A Rare Cause of Ileus: Napkin

TA 75-year-old woman presented to the emergency department with abdominal pain, severe nausea, and vomiting. Physical examination revealed abdominal distention and diminished bowel sounds. Laboratory test results were as follows: sodium, 129 mEq/L (135–145 mEq/L); potassium, 4.3 mEq/L (3.6–4.8 mEq/L); blood urea nitrogen, 180 mg/dL (10–20 mg/dL); serum creatinine 3.2 mg/dL (0.4–1 mg/dL); and white blood cell count, 10,300 cells/mm3. The patient had a past medical history of hypertension and diabetes mellitus for 20 years, coronary bypass for 10 years, and Alzheimer's disease for 3 years. Plain abdominal x-ray revealed dilated small bowel loops with air-fluid levels (Figure 1). Abdomen ultrasound revealed dilated bowel loops. Abdominal computed tomography demonstrated dilated ileal loops, suggestive of ileus, and a foreign body lodged in the terminal ileum, with wall thickening (Figure 2). The patient was hospitalized and hydrated with intravenous saline with potassium supplementation. She was referred to emergency operation. Operative findings showed adhesion and strangulation of the terminal ileum. A 30-cm necrotic segment of the intestinal tract was surgically removed. Macroscopic findings were a largely dilated small bowel proximal to a napkin present in the ileum (Figure 3). Histopathological examination of the ileum revealed necrosis. Intravenous metronidazole and ceftriaxone were administered for 10 days. After treatment, blood urea nitrogen, serum creatinine, and potassium were normal. The patient had a good postoperative course and was discharged on the 18th day following surgery.