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Small Bowel Obstruction in Intellectual Impairment-Time to Revisit: Case Report

Takako Eva Yabe, Suren Subramaniam and Bruce Ashford

Background: Clinical assessment of people with intellectual disability is challenging to the treating clinicians, mainly because these patients are unable to provide an accurate history of their presenting symptoms. In this report, we describe a case in which we faced a diagnostic dilemma before reaching a decision on definitive management.
Case presentation: A 57 year old woman with cognitive impairment from a group home was admitted to hospital with abdominal distension, anorexia and malaise. She had a surgical intervention for trichobezoar many years ago. Her bowel habits were reported to be normal. On examination, she had a distended but non-tender abdomen. A computed tomography (CT) scan showed a small bowel obstruction (SBO). She responded to conservative management and was discharged. She presented a third time 4 weeks later with the same problem. This time, however, she looked lethargic and her biochemistry results were slightly abnormal. A CT scan was performed, which confirmed complete SBO with a clear transition point in the distal small bowel within the pelvis and faecalisation of the small bowel. We decided that, because of her multiple presentations to the hospital with the same symptoms and worsening faecalisation on CT scan, she would benefit from exploratory laparotomy. During surgery, an obstructing mass was identified that was found to be a calcified latex glove. The patient had an uncomplicated postoperative recovery and has not presented to the hospital since then.
Conclusion: A trichobezoar should be suspected and investigated in intellectually impaired patients with gastrointestinal symptoms. Environmental modifications, a neuropsychiatric review and a multidisciplinary approach involving all care-givers should be considered in an effort to avoid this potentially life-threatening complication in a most vulnerable group.