Non-malignant intestinal partial-obstruction of small bowel seems to be very difficult to diagnose and to prove. In our particular case it was complicated as there were two obstructed areas. First area was the IC-Junction (end of small bowel) and the other was 1st loop of efferent jejunum at the wrongly constructed D2-J(beginning of small bowel). Thus we had 3 purely mechanical agents to sort out and each made its presence evident metachronously spread over a span of 6-7 months, instead of showing up synchronously.
•A• The sutures introduced at the time of appendectomy (so many of them-probably to control mesoappendicular bleed from ?escaped appendicular artery) induced adhesions at IC-Junction causing narrowing of the most distal ileal segment
•B• Post duodeno-jejunostomy twisting of D2, thereby creating a partial obstruction to the D2-J junction
•C• Para D2-J herniation of 1st loop of efferent jejunal segment from infra-colic compartment to supra-colic compartment through the mesocolic window created at the 2nd surgery.
The classic signs and symptoms of complete obstruction are not seen. Many investigators wait for the radiological and clinical appearances to show up before naming the problem on hand as partial obstruction.
• Abdominal pain with all the characteristics is seen prominently (colicky pain, related to epigastric or peri-umbilical or infra-umbilical position related to fore or mid or hind gut). I would give it 10 / 10 score on scale of reliability for diagnosing the problem.
In my particular patient, all the 3 mechanical agents were parts of mid-gut and thus she was utterly unable to pin-point to the area of pain. Character of pain had much to be relied upon.
• Vomiting may or may not be a feature. But one has to remember that green stuff in vomit cannot be manipulated by the patient. Vomit that contains frothy matter, blood tinged matter, or yellow stuff can be brought about by pushing fingers in the throat but greenish vomit IS OF PRIME SIGNIFICANCE. I would give it 10 / 10 score on scale of reliability for diagnosing the problem.
My patient had many a bouts of greenish vomiting which I witnessed and believed in a mechanical cause for her symptoms.
• Boborygmy: is also quite an important sign. I would give it 10 / 10 score on scale of reliability for diagnosing the problem.
My patient had so loud peristaltic sounds that I could hear them many feet away from the writhing patient, who had saved some green vomitus in a bowl when I first saw her in her room.
• Abdominal distension is very variable. Even in distal partial obstruction, distension may not be observed. Air-fluid levels are also, therefore, not seen easily. E.g. in case of our patient, in the battery of radiological tests (from 2002 to 2009) only one plain film done in 2004 is reported as having A-F levels. I would rely on it (1-2) / 10 only. Of course, if it is present, it is quite reliable; but its absence does not rule out partial abstruction.
My patient never had any distension except a band of horizontal full ness just under the horizontal scar. I feel that this "fullness" might well have been due to bunching of the abdominal muscles in the suture line.
• Constipation is variable as well. Because of partial block, pt does pass gases. Also fecal matter is passed at a lesser frequency. I would rely on it (1-2) / 10 or perhaps less than that.
• Physical examination may be unrewarding due to the colicky pain and extreme degree of restlessness.
The best chance of picking up an obstruction is by contrast study 'DURING' pain episode. If Ba Meal FT fails to show any dilatation during pain, small bowel enteroclysis MUST be tried 'during' the next pain episode. The suspected areas MUST be personally seen by the investigating doctor in the X-ray room rather than asking the radiographer or radiologist to do the test. Special attention MUST be given at previously operated areas of the gut and if possible one has to record the fluoroscopic findings throughout the various phases of Follow-Through. Fluoroscopic recordings are important as the peristalsis related issues can be settled on the 'live fluoroscopy' appearances.
There is not much data available on the intra-luminal pressures of small bowel during obstruction episode.
There is no correlation between the degree of pain and amount of dilatation of gut.
