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Post operative Case , Diagnosis Mx ??

32 yr female , P1L1E1 , Operated for Right salpingectomy I/v/o ectopic pregnancy POD 7 , C/O lower abd pain with nausea & vomiting Chief Complaints Lower abd pain and nausea vomiting since 2-3 days History Sx/h/o: lscs 4 year before Open Right salpingectomy I/v/o ectopic pregnancy Investigations K+ : 3.07 Na:138 Cl- 102 Mg - 1.8 X-ray abdo pelvis

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paralytic ileus with hypokalemia

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X - Abdomen standing - shows multiple air fluid levels, indicative of Acute intestinal obstruction Post operative day 7 - Intestinal obstruction Could be attributed to 1.Constipation with impaction of faecoliths- Patient have not passed stools since surgery 2 Adhesions following surgery- causing adhesion obstruction 3.Paralytic ileus - early starting oral before bowel sounds were not present 4.Internal herniation of gut in recesses Treatment- Mainly remains conservative 1.NPO 2 RT suction 3.IV fluids 4 patenteral antibiotics 5.inj Pantoprazole If obstruction is not relieved in 48 hours a CECT abdomen followed by Exploratory laparotomy is indicated

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Xray showing multiple fluid label seen which is suggestive of intestinal obstruction on 7 th post operative day and may be due to A hypokalaemia as report shows low potassium label B. Band obstruction C. Impacted stool causing obstruction D. Paralytic ileus Nothing by mouth Ryles tube suction IV drip for nutrition and electrolyte supplement Inj PPI iv daily Correction electrolytes by supplementation Enema Electrolytes estimation To continue treatment for 48 hrs to see potassium label wheather corrected or not if potassium label ok but condition not improved consider exploratory laparotomy after going a CT scan .

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X Ray abdomen shows following finding Multiple are fluid level All dilated small bowel loops are 'characteristically characterless'. Which indicate that they are ileal loops There are no jejunal loops seen, jejunal loops have concertina pattern, so on x Ray abdomen they are easily differentiated from ileal loops There is some gas seen in colon These finding indicates partial intestinal obstruction which is in distal ileum. In Complete intestinal obstruction, there would be jejunal as well as ileal loops seen, which is not present in this case. In complete intestinal obstruction there will be no gas in colon, in this case there is gas seen in colon. What is the significance of partial intestinal obstruction? 80 - 90% cases of partial intestinal obstruction would settle down with conservative treatment with in 48 hours Adv Keep patient Nil by mouth Insert ryles tube and keep it on continuous aspiration mode. Give adequate intravenous fluids. Give IV antibiotics. It is likely that with this management patient may settle down with in 48 hours For those who do not settle down after 48 hours, please do CT scan abdomen and pelvis with oral contrast. Oral contrast agent used during CT scan can further help in resolution of intestinal obstruction and thus obviating need of surgical intervention Please look up this article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1422541/#:~:text=The%20therapeutic%20effect%20of%20water-soluble%20contrast%20in%20adhesive%20obstruction,10%25%20in%20the%20treatment%20group. Impression Adhesive partial intestinal obstruction - suggest - conservative treatment

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Multiple air fluid levels...intestinal obstruction. Do serum.electrolytes , counts. Step up antibiotics. Keep pt NBM

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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Typical intestinal obstruction Laparotomy to be done

Thanks Dr. Chetan Patel, Dr. Mrinal Kantil Pal
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Post operative complication , more handling of intestine may have led to Paralytic ileus Or sepsis. Surgeons opinion and management.

Post surgery... X ray s/o-Intestinal obstruction... Complete nbm RT spiration 1 hrs continue.. Inj kcl 500 ml ns slowly 6 hrs bd Daily electrolyte.. Stat enima Iv fluid 100 cc/hrs Inj meropenam 1gm bd Inj pan, emeset SOS pcm 1gm Obstruction not relieved in 28 hrs adv CT abd and p (p+c) SOS IV contrast.. SOS laparotomy..

Multiple fluid levels suggestive of intestinal obstruction Post surgery

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Intestinal obstruction Opinion of laproscopic surgeon Gynaecologist

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