Goodmorning curofians... Here is a case for discussion. 54 year old female presented with obstipation for 3 days. pain and distension for the same duration . Hx of vomiting multiple episodes, fever. Past medical and surgical hx unremarkable. O/e vitals hemodynamically stable Afebrile No signs of dehydration No pallor, edema or LaP P/A...Tender, mildly distended, guarding present. BS sluggish Other systemic examination reveal no significant abnormality. P/R prolapsed pile mass, Anal tone increased. Greyish soft fleshy mass protruding per urethra. Foley's in situ.



Positive findings in this case are 1.3rd degree - 4th degree haemorrhoids 2.Complete uterine prolapse-Procidentia 3.Constipation 3 days 4.Pain abdomen, distension abdomen , vomitings, fever 5.BS - sluggish, tenderness. guarding Impression is Acute intestinal obstruction with or with out perforation with peritonitis with Procidentia and Prolapsed 3- 4th degree haemorrhoids. Further investigations needed are X- ray abdomen standing USG - abdomen Resuscitate the patient with NPO , RT Suction, IV fluids. Parenteral antibiotics, correction of electrolytes. Exploratory laparotomy may be indicated after patient is haemodynamically stable . Procidentia needs a gynaecologist consultation

mass from urethra needs biopsy

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Picture shows the pt has got 4th degree prolapsed uterus and thrombosed external pile with ? prolapsed piles. As the pt has got fever this may be due to chronic retention of urine leading to UTI for which urine culture and sensitivity to be done and appropriate antibiotic should be started. Abdominal distension and constipation may be due to prolapsed external thrombosed and ? prolapsed internal pile which is a painful condition leading to abdominal distension any structure x-ray in erected position may be done to exclude any organic obstruction and if pt in vomiting pt may be put I've infusion to continue 2/3 days to see any improvement or not . By that time go for complete blood examination including serum Na+ and K+ . For the prolapsed try to reduce . For prolapsed ext thrombosed piles and internal piles , try to make reposition of the mass and go for sitz bath regularly. Hope you can manage the case. If there is organic cause of obstruction treat accordingly.

For permenant relief after making G.condition good high antibiotic go for trial vaghystrectomy perineal repair

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Obstipation and tenderness, guarding of abdomen raises possibility of perforative peritonitis If not treated rapidly and aggressively it can be fatal Morality of perforative peritonitis, 6 hrs delay 20 % mortality 12 hours delay 50% mortality 24 hours delay 80% mortality Therefore it is essential to establish diagnosis quickly Do X ray abdomen standing to look for has under diaphragm, Do USG abdomen, CT abdomen to establish intestinal obstruction with perforation She also has uterine prolapse and prolapse of piles, both these condition take second preference Intestinal obstruction and perforation to be diagnosed and treated aggressively

Yes this os a c/o procedentia 4th grade And prolapsed thrombosed hemorrhoid H/o constipation and sluggish bowel movements are virtually giving symptoms of subacute ileus bxz of procedentia reflexive inhibition of intestinal movements Gynaecologist opinion and go for hysterectomy Piles will also need hemorrhoidectomy Rest can be managed conservatively by iv fluids and symptomatically

Thanx dr Anubhuti Jain

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External Hemorrhoids. Uterine prolapse -third degree. Suspected intestinal obstruction. Further investigation advised... Usg whole abdomen. Complete haemogram. Urine rm, and culture sensitivity. Check for blood sugar levels, KFT and LFT. Planning for surgery.

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Procidentia.. may be . In pelvic cavity mild thin adhesions of bowel because of empty cavity erect abdomen x..ray...Gynaecologist decisions needed and Haemorroudectomy needed first try to reduse and magsulf dressings and cifran metrozyl after decreasing edema plan Haemorroudectomy both Gynaecologist and general surgeon intervention needed

Thrombosed haemorrhoids with uterine prolapse with? Ints obst Conservative treatment till the pt is stable Plan fior haemorrectomy and vaginal hysterectomy

Uterine prolapse _ Procidentia 3 degree thrombosed pile Gently reduction of uterus prolapse Avoid constipation and indigestion Avoid oily and spicy food and nonveg Uses Fibres Green leaf vegetables and fruits Intake Plenty of more water orally X-ray erect abdomen USG full abdomen LacRelax IG granule BD Tab zanocin oz BD Cap rabikind D BD Tab vetory D BD Multivitamins & antioxidant SURGEON & GYNAECOLOGIST opinion for surgery

Diagnosis: Third degree uterovaginal prolapse with prolapsed haemarroids.. X-ray erect abdomen to rule out hollowviscus perforation( tenderness and gaurding of abdomen) But 3 days old history of vomitings, mild distention, thrombosed pile made me think of subacute intestinal obstruction due to ileus... correction of dyselectrolytemia with extraction of thrombus from haemarroid would suffice... Vaginal hysterectomy and haemarroidectomy can be planned electively

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