Incomplete Duodenal Obstruction Caused by Cholecystitis in Burn Patient

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Incomplete Duodenal Obstruction Caused by Cholecystitis in an Extensive Burn Patient

Extensive burn injuries present multifaceted clinical challenges, often compounded by systemic complications that complicate diagnosis and treatment. This report details a rare case of incomplete duodenal obstruction secondary to acute cholecystitis and pericholecystic fluid in a severely burned patient, highlighting the diagnostic complexities and management strategies required in such scenarios.

Clinical Presentation and Initial Management
A 28-year-old male sustained extensive electrical burns covering 95% of his total body surface area (TBSA), with 5% classified as full-thickness (III°) injuries. Initial treatment at a local hospital included fluid resuscitation, tracheotomy, nutritional support, and five debridement and skin grafting procedures over two months. Despite these efforts, 85% of his wounds remained unhealed, prompting transfer to a specialized burn center for advanced care.

On admission, the patient exhibited severe emaciation, with a body weight of 50 kg and a body mass index (BMI) of 16.7. Vital signs included tachycardia (121 beats/min) and mild tachypnea (23 breaths/min). Burn wounds affected the face, neck, trunk, limbs, and buttocks, with granulation tissue predominating. Laboratory findings revealed leukocytosis (11.11 × 10⁹/L), hypoalbuminemia (36.2 g/L), and elevated bilirubin levels (total bilirubin: 20.9 mmol/L; direct bilirubin: 17.4 mmol/L).

Development of Abdominal Complications
Two months post-admission, the patient developed acute abdominal pain, distension, and bilious vomiting exacerbated by meals. Symptoms temporarily alleviated in the supine position. Initial physical examination noted right upper quadrant tenderness without rebound pain or a positive Murphy’s sign. Laboratory tests showed persistent hypoalbuminemia (30.8 g/L) and mild hyperbilirubinemia (total bilirubin: 17.9 mmol/L).

Given the patient’s cachectic state and classic symptoms of postprandial distress, superior mesenteric artery (SMA) syndrome was initially suspected. Conservative measures—including fasting, prokinetic agents, and acid suppression—were initiated but failed to resolve symptoms.

Diagnostic Imaging and Reevaluation
Computed tomography angiography (CTA) revealed critical findings:

  1. Vascular Anatomy: The aortomesenteric angle measured 46.2°, exceeding the diagnostic threshold for SMA syndrome (<35°), effectively ruling out this etiology.
  2. Biliary Pathology: The gallbladder was markedly distended with wall thickening and surrounding fluid, compressing the adjacent duodenum [Figure 1B, 1C]. These features confirmed acute cholecystitis with secondary duodenal obstruction.

Therapeutic Approach and Outcome
Given the patient’s tenuous wound status and infection risk, surgical intervention was deemed high-risk. A conservative protocol was implemented:

  • Antibiotic Therapy: Cefoperazone-sulbactam (3 g every 12 hours) combined with ornidazole (0.5 g twice daily) to target biliary pathogens.
  • Nutritional Support: Gradual reintroduction of enteral feeds alongside parenteral nutrition to address hypoalbuminemia.

Clinical improvement became evident within five days, with complete resolution of vomiting and abdominal distension by August 20, 2018. Follow-up CT on August 29 demonstrated gallbladder contraction, reduced pericholecystic fluid, and restored duodenal patency [Figure 1D].

Pathophysiological Considerations

  1. Burn-Related Cholecystitis:
    Acute acalculous cholecystitis (AAC) represents a life-threatening complication in burn patients, with mortality exceeding 30% in untreated cases. Contributing factors in this patient included:

    • Prolonged fasting and parenteral nutrition, predisposing to gallbladder stasis.
    • Systemic inflammation from burn injuries and wound infections.
    • Hemodynamic instability impairing splanchnic perfusion.

  2. Mechanism of Duodenal Obstruction:
    Anatomic proximity between the gallbladder and duodenum allowed direct mechanical compression from the inflamed gallbladder and surrounding exudate. The patient’s emaciated state (BMI 16.7) reduced intra-abdominal fat padding, exacerbating luminal compromise.

Diagnostic Challenges and Pitfalls

  1. SMA Syndrome Mimicry:
    Both SMA syndrome and cholecystitis-induced obstruction present with postprandial pain and bilious vomiting. Key discriminators include:

    • Positional Relief: SMA syndrome typically improves in prone/knee-chest positions, whereas this patient found supine positioning beneficial.
    • Imaging Findings: CTA provided definitive differentiation through direct visualization of biliary pathology and vascular measurements.

  2. Atypical Presentation of Cholecystitis:
    Burn patients frequently exhibit masked abdominal signs due to:

    • Analgesic use blunting peritoneal irritation.
    • Overlapping systemic inflammation from burn injuries.
    • Difficulty performing physical examinations over extensive wounds.

Therapeutic Implications

  1. Antibiotic Selection:
    The regimen targeted common biliary pathogens:

    • Cefoperazone-sulbactam: Third-generation cephalosporin with β-lactamase inhibitor coverage for Enterobacteriaceae.
    • Ornidazole: Anaerobic coverage critical for ascending infections.

  2. Nutritional Rehabilitation:
    Aggressive protein supplementation (1.5–2.0 g/kg/day) addressed hypoalbuminemia, crucial for:

    • Reducing bowel wall edema.
    • Enhancing antibiotic tissue penetration.
    • Supporting wound healing.

Preventive Strategies

  1. Early Enteral Nutrition:
    Initiation within 24–48 hours post-burn preserves gut integrity and prevents biliary stasis.
  2. Serial Ultrasound Monitoring:
    Weekly biliary ultrasounds recommended for high-risk burn patients with:
    • TBSA >40%.
    • Prolonged ventilator dependence.
    • Persistent hyperdynamic state.

Clinical Takeaways

  1. Imaging Primacy: CTA emerges as the gold standard for evaluating duodenal obstruction in burn patients, providing simultaneous assessment of vascular, biliary, and intestinal pathology.
  2. Dynamic Diagnosis: Initial working diagnoses must be continuously reassessed when patients deviate from expected clinical trajectories.
  3. Multidisciplinary Coordination: Collaboration between burn surgeons, radiologists, and gastroenterologists optimized care in this complex case.

This case underscores the necessity of maintaining a broad differential diagnosis when managing gastrointestinal complications in critically ill burn patients. The successful non-operative resolution of both cholecystitis and secondary obstruction demonstrates that conservative management remains viable in selected cases, provided close radiographic and clinical monitoring is maintained.

doi.org/10.1097/CM9.0000000000000189

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