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.