ✕ 1/52
● Abdominal Distension ✕ 3/7
● Vomiting ✕ 3/7
 History of Presenting Complaint
● Abdominal pain was sudden in onset, progressively
worsened, sharp and colicky, at the lower abdomen
and non radiating. Temporarily relieved by the use of
analgesics and severe enough to prevent patient from
carrying his normal activities.
● Patient was also noticed to have change in bowel habit
(not using the toilet at all as compared to his usual
daily use). There was also no passage of flatus.
● Abdominal distension was progressive and involved the
whole abdomen. No History of swelling in the groin.
 History of Presenting Complaint
● Vomitus was copious, non-projectile, non-billous
containing recently ingested food. He had on average
3 episodes per day.
● No History of trauma to the abdomen.
● No History of fever.
● No History of groin swelling.
● No previous History of abdominal surgeries.
● No History of weight loss.
 History of Presenting Complaint
● At onset of symptoms patient patronized a patent
medicine dealer where he bought some medications.
● With persistence of symptoms patient presented to this
facility for expert management.
 Past medical and surgical history
● Patient is a known hypertensive on medications
(patient did not know the name of the medications).
● Not a known diabetic.
● There was positive previous history of Frequency which
he claimed resolved spontaneously.
● Past surgical history was not contributory.
● No known drug allergy.
 Social History
● Patient uses tobacco product in form of snuff and takes
alcohol occasionally.
O/E: Middle aged man in painful distress, not pale,
dehydrated, anicteric, acyanosed, nil pedal edema.

PR – 104 bpm
RR – 24 cpm
Temp - 37.20C

Chest: clinically clear

CVS- S1S2 only
 Examination
• Abdomen:
• Distended with flank fullness, moved with respiration.
• Soft , with generalized tenderness worse in suprapubic region,
• No rebound tenderness.
• Visible Peristaltic movements.
• Liver and spleen: not palpably enlarged
• Kidneys: not ballotable
• Tympanitic Percussion notes.
• Bowel sounds: Absent.
• Rectal Exam: Good anal hygiene, good sphincteric tone, no palpable rectal
masses
• Prostate: Large, firm, prostate membrane freely mobile, median groove and lateral
sulcus intact.
• Examining finger stained with faecal matter and slight blood.
 Examination
• Other systemic examination: normal

• Assessment: 1) Large bowel obstruction 2◦ ?

Volvulus R/o Malignant Obstruction.
2) Asymptomatic Benign Prostate Enlargement.
Plan:
• NPO
• IVF N/saline 1L fast, then Ivf 5%D/water Ivf N/saline 1L 8hrly (2:1)
• Pass NG tube to decompress the stomach.
• Pass Urethral Catheter to empty the bladder and commence hourly urine monitor
with 30 – 50 ml/hr as target.
• Iv ceftriaxone 1g 12hrly.
• Iv flagyl 500mg 8hrly.
• Im PCM 600mg 12hrly.
• Do FBC, Urinalysis, S/e/u/cr.
• Do Plane Abdominal X-ray.
• Counsel Patient and relatives on the condition and the need for investigations and
possible surgery (Emergency Exploratory Laparotomy).
• Obtain consent for surgery.
• Anaesthetics to review.
Pre OP investigations:
FBC + Diff S/E/U/cr
Hb – 13.6 g/dl Na+ - 135mmol/l
K+ - 2.9 mmol/l
Cl- - 96 mmol/l
Hco3- - 27 mmol/l
Urea – 7.2 mmol/l
Creatinine - 138
mmol/l
Plan: 1) Add 5mmol of Kcl into each 500ml of Ivf.
2)Ct Other Mgt.
 Review 12hrs later

• Patient had received 34mmols of Kcl in 1L of N/S over the last 12 hrs and about 2L of N/S.
Fluid output had been adequate.
• NG tube had been minimal but appeared purulent.
• O/E: Ill looking, NGT in situ, Pale+, acyanosed, anicteric, warm to touch.
• Vital signs: RR- 36 cpm PR-110 bpm
• Chest: Clinically clear
CVS- S1S2 only
• Abdomen: Distended, Tender to touch ++.

• Assessment: Acute Intestinal Obstruction ? Volvulus.

• Plan: 1) Repeat S/e/u/cr.
2) CT resuscitative measures.
3) 11.5mmols of Kcl in 500mls of N/S 4hrly.
4) IV N/S 1L 8hrly in contralateral IV access.
5) Obtain informed consent and book theatre for surgery. (Emergency Exploratory
Laparotomy)
9/5/2022
• Surgery:
Exploratory Laparotomy + Sigmoidectomy + Divided Colostomy.
• Findings:
- 4cm hard sigmoid constrictive tumour.
- Dilated caecum, transverse colon and descending colon.
- No lymph node or Liver secondaries.
• Specimen to pathology:
- Sigmoid segment containing constrictive tumour.
Post OP Plan:
• NPO.
• IVF 5% D/water 5% N/saline 500mls 8hrly.
• Iv Tandak 1.5g dly x 4/7.
• Iv Metronidazole 500mg 8hrly x 4/7.
• Im Pentazoscine 30mg 8hrly.
• Monitor Vitals closely.
• Transfer to ICU.
• Monitor Vital signs closely.
• POD
Vital 1Temp- 38.0℃ RR- 18 cpm PR-122 bpm BP – 170/80mmhg
signs:
Spo2- 88-92%
• Chest: Clinically clear
CVS- S1S2 only
• Abdomen
• Flat, moved with respiration
• Wound dressing clean/dry, Colostomy site soaked
• BS: Absent
• L0s0k20

Assessment: Fair clinical state.

Plan: 1) Rush IVF 500mls N/S stat then continue maintenance.
2) Commence INO2 via Nasal prongs @ 5L/min.
3) IM PCM 600mg 6hrly.
• PODhad
Patient 2 commenced Iv Labetalol for elevated BP prescribed by Medical team.
• Vital signs: Temp- 37.2℃ RR- 20 cpm PR- 90 bpm BP – 147/88mmhg
Spo2- 96% on O2
• Chest: Clinically clear
CVS- S1S2 only
• Abdomen
• Flat, soft, moved with respiration
• Wound dressing clean/dry, Colostomy site dressing clean and dry.
• BS: Present and Normoactive.
• L0s0k20

Assessment: Fair clinical state.

Plan: 1) DO a 2 days Post-OP PCV, S/e/u/cr.
2) Ensure Analgesics.
POD 2
4) KIV weaning off oxygen and observe saturation in room air.
5) Iv Omeprazole 40mg 12hrly.
6) Subcutaneous Clexane 40mg dly.
7) CT other mgt.
• PODof Post
Result 3 OP PCV – 37%
• C/O – Pain at Colostomy site.
• Vital signs: Temp- 37.2℃ RR- 22 cpm PR- 108 bpm BP – 169/91mmhg
Spo2- 97%
• Chest: Clinically clear
CVS- S1S2 only
• Abdomen
• Flat, soft, moved with respiration
• Wound dressing clean/dry, Colostomy site dressing clean and dry.
• BS: Present and Normoactive.
• L0s0k20

Assessment: Fair clinical state.

Plan: 1) DO a 2 days Post-OP PCV, S/e/u/cr.
• PODof Post
Result 4 OP S/e/u/cr – K+ - 2.9mmol
• Patient was not regular with medications due to financial constraints.
• Had commenced oral sips.
• Vital signs: Temp- 37.3℃ RR- 18 cpm PR- 92 bpm BP – 179/91mmhg
Spo2- 88-94%
• Chest: Clinically clear
CVS- S1S2 only
• Abdomen
• Flat, soft, moved with respiration
• Wound dressing clean/dry and well apposed, Colostomy site active with dressing
clean and dry.
• BS: Present and Normoactive.
• L0s0k20

Assessment: Fair clinical state.

 POD 4
2) Commence oral antihypertensive; Tabs amlodipine 10mg dly, Tabs lisinopril
10mg dly.
3) Rush IVF N/S 1L stat, then continue with maintenance adding Kcl to 4hrly IVF.
4) Invite Cardiology team to review for optimal BP control.
5) Encourage to get materials, IVF, medications as prescribed.
6) Transfer to MSW.
7) Apply colostomy dressing/bag.
8) Change wound dressing and diapers.
9) Change colostomy bag when filled.
10) CT other mgt.
•
POD 5
Pale+, not dehydrated, nil pedal edema.

• Vital signs: Temp- 37.0℃ RR- 20 cpm PR- 118 bpm BP – 163/93mmhg

Spo2- 92-94% in room air.

• Chest: Clinically clear

CVS- S1S2 only

• Abdomen

• Flat, soft, moved with respiration

• Wound dressing clean/dry, Colostomy bag clean, Urine bag contained clear urine.

• BS: Present and Normoactive.

• L0s0k20

Assessment: Fair clinical state.

Plan: 1) DO Hb.

2) Tabs Pradaxa 110mg dly, Tabs slow K 1 tds.

3) Remove Urethral Catheter.

4) CT other Mgt.
 POD 7
• D/C IV Antibiotics
• Tabs Cefuroxime 500mg BD x 5/7
• Tabs Metronidazole 400mg tds x 5/7

POD 8
• Tabs Fesolate 200mg tds.
• Tabs Vit. C 100mg dly.
• Encourage Ambulation.
 POD 10 (19/05/2022)
• Patient was discharged on; Tabs Amlodipine 10mg dly
Tabs Lisinopril 10mg dly x 1/52
Tabs Fesolate 200mg tds
Tabs Vit c 100mg dly
Tabs Cefuroxime 500mg BD
Tabs Flagyl 400mg
X 5/7 tds
• To in SOPD in 2 weeks (30/5/2022).
 POD 11
• Patient re-admitted based on result of S/e/u/cr which showed K+ - 1.7 mmol, Cl- -
90mmol
• No clinical features of Hypokalemia or Hypochloremia.
• Plan: Recheck S/e/u/cr
Maintain liberal fluid intake and Oral feeding
Maintain Oral Medications

POD 12
• Patient was yet to do repeat of S/e/u/cr due to financial constraints.
• Scanty yellowish discharge from mid suture below the umbilicus.
• Plan: Remove the mid sutures (below umbilicus)
Encourage to do serum k+
Tabs Slow k 1 dly
Consult to social welfare.
 POD 16
• Not pale, not dehydrated, nil pedal edema.

• Vital signs: Temp- 36.1℃ RR- 22 cpm PR- 90 bpm BP – 140/90 mmhg

• Chest: Clinically clear

CVS- S1S2 only

• Abdomen

• Flat, soft, moved with respiration

• Wound dressing clean/dry, Colostomy functioning.

• BS: Present and Normoactive.

• L0s0k20

Assessment: Stable

Plan: 1) Discharge Home on ; Tabs Amlodipine10mg dly

Tabs Lisinopril 10mg dly

Tabs slow K 1 dly x 5/7

Tabs cefuroxime 500mg BD x 5/7

Tabs Metronidazole 400mg tds x 5/7

 Tabs Fesolate 200mg tds x 2/52
Tabs Vit c 1000mg dly x 2/52
Tabs Paracetamol 1000mg tds x 5/7
2) To do wound dressing in two days time at SOPD.
3) To do serum k+ and see in clinic with the result of investigation.
3) To see in SOPD in General Surgery Clinic in 5 days time.
 26/2/24
• Patient presented to the General Surgery Clinic requesting a Colostomy takedown
• Histology report requested 2yrs prior was yet to be retrieved.
• Patient had no complaint.
• O/E: Middle aged man in no obvious distress, not pale, afebrile, acyanosed, anicteric, not
dehydrated, nil pedal edema.
RR – 20 c/m PR – 70bpm BP – 140/90 mmhg
Chest: Vesicular Breath sounds
CVS: HS – s1s2.
ABDOMEN: Flat, Moves with respiration, soft, non-tender, L0S0K20, Presence of
Colostomy bag.
DIAGNOSIS: Double Barrel Colostomy
PLAN: 1) For Colostomy takedown.
2) Encourage to retrieve Histology report.
3) Admit to MSW and to DO; Chest Xray PA, ECG, ABD USS, FBC + diff, Blood group,
S/e/u/cr, LFT
Pre OP investigations:
FBC + Diff
S/E/U/cr
Hb – 11.5 g/dl Na+ -
143mmol/l
WBC – 5.43 x 10^9/L K+ - 3.6
mmol/l
Neut – 39% Cl- -
105mmol/l
Lymph – 48% Hco3- - 23
mmol/l
 PreOP Investigations (cont.)
• CHEST XRAY – Normal Findings.
• HISTOPATHOLOGY REPORT OF COLONIC SEGMENT
This showed moderately differentiated non-mucinous
adenocarcinoma infiltrating up to muscularis propria, the resection and
vermiform appendix are from tumor, no lymph nodes seen
IMPRESSION: Moderately differentiated adenocarcinoma (T3 Nx Mx).
• ECG – Normal Findings.
29/2/2024
• Surgery:
Colostomy Takedown.
• Findings:
- End sigmoid colostomy and mucus fistula in Left Iliac fossa
separated by 3cm skin budge.
Specimen to pathology:
- None
Post OP Plan:
• NPO.
• IVF 5% D/water 5% N/saline 500mls 8hrly.
• Iv Ceftriaxone/Sulbactam 1.5g dly x 4/7.
• Iv Metronidazole 500mg 8hrly x 4/7.
• Im Paracetamol 900mg 8hrly.
• Im Diclofenac
• Input/Output chart.
• Monitor Vital signs closely.
 POD 6 (6/3/2024)
• Middle aged man in no form of obvious distress, Not Pale, not dehydrated, anicteric, acyanosed, nil pedal
edema.

• Vital signs: Temp- 37.1℃ RR- 20 cpm PR- 84 bpm BP – 120/80 mmhg

• Chest: Clinically clear

CVS- S1S2 only

• Abdomen

• Flat, soft, moved with respiration

• Wound dressing moderately soaked with body fluid, wound edges well apposed

• BS: Present and Normoactive.

• L0s0k20

Assessment: Stable 6DPO

Plan: 1) Change Wound dressing and for stitch removal in 5 days time at SOPD.

2) Discharge Home on ; Tabs Cefuroxime500mg Bd x 1/52

Tabs Metronidazole 400mg tds x 1/52

Tabs Fesolate 1 BD x 1/52

Tabs Vitc 200mg BD x 1/52

18/3/2024
Patient presented to the General Surgery Out-patient
Clinic on the 18th of March, 2024 with complaint of:
● Abdominal Pain ✕ 4/7
● Abdominal swelling ✕ 4/7
● Vomiting ✕ 2/7
 History of Presenting Complaint
● Complaints were of gradual onset but had become
significant and severe.
● Vomiting was nonprojectile, nonbilious, nonbloody, and
contained recently ingested meals.
● Abdominal distension had increased gradually since
onset which was 4 days prior.
● Abdominal pain was colicky, persistent, and worsened
with intake of food.
● Patient had last opened bowel two days prior to
presentation to flatus and faeces.
 History of Presenting Complaint
● There was no associated Fever and no history of
trauma to the abdomen.

● There was positive history of Previous Abdominal

Surgery (Exploratory Laparotomy, Sigmoidectomy,
Divided loop Colostomy and reversal).

● As symptoms persisted , patient presented to this

facility for expert management.
Past Medical and Surgical History
● There was positive history of previous admissions with
blood transfusions and surgical procedures done in this
facility.

● Exploratory Laparotomy + Sigmoidectomy + Divided

loop Colostomy was done on account of Intestinal
obstruction secondary to sigmoid tumour in this
facility.
 Examination

O/E: Elderly man in painful distress, not pale, dehydrated,

anicteric, acyanosed, nil pedal edema.

PR – 114 bpm
RR – 32 cpm
Temp - 37.20C

Chest: clinically clear

CVS- S1S2 only
 Examination
• Abdomen:
• Distended, moved with respiration.
• Soft , with generalized tenderness.
• No rebound tenderness.
• Visible Peristaltic movements.
• Liver and spleen: not palpably enlarged
• Kidneys: not ballotable
• Tympanitic Percussion notes.
• Rectal Exam:
 Examination
• Other systemic examination: normal

• Diagnosis: Intestinal Obstruction 2◦ ? Stenotic

Anastomosis
Plan:
• Admit to MSW
• NPO
• IVF N/saline 1L fast, then Ivf 5%D/water
N/saline 500mls 4hrly.
• NG tube.
• Urethral Catheter.
• Do FBC, Urinalysis, S/e/u/cr.
• Do Abdominal X-ray.
 Admission Day 2
• Patient had opened bowel to flatus twice and stooled
once.
• Patient had financial constraints with procuring drugs
and IVF, hence was not regular
• NG tube drained 200mls of purulent effluent.
• Vital signs: Temp- 36.7℃ RR- 20 cpm PR- 84 bpm
BP-180/110mmhg
• ABD: Distended, Moved with respiration, Visible bowel
markings, midline sub umblical scar, soft, no palpable
organomegaly, bowel sounds were hyperactive.
• Other system examinations were essentially normal.
Plan:
• Rehydrate with 1L of IVF N/saline 1hr and continue daily
maintenance.
• Consult to Cardiology to review with regards to Blood
pressure.
• Encourage parents and relatives to procure drugs and fluids
as prescribed.
• Encourage to sit out of bed and ambulate.
• Replace each NG tube effluent with equal volume of Saline.
• Encourage to do requested investigations.
• KIV Ex-Lap if symptoms persist.
 Admission Day 3
Result of S/e/u/cr (21/03/24)
Na+ - 131 mmol/l
K+ - 2.7mmol/l
Cl- - 99mmol/l
Bicarb- 29 mmol/l
Urea – 3.0 mmol/l
Creatinine- 60 mmol/l
Result of Abdominal Xray
Multiple Air fluid levels with Paucity of gas .

(NB: Patient had been opening bowel to formed stools but still had persisting
symptoms of abdominal pain and distension with visible peristaltic
Plan:
• Rehydrate with 500mls of IVF N/saline over 30mins and
continue daily maintenance.
• Increase Kcl In every 500mls of N/saline to 15mmol/l.
• CT NPO and NG tube.
• Work up and Counselled for Exploratory Laparotomy and
Colostomy.
• Obtain Inform Consent.
• Procure materials for Surgery.
 Admission Day 7
• Patient yet to give consent for surgery and procure
materials due to financial constraint.
• Patient opening bowel to formed stools but not to flatus.
• Patient still having colicky lower abdominal pain.
• Fluid input over past 24hrs = 2500mls IVF
• KCl in the past 24hrs 25mmols.
• Patient still having persistently raised blood pressure
despite receiving Hydralazine as prescribed by the
Medical team. (Had received 2 doses).
• Curent BP – 170/110mmhg.
• NG tube holding 10ml of billous effluent.
Plan:
• Rehydrate with 1L of N/saline over 3hrs separate from daily
maintenance.
• Ensure 90mmols IV Kcl is given Daily.
• Ensure procurement of materials for surgery.
• Get Informed consent for surgery.
• Invite cardiology to review and confirm fitness for surgery.
• CT other ongoing management.
• For Anaesthetic Review.
Pre OP investigations:
FBC + Diff
S/E/U/cr
Hb – 12.5 g/dl Na+ -
132mmol/l
WBC – 2.0 x 10^9/L K+ - 3.4
mmol/l
Neut – 35% Cl- - 102
mmol/l
Lymph – 62% Hco3- - 25
mmol/l
 Admission Day 8
• Rectification of Electrical fault in operating suit not
completed according to the works department
Plan:
• To defer surgery to following day.
• Continue conservative management in the meantime.
 Admission Day 9 (27/3/24)

• Surgery:
Exploratory Laparotomy + Jejunal Resection and Anastomosis +
Sigmoid Colostomy.
• Findings:
- Gross Bowel adhesions generally.
- Descending and sigmoid colon fixed to peritoneum and anterior
abdominal wall.
- Near circumferential adhesion bands approximately 5cm distal to
previous site of anastomosis.
- Anastomotic leak.
- Jejunal Perforation approximately 8cm from Duodeno-jejunal
junction.
Post OP Plan:
• Transfuse with 2nd unit of blood ASAP (Sedimented cells).
• NPO.
• IVF 5% D/water 5% N/saline 500mls 8hrly.
• Iv Tandak 1.5g 12hrly x 72hrs.
• Iv Metronidazole 500mg 8hrly x 72hrs.
• Im PCM 600mg 8hrly.
• Im Pentazoscine 30mg 8hrly.
• Sit out of bed the following day.
• Strict Input and Output recording.
• Monitor Vital signs closely.
 POD 10 (6/04/2024)
• Middle aged man in no form of obvious distress, Not Pale, not dehydrated, anicteric, acyanosed, nil pedal
edema.

• Vital signs: Temp- 36.4℃ RR- 20 cpm PR- 104 bpm BP – 130/90 mmhg

• Chest: Clinically clear

CVS- S1S2 only

• Abdomen

• Flat, soft, moved with respiration

• Colostomy in situ active, Dressing clean and dry.

• BS: Present and Normoactive.

• L0s0k20

Assessment: Stable 10DPO

Plan: 1) Discharge Home on ; Tabs Cefuroxime500mg Bd x 5/7

Tabs Metronidazole 400mg tds x 5/7

Tabs Vitc 200mg BD x 1/52

Tabs Bisoprolol 5mg dly

Tabs PCM 1g tds x 3/7

 Tabs Amlodipine 10mg dly
Tabs Lisinopril 20mg dly
2) To see in SOPD on Monday in General Surgery Clinic (15/4/2024).
• Follow up

• Patient has been discharged but yet to settle bills due to

financial constraints.

• Tolerating orally and opening bowel.

• Nil new complaints.

• Vital signs are stable 16dpo.

• O/E: Clinically stable , stoma functioning, midline wound

well apposed and healing.