Abdomen Case 1

78 year old white female presents from nursing home with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. Pt has a history of chronic constipation.

History & PhysicalT: 99.0 P 115 R 16 BP 110/75Gen: Elderly white female with chronic debilitation, actively vomiting in room.HEENT: PERRL, NC/AT, Oropharynx clear,CV: mildly tachycardic, no m/r/gPulm: CTABAbd: abdominal distention, decreased bowel sounds, diffuse TTP, hyperressonance to percussionExt: 2+ pulses, no c/c/e

Abdominal X-Ray

Abdominal X-RayWhat is Diagnosis?(1) Dilated Colon >6cm(2)Effacement of

HaustraePeripherally located

(3) Multiple Air Fluid LevelsLarge Bowel Obstruction

IV & IVFsAnalgesics & AntiemeticsNG decompressionAntibiotics for Gram (-) Aerobes & Anaerobes

(ie. Flagyl, Cipro, Zosyn, Clindamycin)Surgery ConsultAdmission for all LBOEmergency Laparotomy if:

(1) Peritonitis (2) Peritoneal Free Air (3) Sepsis (4) Cecal Distention >12cm

ED Management

How to Differentiate Large from Small Bowel Obstruction:

Gas in the Large Bowel is usually situated peripherally. Gas in the small bowel is usually centrally located.

Large intestine has haustrae, which are blunter, thicker, and do not completely transverse intestine. Small Intestine has valvulae conniventes that

transverse width of intestine, giving it a ribbed appearance.

Feces are only found in Large Intestine.

Pearls

Rule of 3,6,9: suspect obstruction if small bowel dilated >3cm;

large bowel >6cm, cecum >9cm.

Causes of LBO:Carcinoma (60%), Diverticulitis (20%), Volvulus

(10%)

Pearls

String of Pearls Sign = obstruction Small Bowel: air pockets trapped in valvulae of small

intestine, smaller, rounder Large Bowel: air pockets trapped in haustra, larger, and

have flat underside

Additional Images:

Large Bowel

Small Bowel

Greenberg, Michael. Greenberg’s Atlas of Emergency Medicine.

Ginzberg, Leon. “X-Ray Diagnosis of Acute Intestinal Instruction Without the Use of Contrast Media” Annals of Surgery

Lifeinthefastlane.com “Abdominal X-Ray Interpretation”

Schwartz, David. Emergency Radiology. 2000. pg 527-529.

Tintanelli’s Emergency Medicine: A Comprehensive Study Guide. Chapter 79 Intestinal Obstruction

References