Small bowel obstruction in an adult.

Accepted 27 June 1996 A 50-year-old man presented with a three-week history of abdominal pain and constipation. For three days prior to presentation he complained of increasing colicky abdominal pain with distension, anorexia, nausea and vomiting. The constipation was not absolute and there was no rectal bleeding. For two weeks prior to his presentation he took oral flucloxacillin for an infected chronic venous ulcer of his left leg. There was no history of abdominal surgery. He admitted to a heavy tobacco and alcohol consumption. On examination he was obese, distressed by pain and mildly dehydrated. He was apyrexial but tachycardic. There were no features of chronic liver disease. The abdomen was centrally distended and generally tender with guarding and rebound tenderness, particularly on the right side. Bowel sounds were tinkling. Hernial orifices were clear and rectal examination was normal. He had a raised purpuric rash located mainly on the lower limbs and buttocks. The rash had formed crusts in areas (figure 1). On the left leg a chronic venous ulcer was surrounded by an area of resolving cellulitis. There was pitting oedema of both ankles. Urine microscopy revealed > 100 white blood cells/ml (normal <5) and > 100 red blood cells/ml (normal <1). Plain abdominal X-rays were taken (figure 2). Blood results showed a haemoglobin of 16.7 g/l (normal 135170 g/l) and a white cell count of 19.7 x 109/1 (normal 3.5-9.5 x 199/1) consisting predominantly of a neutrophilia with toxic granulations. Serum urea was elevated at 26.2 mmol/l (normal 2.0-8.5 mmolIl) as was serum creatinine, 0.20 mmol/l (normal 0.07-0.13 mmol/l). Electrolytes and liver function tests were normal except for a serum albumin of 26 g/l (normal 35 52 g/l). Serum amylase and coagulation studies were normal.