The only other patient I saw with this condition was my long case in Edinburgh. (The diagnosis was easy because someone left it written on a document by the patient, and the examiners seemed put out with the apparently spot diagnosis).
This patient is a really unfit man of 70 with COAD, asbestosis, a loculated left pleural effusion, scleroderma affecting the small bowel to a mild extent as well as the oesophagus, a triple coronary bypass, and generally not too robust.
I was asked to see him early last week because of abdominal pain for several months, vomiting for a couple of weeks worse for 3 days, weakness and weight loss.
Examination showed moderate distension, no peritonism (on percussion, of course!), bowel sounds not increased, and some firm faeces in the rectum. I thought he was constipated or had a partial large bowel obstruction, but a plain erect abdo x-ray showed a grossly dilated stomach and duodenum, including most of the third part. A NG tube yielded 3.5 litres and he felt immediately much better.
It had obviously done some nutritional damage – albumen, ascorbic acid and serum zinc down. CT scan showed no nearby pancreatic or other mass, and a barium meal showed that the now emptied stomach and duodenum emptied quickly when he lay on his left side.
Right now he’s free of abdominal symptoms but getting a work-ver from my friendly physician colleague for collapse/consolidation of the left lower lobe. He’s obviously not too fit for surgery right now, and doesn’t seem to need it, even without recourse to TPN, and is about to try a cautious soft diet. (His earlier succussion splash hasn’t returned).
I’ve done an Internet Medline search, but the few abstracts I’ve turned up so far don’t indicate much beyond duodenojejunostomy, Ladd’s procedure to liberate the SMA or derotate the intestine – I haven’t seen the full papers yet or got out my Aird’s Companion to Surgery.
Has anyone else had a recent case? Is non-surgical management practicable in the short and medium term?