Intestinal obstruction caused by a laxative drug (Psyllium): A case report and review of the literature.

INTRODUCTION: Psyllium in granular dosage form is used as an over - the counter safe laxative drug. It has a considerable hygroscopic propriety which allows it to retain water and expands rapidly to become many times of its original size. PRESENTATION OF THE CASE: 21-year-old man presented to the Emergency Department complaining of lower abdominal pain and constipation for five days. He was discharged home on Psyllium for treatment of the constipation. Two days later, he returned to the Emergency Department complaining of increased abdominal distension without passing any stools. The patient was diagnosed to have an incomplete intestinal obstruction resulting from ingesting Psyllium husks without adequate amount of fluids. The patient was treated conservatively. DISCUSSION: Psyllium has a reputation of being safe and effective medication for patients suffering from chronic constipation, especially in elderly. The patient who ingested Psyllium husks as a herbal medication did not receive adequate amount of fluids. Consequently, he developed intestinal obstruction. Similar cases have been reported in the English literature including cases of esophageal obstruction in elderly patients and following gastric banding operations. Furthermore, Psyllium administration with oral contrast in computed tomography enterography may precipitate bowel obstruction in the presence of organic obstruction or post-operative ileus. CONCLUSION: Psyllium can worsen the constipation if not taken appropriately. It is important to instruct patients who are receiving psyllium ingredients to drink a good amount of fluids to avoid the development of bowel obstruction especially in long-term use of such laxatives.

Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital.

INTRODUCTION: Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS: Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS: CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION: Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL.

Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital.

INTRODUCTION: Computed tomography (CT) scan has increasingly become the diagnostic modality of choice for the evaluation of patients with blunt abdominal trauma. CT scan is highly sensitive in the detection of small amounts of free intraperitoneal air (FIA). We aimed to evaluate the usefulness of FIA detected by CT scan in diagnosing bowel perforation in blunt trauma patients. PATIENTS AND METHODS: All abdominal CT scans of blunt trauma patients who were treated at Al Rahba Hospital during the period from October 2010 till December 2013 were retrospectively reviewed. The results of abdominal CT scan were compared with the clinical follow up and operative findings to evaluate the sensitivity, specificity, predictive values, and usefulness index of CT-detected FIA in diagnosing bowel perforation. RESULTS: Abdominal CT scans were performed for 419 trauma patients. 21 (5%) patients were found to have FIA, two of them were true positive (10%), six (29%) needed mechanical ventilation, and eleven (52%) had a pneumothorax. 15/21 (71%) patients had multiple FIA pockets; the median (range) was 3 (2-10) air pockets. Two patients with multiple air pockets of 10mm-thick cuts or more had small bowel perforation. Six (29%) patients had a single air pocket of less than 10mm and none had bowel perforation. 398 patients had negative CT scan for FIA; two of them were false negative. CT-detected FIA scan had a sensitivity of 50% (95% CI: 6.8%-93.2%), specificity of 95.4% (95% CI: 92.9%-97.2%.), a positive predictive value of 9.5% (95% CI: 1.2%-30.4%) and a negative predictive value of 99.5% (95% CI: 98.2%-99.9%) for detecting bowel perforation. The usefulness index for abdominal CT scan FIA for detecting bowel perforation was 0.23 (not useful). CONCLUSIONS: Our study which stemmed from a community-based hospital showed that free intraperitoneal air found on abdominal CT scan of blunt trauma patients was an unreliable radiological finding for bowel perforation. The decision for laparotomy should be based on combined clinical and radiological findings. Conservative management with active observation may avoid unnecessary laparotomy.