A 72-year-old woman with a past history of ulcerative colitis and long-term steroid therapy underwent subtotal colectomy and end ileostomy 11 years previously. Over the preceding 12 months she had experienced multiple episodes of subacute bowel obstruction and abdominal pain. Investigations with plain radiographs and CT had failed to identify a cause, although adhesions were suspected as the most likely cause. The patient presented with a 4-day history of abdominal distension, nausea and vomiting, with decreased output from her ileostomy. Past surgical history consisted of multiple spinal operations, including an L1-4 spinal fusion 9 years earlier followed by an L5/S1 decompression 2 years ago. This second spinal operation was complicated by methicillin-resistant Staphylococcus aureus (MRSA) sepsis and chronic osteomyelitis of the lumbosacral spine. She was obese, type II diabetic and with poor mobility. On initial assessment she was septic, in atrial fibrillation and had a positive urine dipstick for blood, leucocytes and nitrites. The diagnosis of urinary sepsis and ileus was made. She was treated conservatively with nasogastric tube, intravenous fluids and antibiotics. Her stoma output increased and she improved clinically. On day 9 of the admission, she complained of increased abdominal distension and pain, and again the stoma stopped working. She was tachycardic, with a low-grade temperature and raised WCC (25). Abdominal x-ray showed small bowel obstruction, thought to be adhesional (). A CT scan was performed which demonstrated the presence of a foreign body causing obstruction just proximal to ileostomy ().
Plain abdominal taken on admission showing distended small bowel but no evidence of the radio-opaque spinal disc spacer.
Figure 2 Sagittal reformatted (left) and axial (right) CT images demonstrating the L5/S1 disc spacer (block arrow) within the dilated prestomal small bowel (stoma – open arrow). Note the CT attenuation characteristics of the spacer, lower than adjacent (more ...)
The patient absolutely denied passing anything per stoma. A laparotomy with on table ileoscopy via the stoma was performed. Endoscopy was unhelpful and failed to identify the obstruction. At laparotomy adhesions were divided and the point of obstruction with collapsed distal small bowel identified. Enterotomy identified a cage implant used in the L5/S1 spinal fusion, to be the cause of obstruction ().2 3
Following removal, she settled without further complication.
Cage implant used in the L5/S1 spinal fusion, removed from the small bowel.