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Abstract: The patient presented with epigastric pain and discomfort without obvious cause 3 months ago, accompanied by poor nausea and blood in the stool, which was bright red in color. This symptom worsened for 10 days without relief and was seen in the emergency room, where he was diagnosed with large bowel obstruction. The diagnosis of large intestinal obstruction was made. Emergency surgery confirmed that it was a tumor of the ascending colon, and radical surgery of the ascending colon mass was performed.
Basic information】Female, 61 years old
Disease Type】Large bowel obstruction
Hospital】Tianjin Fifth Central Hospital
Consultation time】October 2018
Treatment plan】Surgical treatment (radical resection of ascending colon mass, prophylactic enterostomy, stoma return) + intravenous infusion (amino acid glucose injection, fatty milk injection (C14-24), cefoperazone sodium for injection, omeprazole sodium for injection)
[Treatment period] Hospitalization 14 days
【Treatment effect】The large intestine obstruction phenomenon was relieved and the condition gradually recovered
I. Initial consultation
The patient was 61 years old and had epigastric pain and discomfort with poor nasal function and blood in the stool with bright red color and small amount without fever, chills, nausea and vomiting 3 months ago without any obvious cause. 10 days ago, the patient felt that the pain was aggravated and relieved after exhaustion and defecation. On examination, the abdomen was flat and symmetrical, the whole abdomen was soft, the right abdomen had pressure pain and rebound pain, and the bowel sounds were 4 times/minute with hyperacusis. The patient had no previous history of similar disease.
Figure 1 Significant dilatation of the intestine, suggesting intestinal obstruction
Figure 2 Ascending colonic mass
II. Treatment history
Combining the patient’s symptoms, physical examination and CT findings, the patient was diagnosed with mechanical intestinal obstruction and ascending colon mass, and was immediately given anti-inflammatory treatment with cefoperazone sodium for injection. Open exploration, radical resection of the right hemicolectomy and prophylactic enterostomy were performed. Intraoperative exploration revealed a solid mass in the ascending colon, measuring about 5×3 cm, and the proximal intestinal segment of the mass was obviously dilated. The area was sufficiently flushed during surgery, and the lower abdominal drainage tube facilitated postoperative recovery. After surgery, the patient was given anti-inflammatory treatment with cefoperazone sodium for injection, regular wound dressing changes, nutritional support treatment with amino acid glucose injection and fatty milk injection (C14-24), and acid suppression treatment with omeprazole sodium for injection. When the patient gradually resumed diet, acid suppression therapy was discontinued and the amount of intravenous nutritional support was gradually reduced. Postoperative pathology confirmed a malignant tumor in the ascending colon (Figure 3). The patient underwent 2 surgeries 3 months after discharge, and the stoma was returned to restore anal defecation, and part of the intestinal segment was surgically removed and the intestine was reanastomosed.
Figure 3 Postoperative pathology
III. Treatment effect
After active anti-infection treatment, the patient’s infection was controlled and the patient’s body temperature gradually returned to normal. After 14 days of hospitalization, the patient’s abdomen was free of pain, bloating and other discomforts, eating was normal, and bowel movements were not abnormal. After the abdominal ultrasound was repeated, the drainage tube was removed and the patient was discharged. In order to promote anastomotic healing, a prophylactic enterostomy was performed during the operation, which affected the patient’s quality of life to a certain extent, but this could ensure the patient’s safety and prevent the occurrence of postoperative anastomotic leakage.
IV. Precautions
We are glad that after active treatment, the patient’s large bowel obstruction was resolved. Patients should pay attention to their diet after surgery. Patients with colorectal cancer should moderately reduce the intake of beef and mutton and improve the intake of dietary fiber, such as pumpkin, yam, apple, corn and other foods, which can keep the stool unobstructed to a certain extent, and should actively treat constipation, if any. According to the pathological results, the patient should undergo adjuvant chemotherapy 1 month after surgery to reduce the recurrence. Follow the doctor’s instructions to follow up regularly with the general surgery department and review the colonoscopy after 1 year.
V. Personal insight
Most of the colorectal obstruction is caused by tumor chronic growth to a certain size and occupy the intestinal cavity, as in this patient, the symptoms are usually abdominal pain (right side is more common), abdominal distension, vomiting, stopping exhaustion and defecation, due to the low location of obstruction, it is more likely to manifest as abdominal distension, stopping exhaustion and defecation, vomiting is relatively rare.
For such people, especially those with family history of bowel cancer, they should seek medical attention as soon as possible. Tumor growth is a chronic process, and the development of obstruction is often caused by tumor growth for more than half a year, so early screening is crucial. It is recommended that people with family history of bowel cancer, over 40 years old, who eat a lot of beef and lamb all year round and have little intake of fruits and vegetables, should undergo colonoscopy once a year.