A 41-year-old female was admitted to the Department of Endocrinology at our medical center for the following concerns: "the menstrual cycle is prolonged for half a year, and fatigue, palpitations, and shortness of breath for 2 months". The patient reported a 2-year history of 10-min to 1-h abdominal pain and bloating episodes that were spontaneously resolved without treatment, and she had not been treated for the above symptoms. The physical examination revealed a flat abdomen, no tenderness or rebound tenderness in the abdomen, and bowel sounds present five times/min. The laboratory test results showed the following: a white blood cell count of 12.81*109/l, a red blood cell count of 2.98*1012/l, a hemoglobin level of 48 g/l, and a C-reactive protein level of 9 mg/l. The gynecological ultrasound revealed a cervical cyst. The abdominal ultrasound showed that the patient had a fatty liver and a liver cyst. The patient had no history of abdominal surgery, inflammatory bowel disease, tuberculosis, or long-term medication use.
Iron and 4 U red blood cells were given symptomatically after admission to address the patient's severe anemia. On the morning of the 4th day of admission, the patient's condition changed, and she experienced sudden, severe, and intolerable abdominal pain after defecating. An emergency abdominal CT scan showed intestinal obstruction, possibly caused by the torsion of adhesions (Figure 1). Physical examination of the patient revealed abdominal distension, abdominal muscle tension, whole abdominal tenderness, rebound tenderness, and bowel sounds four times/ min.
Emergency surgery to relieve the intestinal obstruction symptoms was performed after a discussion with the patient and family members. First, exploratory laparoscopic surgery was performed, and we observed that the small intestine and colon were conglutinated and twisted into a mass surrounded by a fibrous membrane (Figure 2). It was difficult to separate the adhesions under laparoscopy; thus, the decision to convert to open surgery was made, and the mid-abdomen was cut to allow access to the abdominal cavity. After separating the adhesions and freeing the bowel, a small intestine obstruction was found approximately 80 cm from the ligament of Treves, and an enteroenteric fistula was observed between the jejunum, ileum, and sigmoid colon (Figure 3).
Due to the obvious edema of the intestinal canal in the abdominal cavity, the enteroenteric fistula was relatively stable, and the patient had not undergone bowel preparation before surgery, after a detailed discussion about the surgical approach, we decided to focus on relieving the obstruction during the surgery to reduce the risk for postoperative anastomotic fistula and abdominal infection. The subsequent treatment of the jejuno-ileo-colonic fistula would be determined based on the patient's recovery and medical review. Ultimately, we successfully relieved the intestinal obstruction, performed adhesiolysis, and oriented the small bowel to its normal position. The intraoperative bleeding volume was approximately 50 ml, and 2 U of red blood cells and 200 ml of plasma were administered.
Anti-infection medication, gastrointestinal decompression treatment, antiacids, nutritional support, and iron supplementation were provided as symptomatic treatments after surgery. On the third postoperative day, the patient presented with anal exhaust and was able to consume water. On the fifth postoperative day, the patient defecated and began a complete liquid diet; on the same day, her laboratory test results showed a white blood cell count of 13.64*109/l, a red blood cell count of 3.62*1012/l, and a hemoglobin level of 76 g/l. On the sixth postoperative day, the patient and her family expressed a strong desire to transfer to a local hospital closer to the patient's home for easier care. After we fully assessed the patient's condition and provided detailed information about the risks, the following future treatment plan was issued: gradually return to a normal diet and continue anti-infection and nutritional support treatment, and undergo dilatation and curettage on the first day of menstruation to explore the causes of the prolonged menstrual cycle. Finally, the patient was discharged from our hospital on the 6th postoperative. Then, after another 11 days of conservative treatment, she recovered and was discharged from Feicheng People's Hospital. We followed up with the patient by telephone. She reported a white blood cell count of 8*109/l, and a hemoglobin level of 181 g/l on March 4, 2022 and she resumed a normal diet and daily exercise activities.