Incomplete duodenal obstruction caused by cholecystitis in an extensive burn patient

Imagine surviving 90% body burns from an electric spark—only to face a hidden threat months later. That’s what happened to a 28-year-old man treated at the Fourth Medical Center of PLA General Hospital in Beijing in 2018. His case, reported by researchers Xin Chen, Qian Wang, and Feng Li, shines a light on a rare but dangerous complication of severe burns: incomplete duodenal obstruction caused by cholecystitis.

The man’s journey began in April 2018, when electric sparks from a short-circuited wire burned 95% of his body (second-degree) and 5% (third-degree). Local doctors acted fast—rehydrating him, protecting his organs, performing a tracheotomy, and starting nutritional support. He underwent five debridements (cleaning dead tissue) and skin grafts, but after two months, 85% of his wounds still hadn’t healed. He was transferred to the PLA General Hospital for advanced care.

When he arrived, he was severely underweight (50 kg, BMI 16.7) with a sunken abdomen. Most wounds showed granulation tissue (new healing tissue), and he had no history of digestive problems. Over the next few months, doctors continued anti-infection treatments, wound care, and skin grafts—by August, 90% of his wounds were healed. Then, suddenly, new symptoms struck.

On August 2, he developed abdominal pain, distension, and intermittent vomiting—worse after eating, better when lying on his stomach. His feeding tube contained yellow-green bile. Doctors first suspected superior mesenteric artery (SMA) syndrome, a rare condition where the SMA (a major abdominal artery) compresses the duodenum (the first part of the small intestine). SMA is common in emaciated patients (like burn survivors) and causes classic symptoms: bile-stained vomit, relief in prone positions.

But a computed tomography angiography (CTA)—a scan combining detailed abdominal imaging with blood vessel visualization—told a different story. The angle between his abdominal aorta and SMA was 46° (well above the 35° threshold for SMA syndrome), ruling it out. Instead, the CTA revealed cholecystitis (gallbladder inflammation) and gallbladder empyema (a pus-filled gallbladder) pressing on his duodenum. The gallbladder’s swelling and surrounding fluid were squeezing the nearby duodenum, causing incomplete obstruction.

Invasive surgery was too risky—his abdominal wounds could easily get infected. Following 2011 acute biliary tract infection guidelines, doctors prescribed antibiotics: cefoperazone sulbactam sodium (3g every 12 hours) and ornidazole (0.5g twice daily). Within days, he could eat small amounts, and his distension eased. By August 20, his symptoms were nearly gone. A follow-up CT on August 29 showed the gallbladder had shrunk, the surrounding fluid had decreased, and the duodenum was no longer compressed.

So why was SMA syndrome the first guess? SMA—also called Wilkie’s syndrome—affects 0.1% to 0.3% of people (per a 2007 study) and is driven by emaciation. Burn patients lose significant abdominal fat, making them prime candidates. But this case highlights the need to look beyond the obvious.

The real culprit here was acute noncalculous cholecystitis (ACC)—a rare, deadly complication of severe burns. Unlike gallstone-related cholecystitis, ACC stems from gallbladder dysfunction, bile buildup, or infection. Burn patients are at risk because of fasting, infections, blood transfusions, and organ stress. ACC is hard to diagnose because symptoms (abdominal pain, fever, abnormal liver tests) are nonspecific—especially in patients on painkillers or breathing tubes. A 2018 review found just 12% of ACC patients survive with conservative treatment (antibiotics, fluids) if diagnosed late.

This patient had all the red flags: prolonged fasting during treatment, systemic wound infections, and positive blood cultures. His thin frame meant his organs had less room to move, making the obstruction symptoms more obvious. Since the duodenum sits behind the gallbladder, lying on his stomach relieved pressure—explaining why his symptoms improved in that position.

Cases like this are rare—there are few reports of cholecystitis causing intestinal obstruction in burn patients. But the takeaways are clear:

Imaging is non-negotiable: CT or CTA can distinguish between SMA syndrome and less common causes like cholecystitis.
Don’t miss ACC: Symptoms like persistent vomiting or distension in burn patients should trigger tests for ACC, not just SMA.
Conservative treatment works—when diagnosed early: For patients with high infection risk, antibiotics can resolve cholecystitis and relieve obstruction.

The study, published in the Chinese Medical Journal in 2019, was led by Xin Chen and Feng Li from the Department of Burn and Plastic Surgery at the Fourth Medical Center of PLA General Hospital, with Qian Wang from the Medical School of Chinese PLA. The patient gave consent for his case to be published.

doi.org/10.1097/CM9.0000000000000189

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