Gastrointestinal - Track and Field

Abstract

HISTORY: A collegiate track athlete presented with a two-day history of nausea, non-bloody, non-bilious vomiting, bloating, inability to tolerate PO, and waves of sharp, crampy abdominal pain. He denied fevers, chills, diarrhea, sick contacts, or recent NSAID or alcohol use. His last bowel movement was two days prior. He endorsed a history of similar symptoms due to constipation that resolved with a laxative suppository. He was evaluated the previous day and noted to have mild epigastric and RLQ tenderness. He was able tolerate PO after Zofran ODT and discharged with strict return precautions. Surgical history includes laparoscopic right sports hernia repair with mesh, open right adductor tenotomy, and umbilical hernia repair in 2014 and left adductor tenotomy in 2016. PHYSICAL EXAMINATION: Afebrile, normotensive, bradycardic. Appears uncomfortable. Abdomen soft. Bowel sounds present. Epigastric tenderness to palpation. Voluntary guarding. No rebound. DIFFERENTIAL DIAGNOSIS: 1. Gastritis 2. Constipation 3. Ileus TEST AND RESULTS: Abdominal radiographs showed gaseous small bowel distension in a non-obstructive pattern with a large amount of stool in rectal vault. He received IV fluids, glycerin suppository, and a Fleet enema with no bowel movement but recurrent emesis. Repeat Fleet enema, 4 mg IV Zofran, and additional IV fluids were given. On re-examination he had worsening abdominal tenderness and guarding. He was transferred to the ED and the differential diagnosis was broadened to include small bowel obstruction and intraabdominal perforation. On arrival to the ED he was in distress with significant bilateral lower quadrant tenderness, rebound, and guarding. CT abdomen and pelvis showed a high-grade distal small bowel obstruction with moderate wall edema along distal ileum with concern for vascular compromise. FINAL/WORKING DIAGNOSIS: Small bowel obstruction related to prior sports hernia repair TREATMENT AND OUTCOMES: 1. Emergently to OR for exploratory laparotomy. 2. Intraoperatively found to have herniation of distal ileum through peritoneum in RLQ inferior to prior mesh placement for sports hernia repair. Herniated loop of bowel non-viable with chronic ischemic changes and stricture requiring 30 cm resection and ileoileostomy. 3. Uneventful post-operative course. 4. Return to sport pending.