Santol Seeds
It was early 2:30 a.m. when the E.R. nurse called me up telling me about a patient from Himamaylan who was referred to BOLMSH with an initial impression of intestinal obstruction secondary to santol seeds. At first I wasn't really paying attention to the nurse's referral. I was still between dreamland and even farther-away-from-dreamland and the words intestinal obstruction due to ingested santol seeds didn't really strike me yet.
So I went down the E.R. in my scrub suit tired and with heavy eyes. I have already admitted so far 7 patients half of which are scheduled for operation the following morning. I went to the E.R. and saw a young 12 year old boy with IV lines and an NGT inserted already. I introduced myself to the folks and asked a brief history of the patient.
According to the folks, patient has been experiencing abdominal pain for the past two days after eating santol and swallowing its seeds. Since that time, patient had episodes of vomiting, anorexia and constipation for two days. On the morning of the admission, patient's abdomen was noted to be distended already. Patient had been having bouts of intermittent low to high grade fever and still with the persistence of vomiting. Patient hasn't been able to move his bowel or had flatus. He was immediately brought to a nearby local hospital where he was started on Paracetamol, Ranitidine and Metronidazole. NGT was immediately inserted and an IV line was started to hydrate the patient. As per folks request, patient was brought to BOLMSH for further evaluation.
Upon examining the patient, the young boy look thin, with slightly sunken eyeballs, conscious, oriented, ambulatory, not in CP distress, with anicteric eyes, no pallor, moist buccal mucosa, unremarkable chest and heart findings, slightly distended abdomen, hypoactive bowel sounds, tympanitic, no shifting dullness, slightly tender on all quadrants. Digital rectal exam was not done unfortunately. I immediately referred him to my Junion Consultant who ordered Abdominal X-ray supine and upright positions. I admitted the patient, and later started him on Gentamicin and hydrated the patient 150 cc/hour for 8 hours with Dextrose 5% Lactated Ringer's Solution. Abdominal X-ray films later showed air fluid levels, step ladder formations, and dilated bowels with presence of the seeds on ascending colon and transverse colon.
The young boy was later seen by the attending surgeon that morning and was scheduled for exploratory laparotomy. During the intra-op, while indeed there were santol seeds inside the bowels, they weren't enought to cause the obstruction. Further investigation later showed a ruptured base of the appendix. The boy's condition was not so much of an intestinal obstruction but rather more of ruptured appendicitis. The rupture could have been spontaneous and the santol seeds according to the surgeon were not the probable cause of the rupture. However, the abdominal pain secondary to the appendicitis was perhaps masked by the excessive amounts of santol seeds which have caused some indigestion. The dilemma now was whether to perform appendectomy and leave the santol seeds or do appendectomy and extract the santol seeds. It was decided that we had to do both.
ruptured appendix
We first extracted the santol seeds from the bowels. Most of the santol seeds were palpated at the transverse colon, ascending colon, distal ileum and sigmoid area. A small incision was done on the transverse colon where the santol seeds were carefully milked and guided out of that incision. The incision was repaired and appendectomy was performed. Some seeds that were close to the rectum were extracted via the anus.
I was busy taking pictures of the whole event and even taking videos through my cellphone camera. I lost the bet though. The entire O.R. staff was betting on how many santol seeds were inside the bowels. I guessed at around 25. Final count was 43 seeds which was perhaps likely because the patient allegedly ate 10 santols according to the folks. One santol fruit contains around 3-4 seeds and if he indeed swallowed all of the seeds, around 40 seeds should have been lodged in his bowels.
So I went down the E.R. in my scrub suit tired and with heavy eyes. I have already admitted so far 7 patients half of which are scheduled for operation the following morning. I went to the E.R. and saw a young 12 year old boy with IV lines and an NGT inserted already. I introduced myself to the folks and asked a brief history of the patient.
According to the folks, patient has been experiencing abdominal pain for the past two days after eating santol and swallowing its seeds. Since that time, patient had episodes of vomiting, anorexia and constipation for two days. On the morning of the admission, patient's abdomen was noted to be distended already. Patient had been having bouts of intermittent low to high grade fever and still with the persistence of vomiting. Patient hasn't been able to move his bowel or had flatus. He was immediately brought to a nearby local hospital where he was started on Paracetamol, Ranitidine and Metronidazole. NGT was immediately inserted and an IV line was started to hydrate the patient. As per folks request, patient was brought to BOLMSH for further evaluation.
Upon examining the patient, the young boy look thin, with slightly sunken eyeballs, conscious, oriented, ambulatory, not in CP distress, with anicteric eyes, no pallor, moist buccal mucosa, unremarkable chest and heart findings, slightly distended abdomen, hypoactive bowel sounds, tympanitic, no shifting dullness, slightly tender on all quadrants. Digital rectal exam was not done unfortunately. I immediately referred him to my Junion Consultant who ordered Abdominal X-ray supine and upright positions. I admitted the patient, and later started him on Gentamicin and hydrated the patient 150 cc/hour for 8 hours with Dextrose 5% Lactated Ringer's Solution. Abdominal X-ray films later showed air fluid levels, step ladder formations, and dilated bowels with presence of the seeds on ascending colon and transverse colon.
The young boy was later seen by the attending surgeon that morning and was scheduled for exploratory laparotomy. During the intra-op, while indeed there were santol seeds inside the bowels, they weren't enought to cause the obstruction. Further investigation later showed a ruptured base of the appendix. The boy's condition was not so much of an intestinal obstruction but rather more of ruptured appendicitis. The rupture could have been spontaneous and the santol seeds according to the surgeon were not the probable cause of the rupture. However, the abdominal pain secondary to the appendicitis was perhaps masked by the excessive amounts of santol seeds which have caused some indigestion. The dilemma now was whether to perform appendectomy and leave the santol seeds or do appendectomy and extract the santol seeds. It was decided that we had to do both.
ruptured appendix
We first extracted the santol seeds from the bowels. Most of the santol seeds were palpated at the transverse colon, ascending colon, distal ileum and sigmoid area. A small incision was done on the transverse colon where the santol seeds were carefully milked and guided out of that incision. The incision was repaired and appendectomy was performed. Some seeds that were close to the rectum were extracted via the anus.
I was busy taking pictures of the whole event and even taking videos through my cellphone camera. I lost the bet though. The entire O.R. staff was betting on how many santol seeds were inside the bowels. I guessed at around 25. Final count was 43 seeds which was perhaps likely because the patient allegedly ate 10 santols according to the folks. One santol fruit contains around 3-4 seeds and if he indeed swallowed all of the seeds, around 40 seeds should have been lodged in his bowels.
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