Small Bowel Obstruction with Post Operative Ascites

A 25 year old male with a prior history of abdominal exploration for a gunshot wound presented with bilious emesis, abdominal pain and obstipation. Work up was consistent with small bowel obstruction and the patient did not respond to initial conservative management (Figure 1). At exploration multiple small bowel adhesions were present. The point of obstruction was the proximal ileum. A segmental resection of the area of obstruction was performed followed by a stapled side-to-side anastomosis. Several small bowel serosal tears were imbricated and the abdomen was closed using a running looped PDS suture. Staples were used for the skin. The pathology report of the resected specimen revealed extensive mucosal necrosis and adhesions. 4 days later there was serosanguinous drainage from the incision and the patient was returned to the operating room for local wound exploration. Although the fascial closure was intact overall there was some slackening of the PDS suture. This area was reinforced with an interrupted 1-0 vicryl suture. A drain was placed subcutaneously in the region of the umbilicus and the incision was closed. Postoperatively a large volume of clear fluid began to drain from the JP drain. His serum albumin dropped to 1.5. The ascitic fluid was evaluated and the creatinine of this fluid was 1.0. The serum creatinine was 0.9. The serum ascites albumin gradient was not determined. Drainage volume varied from 500 cc’s to 1 liter per day. Intravenous hyperalimentation and intravenous albumin replacement was initiated. Eventually the patient was able to tolerate oral intake and the hyperalimentation was discontinued. A post-operative CT scan was done (Figure 2). No evidence of superior mesenteric venous or arterial obstruction from a thrombus was seen. Small bowel ileus was evident (Figure 3). Once the serum albumin increased to 2.7 the drainage stopped. The patient ambulated and began to tolerate soft food. The drain was removed and he was discharged to home in good condition.