Successful use of Water-Soluble Contrast in patients with small bowel obstruction and virgin abdomen: A case Report
Sergio Mazzola Poli de Figueiredo MD, Sara Demola MD
Presenter: Sergio Mazzola Poli de Figueiredo, MD, University of Texas Medical Branch – Galveston
Introduction/Objective: Small bowel obstruction (SBO) is one of the most common causes for surgical admission and is most commonly secondary to adhesive bowel disease. Nonoperative management of adhesive SBO is well established but management of SBO in patients without prior abdominal surgery remains a challenge. We aim to report a case of successful nonoperative management with the use of enteral hypertonic water-soluble contrast administration in a patient with virgin abdomen.
Case Presentation: A healthy 24-year old man with no previous surgical history presented to the emergency room with one-day history of sudden onset abdominal pain associated with vomiting and absence of bowel function. On physical examination, the patient had abdominal distention and diffuse tenderness to palpation with no peritonitis. A CT abdomen and pelvis with IV contrast was obtained (Image 1). The patient was offered diagnostic laparoscopy given the presence of SBO without clear anatomic etiology. The patient refused surgical intervention, so we performed a trial of nonoperative management. Over the first 24h of hospital admission, the patient had 1.4 liters of nasogastric output. On hospital day 2, a repeat CT A/P with enterally administered water-soluble contrast showed resolution of SBO (Image 2) and the patient was discharged the following day after tolerating diet. The patient has had no symptoms since hospital discharge on 6 months follow up.
Discussion: Small bowel obstruction accounts for up to 15% of surgical admissions for acute nontraumatic abdominal pain and is most commonly secondary to adhesions from prior surgeries.
Even in patients without previous abdominal surgery, adhesions were found to be the cause of SBO at time of operative intervention in 53%-73%. We suspect this to be the etiology for the patient we present.
A study with 63 patients with virgin abdomen showed that 92.1% that underwent nonoperative management did not have a recurrence of SBO with mean follow-up of 4.5 years, while another study of 29 patients reported 3.4% of SBO recurrences. Nonoperative management with the use of water-soluble contrast in patients with virgin abdomen was reported to have 92-97% success rate in two studies with 36 and 38 patients.
A recent meta-analysis showed a pooled prevalence of 7.7% of malignant etiology of SBO in patients with virgin abdomen, which is more common in patients with previous SBO admission or history of malignancy. Given that our patient was young and healthy, he was successfully managed nonoperatively with the use of water-soluble contrast and remains asymptomatic 6 months after hospital discharge.
Conclusion: Adhesions are the most common cause of SBO in patients with virgin abdomen, just as in patients with prior surgery. Nonoperative management with the therapeutic use of hypertonic water-soluble contrast is a viable treatment option in select cases when adhesions are suspected and avoids the morbidity of surgical exploration.
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