EGS P31 A Rare Case of Jejunal Obstruction Secondary to Necrotic Peripancreatic Abscess (CASE REPORT)

Abstract

Abstract Background Acute pancreatitis is one of the major causes for emergency hospital admissions worldwide. Bowel obstruction following acute pancreatitis usually occur as a result of retroperitoneal inflammation and mesenteric infiltration in the inflammation; especially at duodenum, transverse colon and splenic flexure due to the proximity to pancreas. We hereby, present a rare case of jejunal obstruction secondary to sterile necrotic peripancreatic abscess. Through this case report, we aim to emphasize increased awareness required among general surgeons and the need for appropriate clinical judgement in the management of bowel obstruction - medical versus surgical intervention. Methods Case Report: A 65-year-old lady presented in emergency with an acute 10-hour history of epigastric pain with nausea. She drank no alcohol, was otherwise well and had no other significant co-morbidities. On examination, she was tender in the epigastrium with no signs of peritonitis. She had raised serum amylase diagnostic of acute pancreatitis. All other blood investigations and an ultrasound abdomen was unremarkable. The cause of pancreatitis was unclear. She was admitted and treated in a conventional fashion. Over next 2 days, the patient's C-reactive protein increased and she became hypotensive warranting HDU care. Computed Tomography of abdomen and pelvis (CTAP) confirmed acute pancreatitis with no associated complications. She made slow progress. A Nasojejunal tube was inserted for nutritional support. Over the next five days, she had abdominal distention with absolute constipation and was treated for ileus. Further CT imaging suggested partial small bowel obstruction. Clinical condition failed to progress despite 48 hours of conservative management and decision was taken for a diagnostic laparoscopy. Results Intra-operatively, multiple small bowel loops were found densely adherent to the inferior border of pancreas, each with a clear evidence of upstream bowel dilatation. The cause was a peripancreatic necrotic abscess cavity. Laparoscopic division of adhesions allowed access to the cavity. A washout was performed and a drain inserted. Post-operatively, she had an uneventful recovery. She was gradually built on enteral nutrition and her bowels started working normally. She was discharged on post-op day 5 and drain removed as an outpatient. She had no complications at 60-day follow-up. Conclusions Bowel complications of acute pancreatitis (paralytic ileus, mechanical obstruction, bowel ischaemia and perforation) are relatively infrequent, with few cases reported in literature. Prediction of disease severeity is crucial to guide the treatment plan. In majority of cases, abdominal distention and absolute constipation is usually ileus and managed conservatively. Care should be taken in unsettling patients and diagnostic laparoscopy should be undertaken to evaluate the cause and manage accordingly.