- Vomiting, soft stool, anorexia
- Blood work:
- Severe metabolic alkalosis
- The stomach is mildly distended and filled with echoic fluid. No contractions were noted.
- The duodenum is within normal limits.
- Multiple loops of jejunum are moderately distended to 7 mm in diameter and filled with echoic fluid. No contractions are noted. The dilation of the small intestines abruptly terminates to normal empty intestine.
- Within the most distal dilated small intestine a 1 to 3 mm hyperechoic, flat structure is noted.
- The distal jejunum and large intestine are empty and within normal limits. The pancreas and mesenteric lymph nodes are within normal limits.
- Abdominal surgical exploration revealed firm stool-like material in jejunum and no apparent foreign body or obstruction. Small white circular flecks were found throughout the peritoneum.
- End of right pancreatic limb appeared to have green staining and was slightly swollen. Small sample was obtained.
- Pancreatic Histopath:
- Moderate, multifocal, acute, necrosuppurative, pancreatitis with peripancreatic fat necrosis, saponification and dystrophic mineralization.
This case seemed striking in what I didn’t see or pick up on with ultrasound. It was also unusual in that I was able to follow the dilated jejunum from the duodenum to the point of acutely normal empty intestine.
The proximal ~1/2 of the jejunum was dilated and amotile and the distal 1/2 was completely empty.
DDX included: functional ileus (metabolic, electrolyte imbalance, drug, toxin or garbage exposure, pancreatitis, enteritis, etc.) and mechanical ileus (secondary to a constricting lesson, adhesion, or a possible unidentified foreign body associated with the small flat object just proximal to the normal intestine).
The pattern of jejunal dilation along with a full stomach and completely empty colon along with the lack of other abdominal changes suggested that mechanical obstruction was a real possibility, especially with the history of vomiting and metabolic alkalosis. (I actually let the surgeon make the call on this one).
The histopathology on the white flakes revealed normal fat.