Differential Diagnosis
The patient's symptoms of not having a bowel movement or gas in two days, seeing blood in her stool, and pain to palpation after a sigmoid resection two months ago suggest several possible diagnoses. These can be categorized as follows:
Single Most Likely Diagnosis
- Small Bowel Obstruction: This is the most likely diagnosis given the patient's history of recent abdominal surgery (sigmoid resection) and symptoms of bowel obstruction, such as not having a bowel movement or passing gas, which are indicative of a mechanical blockage in the intestines. The presence of blood in the stool could be due to the obstruction causing ischemia or from a complication related to the previous surgery.
Other Likely Diagnoses
- Adhesions: Adhesions from the previous surgery could be causing a partial bowel obstruction, leading to the patient's symptoms. Adhesions are a common complication after abdominal surgery and can cause bowel obstruction at any time post-operatively.
- Infection or Abscess: An infection or abscess related to the previous surgery could cause pain, fever, and alterations in bowel habits. The presence of blood in the stool might indicate an infectious process affecting the bowel.
- Bleeding from the Anastomosis Site: Given the recent sigmoid resection, there's a possibility of bleeding from the anastomosis site, which could explain the blood in the stool. This could be due to a complication from the surgery.
Do Not Miss Diagnoses
- Ischemic Bowel: Ischemia of the bowel can occur due to various reasons including embolism, thrombosis, or venous thrombosis, and can present with abdominal pain, bloody stools, and signs of obstruction. This condition is critical and requires immediate attention.
- Perforation: A perforation of the bowel, either from the previous surgery or from a new cause like a ulcer or diverticulum, is a life-threatening condition that requires immediate surgical intervention. Symptoms can include severe abdominal pain, tenderness, and signs of peritonitis.
- Hemorrhage: Significant bleeding within the bowel can lead to hemodynamic instability and requires prompt diagnosis and treatment. The source of bleeding could be from the surgical site, ulcers, or other vascular anomalies.
Rare Diagnoses
- Intussusception: Although more common in children, intussusception can occur in adults and is characterized by the telescoping of one segment of intestine into another, leading to obstruction and potentially ischemia. It's a rare cause of intestinal obstruction in adults but should be considered, especially with the presence of blood in the stool.
- Tumor Obstruction: A tumor causing mechanical obstruction of the bowel is less likely given the recent surgery but could be a consideration if the patient has a history of cancer or if the symptoms persist without a clear cause being identified.
Workup and Plan
The workup should include:
- Imaging: CT scan of the abdomen with contrast to evaluate for obstruction, infection, or other complications.
- Laboratory Tests: Complete blood count (CBC), electrolyte panel, blood urea nitrogen (BUN), and creatinine to assess for signs of infection, dehydration, or renal impairment.
- Surgical Consultation: Early consultation with a surgeon is crucial given the patient's surgical history and the possibility of needing urgent surgical intervention.
The plan would depend on the diagnosis but may include:
- Fluid Resuscitation: For dehydration or signs of shock.
- Nasogastric Suction: To decompress the bowel in cases of obstruction.
- Antibiotics: If there's suspicion of infection.
- Surgery: For conditions requiring immediate surgical intervention such as perforation, significant bleeding, or obstruction not resolving with conservative management.