What happened, in summary

A 77-year-old woman admitted with community-acquired pneumonia deteriorated with acute abdominal pain after six weeks of colicky central pain, vomiting, nausea, and diarrhea. Examination found tenderness, abdominal distension, reduced bowel sounds, and an empty rectum. Emergency antibiotics were started for suspected intra-abdominal sepsis before she was taken to theatre.

Exploratory laparotomy found a long intussusception involving the terminal ileum, caecum, and ascending colon, with a separate perforation in the proximal transverse colon and faecal contamination throughout the abdomen. She underwent extended right hemicolectomy with formation of an end ileostomy and mucous fistula, followed by intensive-care and surgical-ward management. She initially made an uneventful surgical recovery, although her later hypoactive delirium did not resolve during the admission. Pathology revealed moderate and poorly differentiated adenocarcinoma arising at the ileocaecal junction. Final staging after chest CT was pT3 pN0 pM0.

Her recovery was complicated by hypoactive delirium, limited participation in rehabilitation and stoma care, and a high-output stoma requiring loperamide, double-strength St Mark’s solution, and fluid restriction. Given Alzheimer’s dementia, chronic kidney disease, bipolar disorder, psychosis, and her overall condition, a multidisciplinary team chose conservative management rather than chemotherapy. Social and placement problems prolonged the admission to five months. She eventually left hospital for a nursing home with regular follow-up.