What is the appropriate management and treatment for a 34-year-old male patient with infective intestinal obstruction, including initial assessment, medication regimen, and supportive care?

Management of Infective Intestinal Obstruction: A Hypothetical Case Paper

Initial Assessment - Day 1

Patient Information:

• 34-year-old male
• Chief complaint: Severe abdominal pain, vomiting, and abdominal distension
• Vital signs: Temperature 39.2°C, Pulse 110/min, BP 100/70 mmHg, RR 22/min, SpO2 96% on room air
• Physical examination: Diffuse abdominal tenderness with guarding, decreased bowel sounds, abdominal distension

Initial Investigations:

• Complete blood count: WBC 18,500/mm³ with neutrophilia (85%)
• CRP: 180 mg/L
• Serum electrolytes: Na+ 132 mEq/L, K+ 3.2 mEq/L, Cl- 95 mEq/L
• Renal function: BUN 45 mg/dL, Creatinine 1.3 mg/dL
• Arterial blood gas: pH 7.32, HCO3- 18 mEq/L, lactate 2.8 mmol/L
• Abdominal X-ray: Multiple air-fluid levels, dilated small bowel loops
• CT abdomen with contrast: Small bowel obstruction with thickened bowel wall, mesenteric fat stranding, and a small intra-abdominal abscess (4.5 cm) in the right lower quadrant

Initial Management Plan:

1. NPO (nil per oral) status
2. Nasogastric tube placement for decompression
3. IV fluid resuscitation with isotonic crystalloids at 150 ml/hr
4. Antibiotic therapy: Piperacillin-tazobactam 4.5g IV q8h and Metronidazole 500mg IV q8h 1
5. Electrolyte correction: Potassium supplementation
6. DVT prophylaxis: Enoxaparin 40mg SC daily 1
7. Percutaneous drainage of the intra-abdominal abscess under CT guidance 1
8. Foley catheter insertion for strict input/output monitoring 1
9. Pain management: Morphine 4mg IV q4h PRN

Doctor's Progress Notes - Day 1

Morning Note (8:00 AM)

Patient admitted with signs of intestinal obstruction and intra-abdominal infection. Initial resuscitation started with IV fluids and antibiotics. Nasogastric tube placed with 800ml initial output. Surgical consultation obtained. Plan for percutaneous drainage of abscess today.

Afternoon Note (2:00 PM)

Patient underwent CT-guided percutaneous drainage of abscess. 120ml of purulent fluid drained and sent for culture and sensitivity. Patient remains febrile at 38.8°C. Abdominal pain slightly improved after drainage. Continuing IV antibiotics and supportive care.

Evening Note (8:00 PM)

Patient's condition stabilized. Nasogastric output 650ml since afternoon. Vital signs: Temperature 38.5°C, Pulse 105/min, BP 110/75 mmHg. Abdominal distension persists. Plan to continue current management and reassess in the morning.

Nursing Notes - Day 1

Morning (8:00 AM)

Patient in acute distress with abdominal pain rated 8/10. Nasogastric tube inserted and secured. IV access obtained with 18G cannula in right forearm. Administered first doses of antibiotics as ordered. Foley catheter inserted with clear yellow urine output.

Afternoon (2:00 PM)

Accompanied patient to radiology for abscess drainage procedure. Post-procedure vital signs stable. Pain score decreased to 6/10 after morphine administration. Drainage bag from percutaneous catheter secured and monitored.

Evening (8:00 PM)

Nasogastric tube draining bilious fluid. Abscess drain output 50ml of serosanguineous fluid. Patient able to rest intermittently. Continued IV fluid administration as ordered. Urine output 600ml since admission.

Vital Signs Chart - Day 1

Time	Temperature	Pulse	BP	RR	SpO2	Pain Score
8:00 AM	39.2°C	110/min	100/70 mmHg	22/min	96%	8/10
12:00 PM	39.0°C	108/min	105/72 mmHg	20/min	97%	7/10
4:00 PM	38.8°C	106/min	108/74 mmHg	18/min	97%	6/10
8:00 PM	38.5°C	105/min	110/75 mmHg	18/min	98%	6/10
12:00 AM	38.3°C	102/min	112/76 mmHg	18/min	98%	5/10

Fluid Chart - Day 1

Time	IV Fluids In	NG Output	Urine Output	Drain Output	Total Balance
8:00 AM - 4:00 PM	1200 ml	800 ml	400 ml	120 ml	-120 ml
4:00 PM - 12:00 AM	1200 ml	650 ml	200 ml	50 ml	+300 ml

Doctor's Progress Notes - Day 2

Morning Note (8:00 AM)

Patient's temperature decreased to 38.0°C. Abdominal pain improved to 4/10. Nasogastric output 500ml overnight. Abscess drain output 80ml. Laboratory results show WBC 16,200/mm³, CRP 160 mg/L. Electrolytes improving with K+ 3.6 mEq/L. Continue current management.

Afternoon Note (2:00 PM)

Preliminary culture from abscess shows mixed enteric bacteria. Continuing antibiotics as per sensitivity. Nasogastric output decreased to 350ml since morning. Abdominal distension slightly improved. Patient tolerating treatment well.

Evening Note (8:00 PM)

Patient afebrile (37.8°C). Abdominal examination shows decreased tenderness. Bowel sounds still hypoactive. Plan to continue current management and reassess for signs of resolution of obstruction tomorrow.

Nursing Notes - Day 2

Morning (8:00 AM)

Patient slept intermittently overnight. Pain controlled with IV morphine. Nasogastric tube patent and draining. Percutaneous drain secured and draining. Personal hygiene provided.

Afternoon (2:00 PM)

Patient more comfortable, pain score 4/10. Encouraged deep breathing exercises. Repositioned every 2 hours to prevent pressure sores. IV site clean without signs of phlebitis.

Evening (8:00 PM)

Patient watching TV and interacting with staff. Abdominal pain further decreased to 3/10. Continuing IV fluids and medications as ordered. Drain and nasogastric tube care provided.

Days 3-5 Summary

Clinical Progress:

• Gradual improvement in clinical status
• Temperature normalized by day 4
• WBC decreased to 12,000/mm³ by day 5
• Nasogastric output progressively decreased
• Abscess drain output minimal by day 5
• Abdominal distension improved significantly

Management Changes:

• Repeat CT scan on day 5 showed decreased abscess size (1.5 cm) and improvement in bowel wall thickening
• Nasogastric tube clamped intermittently on day 5 to assess tolerance
• Clear liquid diet initiated on day 5 and tolerated well

Days 6-10 Summary

Clinical Progress:

• Complete resolution of fever
• WBC normalized to 9,500/mm³
• Nasogastric tube removed on day 7
• Diet advanced to soft diet by day 8
• Bowel movements resumed on day 7
• Percutaneous drain removed on day 8

Management Changes:

• Switched to oral antibiotics (Ciprofloxacin 500mg BID and Metronidazole 500mg TID) on day 7
• Mobilization increased progressively
• IV fluids decreased as oral intake improved

Days 11-15 Summary

Clinical Progress:

• Patient fully ambulatory
• Regular diet tolerated without issues
• No abdominal pain or distension
• Normal bowel movements
• Follow-up CT scan on day 14 showed complete resolution of abscess and obstruction

Management Changes:

• Antibiotics completed on day 14
• Discharge planning initiated
• Patient education on signs of recurrence
• Follow-up appointment scheduled for 2 weeks after discharge

Discharge Summary - Day 15

Diagnosis: Infective intestinal obstruction with intra-abdominal abscess, successfully treated with conservative management and percutaneous drainage.

Hospital Course:

• 34-year-old male presented with abdominal pain, vomiting, and fever
• Diagnosed with small bowel obstruction and intra-abdominal abscess
• Managed with nasogastric decompression, IV fluids, antibiotics, and percutaneous drainage
• Gradual improvement with resolution of obstruction and infection
• No surgical intervention required

Discharge Medications:

• Probiotic supplement daily for 1 month
• No other medications required

Follow-up Instructions:

• Outpatient clinic visit in 2 weeks
• Return to normal activities gradually over 2-4 weeks
• Return immediately if experiencing recurrent abdominal pain, fever, vomiting, or constipation

Justification for 15-day hospitalization: The extended hospitalization was justified due to:

1. Presence of both intestinal obstruction and intra-abdominal abscess requiring careful monitoring
2. Need for percutaneous drainage and ensuring adequate drainage of abscess
3. Gradual resolution of obstruction requiring prolonged bowel rest and decompression
4. Need for completion of parenteral antibiotic therapy for complicated intra-abdominal infection 1
5. Ensuring complete resolution of infection before discharge to prevent recurrence 1

This conservative approach with percutaneous drainage avoided the need for surgical intervention, reducing the risk of surgical complications and prolonged recovery 1.

Investigation Reports

Complete Blood Count:

• Day 1: WBC 18,500/mm³, Hemoglobin 13.5 g/dL, Platelets 280,000/mm³
• Day 5: WBC 12,000/mm³, Hemoglobin 12.8 g/dL, Platelets 290,000/mm³
• Day 10: WBC 9,500/mm³, Hemoglobin 13.0 g/dL, Platelets 300,000/mm³

Inflammatory Markers:

• Day 1: CRP 180 mg/L, ESR 75 mm/hr
• Day 5: CRP 80 mg/L, ESR 45 mm/hr
• Day 10: CRP 20 mg/L, ESR 25 mm/hr

Microbiology:

• Abscess culture: Mixed enteric bacteria (E. coli and Bacteroides fragilis), sensitive to piperacillin-tazobactam and metronidazole
• Blood cultures: No growth after 5 days

Imaging Studies:

• Day 1 CT: Small bowel obstruction with thickened bowel wall, mesenteric fat stranding, and 4.5 cm intra-abdominal abscess
• Day 5 CT: Decreased abscess size (1.5 cm), improvement in bowel wall thickening and obstruction
• Day 14 CT: Complete resolution of abscess and obstruction, normal bowel appearance