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Patient Details

Referral (311 days ago 15:15)

Referral Fri 30 May 2025 15:15

Last Modified: 311 days ago

MRN:

Content:

Investigations:
Upper GI endoscopy 28/05/2025: Moderate oesophagitis with linear erythema and erosions at the lower oesophageal sphincter, grade 2 oesophagitis, antral erythema, moderate duodenitis, normal ampulla
MRI small bowel 27/05/2025: No abnormal small bowel wall thickening enhancement and no inflammatory change, no free fluid or collections. Oral contrast has flowed through the proximal to the mid small bowel. No positive oral contrast within the distal terminal ileum
CT abdomen and pelvis 28/05/2025: 10 cm section of small bowel on the left side of the abdomen dilated up to 3.4 centimetres containing fluid, gas and small volume faecalisation with sudden transitional narrowing which may represent an adhesion or stricture. Subsequently reviewed by GI radiology who feel no abrupt transition or other features to suggest adhesional obstruction. Small foci of slightly increased attenuation of the small bowel loops in the left side of the abdomen. Single loop of small bowel on the left side mildly dilated leading to gradual tapering
CRP: 13 (normal)
White cells and neutrophils: Normal
ALT: 38 (from 87)
Blood gas: Normal

Thank you for referring Mr Ben Murphy-Davies, a gentleman who presents with recurrent vomiting and inability to tolerate solid food following cholecystectomy in July last year.

He describes a pattern of symptoms that have progressively worsened over the past 8 weeks. He can tolerate small amounts during the day but develops significant bloating, gas and burping in the evenings, followed by vomiting of all consumed food. The vomitus is described as brown, stagnant-smelling material, sometimes dark green or black. He has been on a liquid diet for the past week and has lost one stone during this admission.

His medical history is significant for a syndrome requiring surgery every 6 weeks for the past 18 months, superficial thrombophlebitis and a small DVT for which he is anticoagulated. He was recently on sirolimus which has been stopped due to current symptoms.

On examination, he appears uncomfortable with visible abdominal distension.

The MRI small bowel study shows poor progression of oral contrast beyond the mid small bowel, which could represent either slow transit or a partial obstruction. The recent CT shows a dilated segment of small bowel with transitional narrowing, though GI radiology review suggests this may not represent a true adhesional obstruction.

He is understandably not keen to go home when he is not tolerating more than a liquid diet and losing weight.

Impression:
Clinically feels likely partial small bowel obstruction, possibly adhesional following cholecystectomy, though other causes including stricture need to be excluded.
- Conflicting radiology reports need GI radiology review

Suggest:
1. Discuss with GI radiology regarding optimal imaging - consider delayed contrast MRI small bowel study or specialist ultrasound assessment - I will try to undertake this.
2. If further imaging non-diagnostic, consider patency capsule study prior to capsule endoscopy to assess for obstruction
3. Continue liquid diet with nutritional supplementation
4. Antiemetics as required
5. Surgical review if obstruction confirmed or symptoms fail to resolve
6. Consider dietitian input for optimal liquid diet management

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Meeting (311 days ago 17:03)

Meeting Fri 30 May 2025 17:03

Last Modified: 310 days ago

MRN:

Content:

MDT discussion regarding a 33-year-old male patient who presented with vomiting and is currently an inpatient. He has been experiencing symptoms since his laparoscopic cholecystectomy in June last year.

Current symptoms:
- Unable to tolerate solid food
- Tolerates liquids and thick soups only
- Develops symptoms approximately 4 hours after eating solids
- Has lost one stone since admission
- Currently on liquid diet with improvement

Previous investigations:
- CT scan (1 month prior): Unremarkable, post-cholecystectomy changes noted. Initial report by MSK radiologist suggested possible abrupt narrowing and transition in small bowel with some faecalisation, but this was subsequently reviewed and felt to be non-specific
- MR small bowel (27 May): Unremarkable with no free fluid. Poor bowel distension noted. Patient tolerated 1.4 litres of mannitol contrast well with subsequent loose stools
- OGD: Showed duodenitis and oesophagitis (possibly secondary to vomiting)

Past medical history:
- Multiple hospital admissions including episodes in December 2023 (campylobacter, profuse diarrhoea, vomiting, chest pain) and March 2024 (severe epigastric pain, vomiting, loose stools, rigors)
- Previous CT and MRCP showing possible ascending cholangitis
- Multiple leg operations over several years
- Stable transaminitis likely secondary to fatty liver
- Normal inflammatory markers

Discussion points:
- Differential includes adhesional stricture post-cholecystectomy, though distal small bowel obstruction following laparoscopic cholecystectomy would be unusual
- Other considerations include ischaemic stricture, coeliac disease (TTG not yet checked), or AVM-related stricture
- Poor distension on MR small bowel limits diagnostic value

Plan:
1. Check TTG to exclude coeliac disease
2. Proceed with patency capsule study as next investigation (minimal radiation exposure)
3. If patency capsule demonstrates obstruction, this would help localise any stricture
4. Further imaging options to be discussed with Dr Fox (senior colleague) including:
   - CT enterography
   - Fluoroscopic examination
   - Repeat MR small bowel with improved technique
5. Continue inpatient management for nutritional support
6. Surgical review may be required depending on findings

Dr Rob Miller (gastroenterology registrar) to email Dr Miles (g.miles@nhs.net) after discussing patency capsule with Dr Stummelt before proceeding.

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