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!

So I wheeled out the trusty beside US machine and here is what we saw.

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…

Add a little colour to the image!

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?