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Clinical Case 132: Parker’s Peristaltic Palsy

Another case from the archives with a fair helping of ultrasound.

59 year old man with a complex surgical history.  He had an open cholecystectomy 20 years prior complicated by CBD injury and required a Roux-en-Y & CBD re-plumbing.  He has been doing pretty well until now.  He has some chronic hypertension and COPD which is well controlled.

Yesterday he developed increasing right-sided abdo pain with vomiting and increasing distension.  There is no jaundice, fevers or bowel activity on examination.  He is very tender and tympanic over the right abdomen with peritonism.

The Obs are not pretty: pulse SR 120/min, BP 85/60, RR = 20 in pain, afebrile, SpO2 = 97% on nasal oxygen.

Somebody orders some bloods:  mildly neutrophilic, slightly abnormal LFTs (non-specific), normal VBG aside from slight respiratory alkalosis commensurate with his pain and Obs.  The lactate is 1.8 mmol!

An AXR is as usual – largely unhelpful.  Lots of old bowel staples, clips and maybe a fluid level in the RUQ.

So, what did the US show?  How would you interpret these images?

Multiple bowel loops. Dilated and fluid filled.

There is some subtle extraluminal fluid.  I cannot see any intramural or free air artefact. There is ZERO peristalsis. I watched it for a few minutes – never saw it move once. Colour Doppler showed no clear flow in the walls or arcades of the mesentery.

So what is going on here?  This looks like a bowel obstruction clinically and on US.  However he looks pretty crook and in need of Resus.  So we will start some fluids, line him up and get some pressors started to keep his cardiac output “Anaesthetic-ready” – ‘cos in Broome, that is the next hat I will be putting on.

… but it really doesn’t add much in this case.  There is a series of bowel loops that look obstructed and dilated int he RUQ.  No free air or much ascites.  The flow in the larger mesenteric arteries was present. No clear cause seen for the obstruction.

Time for a checklist…

  • Resus up ‘n running – yep
  • Surgeons ready – yep
  • Theatre ready – yep
  • Diagnosis – ummmm!  Well we still needed to open his belly to find that.

After a “Rocketamine”-based induction the diagnosis is revealed.

There is an obstruction based around a tight adhesion in the blind-ending Roux loop and those loops are looking dusky and grey.   So now we have a serious problem.  This section of ischemic gut is the loop into which his CBD has been plumbed.   This is going to need some serious surgery and we are 2000 km from an ICU or a specialist upper GI surgeon.  What is the next move?  The way ahead is not too clear.

What did I learn from this?  Well I think that using US to look at bowel dynamically might be useful to diagnose bowel ischemia.

Features that might make you think dead gut:

  • The absence of peristalsis in a loop that looks “obstructed” – I’m going to call it Parkers’ Peristaltic Palsy.
  • Extraluminal fluid – ie. transudate through the wall
  • Intramural air / localised air/fluid artefacts
  • No flow on Doppler of the bowel wall.

I am not sure of the exact diagnostic utility / characteristics of each of these signs – however put together they make a good case for the diagnosis.

So let me know – have you seen any of these signs?

What would you do next with this case?

Casey

 

Comments

  1. David Berger says:

    Usually the CT is pretty good at picking up ischaemia with bowel wall oedema, so it is odd that it didn’t in this case. Also, it would be interesting to know what his bowel sounds were. ‘Simple’ sound is pretty good at distinguishing dynamic and adynamic obstruction; you don’t necessarily need ‘Ultra’ sound!

    In a sense, though, neither CT, nor ultrasound, were necessary. This guy was clinically obstructed and very crook. He needed a laparotomy and it was unlikely that either ultrasound or CT were going to change that or even direct the surgeons in any particular direction. Of course, the surgeons in most hospitals will probably still insist on the CT before they even deign to see the patient (not in ours, actually).

  2. Agree. CT is a good test -- reasonable to do, which we did. But it didn’t add to the outcome in the end. Delays in regional towns to get CT done (Esp on weekends or after dark) can be many hours til read and decisions made.
    In this case delay could be costly.
    We should look at the patient first to make these calls, imaging can give good direction but it’s pointless if the patient dies awaiting Dx?

  3. ffolliet (@ffolliet) says:

    Small question, why ANY radiological investigations? He needed a stat laparotomy as soon as his condition was maximised.

    • Agree in an ideal world. However, to counter argue.
      Bedside US took me less than minute to do and made it very clear we had time-dependent badness happening.
      Therefore the subsequent trip through to theatre expedited, saving time and possibly bowel. The reality of a small hospital is these patients tend to linger in ED awaiting a proper Dx or transfer for Ix

  4. robyn cooke says:

    was there a lactate in the basic bloods? Just curious?

    • HI Robyn, the lactate was noted as 1.8 mol in the case.
      Ive read a bit around this and lactate appears to be a really late and insensitive marker of bowel ischemia. Unfortunately there are no currently available blood markers that seem to offer much in terms of positive or negative LRs for this disease
      Good point -- this is a widely taught and accepted diagnostic strategy.
      Casey

  5. kylie baker says:

    Hi Casey. I am really interested in putting the colour on abnormal bowel as the question of infectious vs ischaemic colitis rises often and our CTs are often delayed or less than helpful. Was thinking that we need to standardise the use of colour -- eg use power doppler or specified flow rates and scale (?? or one for arterial ischaemia and one for mesenteric thrombosis) and then compare the suspect bowel with a consistant normal somewhere. Haven’t found much on it though and keen to hear what you find out.

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