Paralytic Ileus In Post CABG Patient; Always A Late Diagnosis

Consoling always does not work. A common problem after cardiac surgery- “not passing stool and feeling uncomfortable.” It makes us irritable and annoying. Then and there we turn our head or start consoling the patient, “Everything will be ok, don’t worry.”

Fig: Abdominal X Ray AP Erect view. Gaseous distention of the bowel loops seen succinctly.

In my case it was no different. I have been told by my consultant to check for the post operative CABG patient, who have complaint of uneasiness, an hour ago, during our morning round.

I was really hesitant to do that but I had to report to him. Anyway, i reached upto the patient and queried, “Are you ok?”

“I am not good doctor” the patient turned toward me and waited for my sympathy to do something.

“Don’t worry, everything will be ok.” I forced again.

“Something wrong with me” the patient replied with utmost respect.

Sympathized patients makes us more sympathised. I realised, something actually wrong, I need to find out.

“You have pain?” I asked. ” Yes, in the chest.” he replied.

He was on dual pain killers tablets and on fentanyl patch. I was forced to do a ECG.  No change came without the previous old changes.

“Sister, Is the patient mobilised today” I was asking the sister.

The patient replied, “No sir, I am feeling so weak and lethargic, not able to take even a single step.”

“Have you passed motion and flatus.”  I asked and looked for an answer.

Before the patient say “No” I reached for his abdomen and asked “Are you feeling uncomfortable with your belly.”

“Yes, since today morning”

I looked forward to check for his bowel sound. Big fatty belly and you don’t know where to put the stethoscope. Could not hear it. Tried again… could not hear it… waited for more a minute with my best ears on.

Ordered a proctoclysis enema and came back in 15 minutes. No change. Patient was getting more uncomfortable. No motion passed, no flatus yet and distention- you never measure how much with a big belly.

We usually don’t do abdominal X ray. In my 4 years in Cardiac surgery, I have not seen any patient having bowel issue 5 days after surgery, as this one. I met my consultant to do abdominal X ray. He hesitated first and insisted everything will be alright.

Anaesthesist’s advice was to go for an abdominal X ray and everything was clear in the film-gaseous distention of small intestine mostly paralytic ileus. Patient was kept NPO, started on IV fluids and was alright overnight.

Patient is always an open book. You need to read it.

19 Year Old Having Angina; Myths Are Now Reality

I was having lunch with our anaesthetist sir, Dr. Elvin. We had been talking all of politics, cricket and food.

When food came to discussion, he told,  “anybody among us can have disease; even coronary artery disease.” I admitted but added, “Sir, I am diseased. but definitely not the heart.” He looked serious and added, “yesterday night, I was in a case for primary angioplasty and the patient’s age was only 19.”  “confirmed twice before believing” he forced it for me as he looked strangely while taking a carrot piece to his mouth.

It was hard for me to believe too. I questioned him,  “Is he still in the hospital?”

“Yes, he will be in CCU” dr. Elvin added.

I was looking for a peculiar case to write for my blog. I told him to tell me the name and bed of the patient. Seeing my interest he took me to the patient after we finished our lunch.

A heavily built young man, over 90 kg in weight, lying in the bed and smiling at us when we stood beside him. Dr. Elvin told me, “this is the patient.”

The patient was muscular and obese both. Though he was looking strong but had managed to get up from supine to sitting posture when he tried to reply to our questions.

Patient had come to casualty with complaints of typical chest pain, retrosternal type, radiating to both arms, associated with sweating and uneasiness, not responding to pain killer and relieved on sublingual nitrates, that had been given in the casualty.

Fig: ST Elevation in the Inferior leads. Lead II, III and aVF.

ECG showed ST elevated Inferior Wall Myocardial Infarction. Trop T was elevated. After loading dose of dual anti platelets, patient was shifted to cathlab for coronary angiography.

 

 

Fig 2: Complete occlusion of the mid RCA ( Upper panel). Restored flow after PTCA stent (lower panel)

ECG never lies and same reflected in the coronary angiography. Patient had complete occlusion of the mid right coronary artery. PTCA with stent to RCA was done. Patient was stable after that with relieve of the symptoms.

Strangely, patient had no family history of coronary artery disease, no history of smoking or diabetes or hypertension.

How common is coronary artery disease becoming in the society? The disease we used to think is a disease of old  has now grippled all age groups. Young as old as 19  are not spared. Other coronary vessels were also diseased.

Dr. Elvin tapped me on both shoulders before he left me with the patient. His last word was, “I had seen a young boy of 17 year needing coronary intervention.”

I have always neglected chest pain in young. I used to say, “its nothing.” “Take some antacids or PPI, it is gastric burns.” But the scenario could be totally different and life threatening if otherwise !!