GASTROINTESTINAL

CASE STUDY

• Symptom free during the intervening period until 8 months prior to current admission

• February 2010– Colicky but tolerable abdominal pain • Refers to hollow organs

– Bloatedness– Abdominal distention which subsides upon

passage of flatus or stool• Intermittent abdominal distention is the hallmark of all

forms of intestinal obstruction

• 4 Weeks Prior to Consult – Vomiting of previously ingested food occurring 1-2

times/week• Possible upper bowel obstruction

– Progressed to daily intolerance of both solid and soft diet (daily)

– Abdominal distention becomes more frequent and severe

– Colicky pain localized in RLQ– Anorexic• Lost 20-30% of her weight during the last month• Weight loss may be due to her TB since she denies a

history of cancer in the family – LMP is 18 days ago

• On admission– Stable vital signs– Hyposthenic• Lack of strength or weakness

– Ambulates freely but with evidence of muscle wasting

– Minimally worked up and diagnosed but she cannot be cleared for definitive intervention due to high risk for pulmonary circulations

– Wasting fast, nutrition is a compounding problem

Additional Questions Needed• Other symptoms felt before? – Fever, constipation, diarrhea?

• TB related symptoms?– Cough, night sweats?

• Abdominal pain– Duration? Hours? Days? – Pain scale? 1-10?

• Patient was minimally worked up upon admission– What tests were done?– How did they treat her?

• Dehydrated?– Sunken eyeballs, dry oral mucosa, poor skin

turgidity• Anemic?– Pale conjunctivae, pallor

Is there a history of previous abdominal surgery?

NONE

What are the pertinent abdominal and rectal exam PE findings?

• Inspection– Contour = protruberant

• Due to accumulation of gas and fluid proximal to and within the obstructed segment

– Tense and shiny– Visible peristalsis = increased abdominal activity

• Abdominal girth should be measured!• Auscultation– Hyperactive

• Bowel is trying to overcome the obstruction– Hypoactive

• Already a late sign indicating peristalsis

• Palpation– Are there any palpable masses?• A palpable mass in the right iliac fossa implies colonic TB

• Percussion– Tympanitic• Presence of excessive gas within the bowels

• Rectal Exam– Patency of anal sphincter– Any discomfort – Gross or occult blood• Suggests a late strangulation or malignancy

Chest X-ray

Check- Opacifications- Cavity-High diaphragm

Overall- TB[?]

Check

Abdominal X-ray

Check- Bone in legs[?]

http://dc217.4shared.com/img/359883450/84f8edb9/s7/DSC02208.JPG

Check- Narrowing on the lower right side

Check- Ascending, descending or transverse

Primary Clinical Impression

Gastrointestinal Tuberculosis

Intestinal TuberculosisColonic Tuberculosis