Case Report
A 75-year-old male with no known comorbidities arrived at the Emergency
Department complaining of constipation, nausea, and vomiting for the
past 3-4 days. The patient was in his usual state of health when he
experienced constipation. He has not passed flatus for the past 3-4
days. The patient also complained of localized pain in the lower
abdomen, which was gradual in onset, dragging in character, and
non-radiating. The patient had 3-4 episodes of vomiting, which was
non-projectile and did not contain any blood or mucous. He had a prior
history of intermittent constipation.
On general physical examination, the patient was pale and dehydrated.
His blood pressure was 149/76 mm of Hg, and heart rate of 94 beats/min.
On examination, the abdomen was firm and swollen, with discomfort in the
lower abdomen on palpation. The bowel sounds were audible. Laboratory
results showed a total WBC count of 1.9 B/L, Hemoglobin 13.7 gm/dl, RBC
count of 4.12 B/L, Platelet count of 122 B/L, Absolute Neutrophil Count
of 1520, Sodium 138 mEq/L Potassium 3.5 mEq/L, Bicarbonate 21 mEq/L,
Chloride 106 mEq/L, Total Bilirubin 2.6mg/dl, Direct Bilirubin 1.5 mg/dl
and Alkaline Phosphatase 150 IU/L. X-RAY imaging of the abdomen in
supine posture indicated a few dilated bowel loops and a few air-fluid
levels, suggesting most likely sub-acute blockage (Figure-1). No
abnormal calcification was found. Normal densities of soft tissue were
identified. No radio-opaque stone was seen in the KUB area. Chest X-ray
in posteroanterior view revealed lucency under the right diaphragm dome,
suggesting pneumoperitoneum (Figure 2). There were no gross signs of
consolidation or collapse in either lung field. Hila and mediastinum
were normal. Normal costophrenic angles along with normal transverse
cardiac diameter were identified. Normal skeletal rib cage symmetry was
identified. In the context of the aforementioned indicators, acute
peritonitis due to intestinal perforation was hypothesized.
Prior to the procedure, a platelet transfusion was performed.
Exploratory laparotomy indicated the presence of 1000 ml of ileal
contents within the peritoneal cavity. A diverticular perforation
(mesenteric boundary) was discovered 1 foot from the ileocecal junction.
One diverticulum was 1 foot away from the duodenojejunal (DJ) junction,
while the other was 2 feet away from the DJ junction. There was an
edematous ileal wall at the site of the perforation. Significant ileal
edema necessitated ileal resection and a double barrel ileostomy (Figure
3). The patient was administered Ceftriaxone, metronidazole, Ketorolac,
Metoclopramide, and Omeprazole postoperatively. The patient recovered
without incident and was discharged after four days. On discharge,
Omeprazole 40mg once daily (OD) for 14 days, mefenamic acid for pain as
needed, metronidazole 400mg three times a day for 7 days, and Linezolid
600mg twice daily for 14 days were prescribed, along with milk intake of
200ml+ 4 scoops a day and a high-protein diet.