A Fatal Cause of Small Bowel Obstruction

Abstract

Question: A 76-year-old man presented to our clinic complaining of nausea and nonbilious vomiting for the past 4 months that has worsened over past 3 days. He noted a weight loss of >20 pounds over the past month associated with decreased appetite. He also complained of intermittent abdominal pain, which is diffuse and not related to food intake. He denied having any fever, chills, diarrhea, or constipation. Past medical history was significant for hypertension, hyperlipidemia, diabetes mellitus, seizure disorder, and blindness owing to glaucoma. Past surgical history was significant for cholecystectomy for acute cholecystitis and prostatectomy for prostate cancer. Vital signs were remarkable for elevated blood pressure at 153/103 mm Hg and elevated heart rate at 103 beats/minute. Physical examination showed the patient appears cachectic. The abdomen was soft, nondistended, and nontender. Guarding and rebound tenderness were not elicited. Laboratory studies showed mild decrease in hemoglobin at 13.7 g/dL (normal, 14.0-18.0 g/dL). The total white blood cell count was normal at 7.63 K/mL (normal, 3.50-10.80 K/mL) with neutrophilia at 80.2% (normal, 40.0%-74.0%) and lymphopenia at 8.7% (normal, 19.0-48.0%). Comprehensive metabolic panels showed decreased sodium at 129 mmol/L (normal, 136-145 mmol/L) and decreased chloride at 83 mmol/L (normal, 98-107 mmol/L). The patient was then admitted for further evaluation. A nasogastric tube was placed and 1 L of bilious fluid was drained. Subsequently, the patient developed altered mental status and hypotension, his blood culture showed gram-negative bacteremia. Abdominal and pelvic contrast-enhanced computed tomography scans revealed multiple loops of distended proximal small bowel measuring up to 5.25 cm (Figure A, red arrows), with a transition point seen within the anterior epigastrium (Figure B, white arrow), consistent with a small bowel obstruction. What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

An Unusual Cause of Duodenal Obstruction: Watch Your Feet!

“…Due to loss of follow-up, endoscopic reassessment was not performed. S. stercoralis is a parasitic nematode that infects the gastrointestinal tract through skin contact with contaminated soil [1]. It is more prevalent in tropical and subtropical regions [1].…”

“…S. stercoralis is a parasitic nematode that infects the gastrointestinal tract through skin contact with contaminated soil [1]. It is more prevalent in tropical and subtropical regions [1]. It has the ability of completing its life cycle entirely within the human host to establish an autoinfection cycle.…”

“…The prognosis of duodenal obstruction due to S. stercoralis infection is not well established. Nevertheless, late diagnosis seems to add to its dismal prognosis, mostly due to bacterial translocation and sepsis [1].…”

“…Chronic infection by S. stercoralis is often asymptomatic and clinical manifestations can occur long after initial infection, including nonspecific gastrointestinal, dermatological, and respiratory symptoms [2]. Small bowel obstruction is a poorly recognized and probably underreported complication of S. stercoralis infection, with only a few cases reported in the literature [1]. Severe mucosal edema is suggested to be the cause of bowel obstruction in these cases [1].…”

“…Small bowel obstruction is a poorly recognized and probably underreported complication of S. stercoralis infection, with only a few cases reported in the literature [1]. Severe mucosal edema is suggested to be the cause of bowel obstruction in these cases [1].…”