[The following patient story was adapted from our medical@ listserv, which provides a forum for collaboration between medical professionals at Bayalpata Hospital and around the world.]
An 8 year-old boy presented with periumbilical pain for 4 days, which was non-radiating, with multiple episodes of vomiting and the inability to pass stool and flatus for same duration.
Besides these symptoms, he has no history of headache, loss of consciousness, abnormal movements of the body, chest pain, diarrhea, joint pain, or rash.
Upon examination, the patient appeared ill. His pulse was 120 beats per minute, with a respiration rate of 30 breaths per minute, temperature of 99ºF, and blood pressure of 110/70 mm Hg. He exhibited signs of dehydration, but showed no pallor, icterus (yellowing of the skin), lymphadenopathy (swollen glands), clubbing (enlargement of the fingers), edema (accumulation of fluids), or cyanosis (discoloration of the skin due to oxygen insufficiency). Upon abdominal examination, the patient’s abdomen was distended, firm, tender, and warm to the touch, but there was no organomegaly (enlargement of the internal organs). Examination of the chest, cardiovascular system, and central nervous system were unremarkable.
With this history and examination, I came to the provisional diagnosis of acute intestinal obstruction. We ordered lab tests, with the following results:
Urea, Creat, Na+: WNL
Plain X-rays of the patient’s abdomen, both supine and erect, showed multiple air fluid levels and the features (valvulae conniventes) of a small bowel obstruction. With these investigations, I got the impression that the boy’s acute intestinal obstruction was most likely due to volvulus (intestinal twisting), though I also considered the possibility of paralytic ileus (paralysis of intestinal movement).
We decided to keep the patient NPO (nothing by mouth), inserted a nasogastric tube, which drained 1.5 liters of bilious aspirate, and began treatment with Metronidazole and Ceftriaxone. We are taught that we “don’t let the sun rise in case of a small bowel obstruction,” and I thought of referring the patient to Nepalgunj (a 12 hour bus ride from our Hospital). I counseled the patient accordingly, but the mother was unable to take the poor boy because of financial reasons. In lieu of referral, we tried an enema for the child, and luckily he passed some stool and flatus the same night he was in the emergency room. We were all a bit relieved.
The next morning, when I went to see the patient at 8 a.m., the mother held a cloth with a worm about 15-16 cm long that the child had defecated. We had found the cause of obstruction. When I shared this finding with Drs. Paul Farmer, Duncan Maru, Ryan Schwartz, and Payel Gupta, and Executive Director Mark Arnoldy, Dr. Farmer said: “the poor guy made the diagnosis for you!” Indeed, the boy had made his own diagnosis. We proceeded to treat him with Ivermectin immediately, and the boy is doing fine now. Thank god.
Dr. Roshan Bista graduated from the Institute of Medicine, Kathmandu with an MBBS. He is currently the Medical Officer at Nyaya Health.