Recurrent acute small bowel obstruction due to a narrow ileocolic anastomosis: a surgical complication with distinctive features.

Abstract

ANARROW ileocolic anastomosis may result in a distinct syndrome of repeated episodes of acute small bowel obstruction which are relieved by enemas. This surgical complication must be differentiated from bowel obstruction due to postoperative adhesions or recurrent ileitis because reconstruction of the anastomosis provides a permanent cure. A case is reported in which the diagnosis was overlooked clinically, radiologically, and at surgery for four years. During this time the patient had at least 40 episodes of acute small bowel obstruction with relief by enemas. Case report A 31–year–old housewife had a resection of the terminal ileum with an end–to–side, right ileotransverse colostomy in 1964 for chronic, stenotic, terminal regional enteritis. One month after the surgery severe colicky periumbilical pain suddenly developed, associated with obstipation, abdominal distension, and increased peristalsis. A plain water enema intensified the pain and resulted in an explosive bowel movement of flatus and liquid stool after which the patient immediately became completely asymptomatic. Four similar episodes occurred in thc next few weeks. On each occasion radiographic examinations showed a patent ileocolic anastomosis, although the stoma was narrow , with a diameter one–third that of the adjacent small intestine. The diagnosis of postoperative intestinal adhesions was made. After a fifth episode of bowel obstruction, a second laparotomy was performed. The small intestine was explored and a few insignificant adhesions were divided. The ileocolic anastomosis was considered to be functioning satisfactorily and was not opened. Following the procedure the acute episodes of small bowel obstruction recurred, and again the diagnosis of postoperative adhesions was made despite the absence of significant adhesions at surgery. The patient continued to have occasional episodes of acute small bowel obstruction relieved by enemas for the next three years. Then in 1967 diarrhea developed, associated with right upper quadrant pain, abdominal tenderness, chills, and malaise. Radiographic studies showed recurrent ileitis in the distal ileum beginning at the anastomosis (Fig. 1) The diameter of the stoma was the same as at the earlier examinations with no obstruction to the flow of barium. In the next several months episodes of periumbilical pain and obstipation continued but were only partly relieved by enemas. The pain became more constant and required increasing amounts of narcotics for relief. The diagnosis of recurrent ileitis with intestinal obstruction due to adhesions or due to ileitis with spasm was made. Surgery was delayed because of the high recurrence rate of both adhesions and ileitis. Intestinal drainage for twelve days with a Cantor tube produced relief of the pain and distension for several weeks, but despite daily enemas the symptoms of obstruction recurred, and surgery became mandatory.