A 78‐year‐old woman with a history of small bowel obstructions with subsequent resections presented with a 3‐week history of progressive abdominal distention, escalating pain, and nausea. Her symptoms reached maximum intensity in the late evening and were all but resolved the following morning. She denied weight loss or diarrhea; however, she did endorse chronic constipation. Four weeks earlier, the patient underwent shoulder replacement and reported intermittent narcotic use since. She also described a recent, but significant increase in her intake of wine. Her abdomen was distended, tympanic with “tinkling” bowel sounds, and tender in the midepigastric area. Laboratory workup was significant only for a hemoglobin of 10.8 g/dL and MCV of 97.2. Plain film suggested early obstruction, although abdominal CT and a daytime upper GI with small bowel follow‐through did not support this. The following morning, the abdomen was soft and nontender, with normoactive bowel sounds. This pattern of evening symptoms with overnight resolution continued throughout the hospitalization. Because of the rapid cycle of symptoms, bacterial overgrowth was suspected; a low‐carbohydrate diet with aggressive bowel regimen was initiated, and 6 weeks later, the patient had experienced no further episodes.
Small intestine bacterial overgrowth is commonly seen as a state of malabsorption, with patients presenting with chronic diarrhea, weight loss, and abdominal bloating. Only a small number of patients have chronic constipation. Symptoms can fluctuate in intensity over months or years before a diagnosis is made. It is classically seen with abdominal surgeries that result in a blind loop such as a Billroth II gastrectomy or gastric bypass, although newer studies show that conditions such as gastroparesis, chronic pancreatitis, and irritable bowel syndrome can also predispose to bacterial overgrowth. This patient was predisposed to bowel dysmotility because of a functional blind loop from previous surgical adhesions. Dysmotility was exacerbated by narcotics, and the increase in carbohydrate intake provided a substrate for gas production, resulting in a clinical picture that mimicked small bowel obstruction. As the substrate was eliminated overnight, the gas dissipated, resulting in diurnal symptomatology. Although a macrocytic anemia may be suggestive, the gold standard for diagnosis is a bacterial count of small intestinal fluid; however, this is invasive and time consuming and thus has largely been replaced by less invasive breath tests. Treatment consists of dietary modification, a scheduled bowel regimen, and if that fails, intermittent courses of nonabsorbable antibiotics.
Although a finding of small intestine bacterial overgrowth should not replace the initial workup for intestinal obstruction, hospitalists should recognize it as a potential cause of acute or subacute abdominal pain in patients with a history of bowel surgery.
H. Masters ‐ none
To cite this abstract:Masters H. A Perfect Storm: Percocet, Pinot, and Previous Bowel Surgery. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 334. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-perfect-storm-percocet-pinot-and-previous-bowel-surgery/. Accessed May 26, 2019.