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Case report - Ileus and jaundice

2016/12/09,12:36

CASE REPORT

Male patient, 77 years old, has got pain in the upper part of the abdomen, flatulence, fatigue and opstipation which lasts 5 days. Anamnesticall, we are getting information that he has not got gall bladder, and he had cholecystectomia about 30 years ago.

He is bringing document of Gastroenterologist examination, and also brings Ultrasound of abdomen and blood analysis from 2 days before:

WBC 15,8...Gran 86,3

Total bilirubin 59,4, and conjugated 11,1

LDH 547

Ultrasound of abdomen showed presence of small amount of water between winding of small guts. The patient is referred on RTG of abdomen.

On the developed X-ray of abdomen, we can see distended stomach and distended windings of small guts, with formed hydro gassy levels, without signs of pneumoperitoneum.

That day, we also made blood tests:

WBC 15,8...Grn% 85,8

Total bilirubin 66,5, and conjugated bilirubin 13,3

CRP 23,9 mg/L

We did ultrasound of abdomen which showed presence of free liquid in subhepatic space. After that we admitted patient on surgical departmen. After putting nasogastric tube, we get liquid content, which by the smell and color, corresponding to faecal content. This was sign for emergency surgical treatment.

Xyphopubic median incision approaches the opening of the abdomen. After opening the peritoneum, we have noticed the multitude of adhesions which are more complicates the preparation. In further preparation, it comes subhepatically, where eve of jejunal perforation almost the entire circumference of the wall, and then on the eve of yet another site of perforation and to the terminal ileum. The cause of the perforation was adhesion ileus that the small bowel, in the form of omega gyrus, was compressed. Followed by resection of the small intestine in the length of 150 cm and create a latero-latero anastomosis of the small intestine. Lineups are two drains, one subhepatically and the other in the Douglas area. The abdomen is closed in one layer.

This case is interesting because of elevated bilirubin levels, which are in this patient were on account of the impossibility of passing conjugated bilirubin through small guts caused by mechanical ileus, adhesion characteristics and, jejunal spill the contents of the abdomen and subsequent absorption of the same.

For surgery are significant posthepathitic jaundice, or conjugated hyperbilirubinemia. In this patient is primarily occurred mechanical intestinal obstruction caused by adhesions previous subhepatically, and it was the first cause of elevated bilirubin. Subsequently, after perforation of the small intestine, there has been a discharge of intestinal contents into the abdomen and subsequent absorption of the same.

CONCLUSION

Therefore, in patients with clinical and differential diagnosis in doubt in the diagnosis, but in terms of the formation of ileus, elevated bilirubin could be of great help in the diagnosis and timely surgical treatment.

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