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Wed Jul 9 00:35:39 BST 2008

The redness in both flanks worries me.
I'd want to make sure it wasn't pancreatitis with ileus before operating.
I'd want to take a more careful history (incluiding alcohol intake and previous surgery), resusscitate and re-examine, get an urgent amylase/lipase, and look at the CT myself. I'd like to make a decision within an hour. Is a Ryle tube a nasogastric? If it's putting out whitish fluid only, it's either in the wrong place, or SBO is the wrong diagnosis.  Gastric volvulus? Obstructing gastric cancer? Both of these should be apparent on the CT.
I think acute pancreatitis is the only diagnosis that won't require laparotomy. Pneumonia or urinary sepsis with secondary ileus would be very uncommon in a healthy man his age.
I assume there's a twist, as you are presenting it on the site.
Let us know how it goes.
Julie Miller 
Royal Melbourne Hospital

----- Original Message ----
From: rm khattar <dr_rm_khattar at yahoo.co.in>
To: trauma-list at trauma.org
Sent: Tuesday, July 8, 2008 9:52:29 PM
Subject: A difficult abdominal case

A 40 year man is admitted with 5days history of abdominal pain ,inability to pass flatus and motion,distention of abdomen and vomiting. No significant past history. On examination he is mildly dehydrated ,looks sick,and has tachycardia and looks in agony and has tender hugely distended abdomen with absent bowel sounds. There is redness on abdominal wall in both flanks. He has a indwelling urinary catheter draining concentrated urine, Ryle's tube in situ with whitish aspirate.His TLC,Urea ,Creatinine are high and he has mild  non obstructive jaundice,biochemically.He is carrying a CECT abdomen  from the hospital where he was previously admitted which shows intraperitoneal fluid and diagnosis of SBO.
What are the diagnostic possibilities?
What is the further work up?
What treatment should be offered?
R.M.Khattar
Delhi,India
Consultant Surgeon.  

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A difficult abdominal case