CASE
Our patient is an active and healthy 71-year-old white male who presented to his primary physician after a 1-week history of postprandial nausea with emesis. He recalled that 12 months earlier, similar symptoms occurred and resolved without intervention. His symptoms occurred twice a day approximately 10 minutes after eating and were associated with hiccups. He denied abdominal pain, bloating, diarrhea, hematemesis, hematochezia, or melena.
His primary physician started him on metoclopramide, 10 mg, 30 minutes before meals and instructed him to follow up if his symptoms did not improve. There was no change in his symptoms, which prompted an emergency department (ED) visit the next day.
The patient's vital signs in the ED were temperature, 37.3°C; heart rate, 80 beats per minute; respirations, 16 breaths per minute; and BP, 154/92 mm Hg. Results of laboratory studies revealed a CBC with a left shift; WBC count, 8.6 109/L; and neutrophils and monocytes, 71% and 17%, respectively. Comprehensive metabolic panel findings and urinalysis were within normal limits.
A two-view abdominal plain radiograph revealed several dilated loops of small bowel with two dynamic air-fluid levels, a moderate amount of stool in the ascending colon, and gas in the descending colon (Figure 1). No free air was present. CT of the abdomen and pelvis showed a mechanical small bowel obstruction (SBO) related to an area of narrowing in the distal jejunum at the ileal junction. Also noted on CT was a minimal right basilar atelectasis and cholelithiasis with an indistinct gallbladder wall, which raised suspicion of an associated acute cholecystitis (Figure 2). The patient was admitted to the hospital for hydration and further evaluation. A nasogastric tube was placed for gastric decompression, he was to receive nothing by mouth, and general surgery was consulted concerning the SBO.
The patient's medical history was significant for 1 year of untreated hypertension. He denied any other medical history and was not currently taking any medications. Surgical history revealed no prior procedures. He did admit to a 50 to 60 pack/year smoking history but had been abstinent for the past 30 years. He denied current alcohol use but admitted to prior heavy alcohol consumption. Colonoscopy findings within the past 2 years were negative. The only positive in his family history was venous thromboembolism with pulmonary emboli. Treatment consisted of nasogastric decompression, IV hydration, daily monitoring via laboratory studies, abdominal plain radiography, and bowel rest; however, 3 days later, the patient's symptoms had not improved, and he was taken to the operating room for an exploratory laparotomy. A limited midline incision was made and the abdomen entered. Several dilated loops of small bowel were initially evident and palpated to a transition point, where a firm, cylindrical object was detected. A lateral enterotomy was made to remove the intraluminal foreign body, which was found to be a 3.5 2.5-cm impacted gallstone (Figure 3). The enterotomy was repaired in two layers. The small bowel was palpated from the ligament of Treitz to the ileocecal valve along with the colon. No other masses or points of obstruction were found. The abdomen was irrigated with 5 L of sterile normal saline followed by a three-layer closure of the midline incision. The patient was discharged on postoperative day 4 on a regular diet with only a lifting restriction.
