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Clinical Case 064: Um-bil-obstruction

Another ripper ultrasound case this week!  I was doing a Sunday – my favourite day!  No lab, no Xray department, no Admin folk doing QI stuff etc…..   Just straight clinical work.  Of course it is tourist season – so the average age of Broome goes up about 30 years!

Elderly chap presented with 24 hours of vomiting.  He had had a bit of diarrhea the week prior, but then went on a rough boat ride and developed a tender lump over his umbilicus.  Being a stoic fellow he didn’t present until the vomiting was bilious and he was all out of buckets!

On exam he looked pretty crook with a distended belly and a firm, red, warm lump ~ 5 cm above his umbi.

Medical school diagnosis really – SBO secondary to incarcerated umbi hernia.  But, here is the trick.  This chap had a list of comorbidities a page long, was on another page of meds and was not the sort of person I would usually opt to anaesthetise.  Having said that – not a good candidate for a 12 hour plane ride either!

Clear bowel loop within the hernial sac. 

So what to do?

A quick call to the surgeon – he wants to have a look.  There are 2 operations we could do here:

(1) A small hernia repair – if the gut is viable and no bowel resection is required.

(2)  Laparotomy with small bowel resection of dead gut, possible ileostomy etc – this is major stuff for Broome, especially with a man with this many chronic problems.

 

So how do we decide what to do?  Traditionally I think we would have gone in and hoped for the best, with a plan to evacuate ASAP if it turns out to be a major resection.

BUT bring back the US machine with the surgeon at the bedside…

We could demonstrate good venous and arterial flow in all the walls of the entrapped loop. 

So – off to theatre and a modest incision, nice healthy bowel returned to the peritoneal cavity and a mesh in.  Of course we used the US to do a few TAP blocks at the end of the case – no opiates if we can get away with it.

Over all – a very satisfying case, a happy patient and a lot less stress for all concerned.

WHat do you think – how would you play this one?

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