Abdominal pain and fever after an ileostomy reversal
Posted in Pictures on 26 February 2015
Gabriel Díaz (Gastrointestinal Surgery Specialist)
Xavier Morales (Gastrointestinal and Emergency Surgery Specialist)
Hospital Clínic, Barcelona – Spain
A 71 year old female with a previous history of high rectal rectal cancer, underwent a high anterior resection, at the postoperative period she developed an anastomotic leakage that was treated with an abdominal cavity lavage and a loop ileostomy. This strategy was successful and the patient was discharged.
The pathology revision described a T3N1b moderately differentiated adenocarcinoma, so adjuvant therapy was indicated with XELOX. During this period the patient had a correct oncological follow up and a water soluble enema was compatible with the resolution of the leak.
The closure of the ileostomy was delayed due to the chemotherapy, surgery was performed uneventfully and early oral intake was performed. The first postoperative day the patient presented vomiting and abdominal pain, an X-Ray (FIG. 1) revealed a dilated loop (not clear if it was the small bowel or the colon).
Then the patient developed fever and CRP of 10 mg/dL. The first suspicion was an anastomotic leakage, but there was no pneumoperitoneum and the patient had abdominal distention plus the pathological findings of the X-ray.
In order to clarify the diagnosis a CT scan was ordered, the anastomosis was correct but abdominal fluid was found, the colon was distended with a pseudo-fecaloid pattern (FIG. 2) and seemed to have a change of gauge, (FIG. 3) rising the diagnosis of mechanical colonic occlusion.
As the clinical – radiological findings were inconclusive, a laparoscopic revision was performed. The anastomosis was correct, the abdominal fluid was serous and the colon had inflammatory changes and was distended. No adhesions or other causes of mechanical occlusion were found.
Medical therapy was performed with bowel rest and antibiotics (Piparacilin Tazobactam) and the patient experienced a good clinical response.
Cultures, (blood and stools) were negative, including detection of clostridium difficile toxin, the patient started oral intake on the second day after revision and left hospital on the 3rd postoperative day.