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March 2009 Radiology Quiz
This patient is a 65 year old female who presents to the ED with the complaint of abdominal pain for several days. The following x ray is shown.
Questions:
1. Describe what you see?
- The small bowel is markedly dilated. The colon, however, is collapsed. Small bowel obstruction is suspected.
- Diagnosis: Small Bowl Obstruction.
2. The most common cause is?
- The most common cause of SBO is postsurgical adhesions. The second most common identified cause of SBO is an incarcerated groin hernia. Other etiologies of SBO include malignant tumor (20%), hernia (10%), inflammatory bowel disease (5%), volvulus (3%), and miscellaneous causes (2%). The causes of SBO in pediatric patients include congenital atresia, pyloric stenosis, and intussusception.
3. How do these patients typically present?
- Abdominal pain (characteristic with most patients)
- Pain, often described as crampy and intermittent, is more prevalent in simple obstruction.
- Often, the presentation may provide clues to the approximate location and nature of the obstruction. Usually, pain that occurs for a shorter duration of time and is colicky and accompanied by bilious vomiting may be more proximal. Pain lasting as many as several days, which is progressive in nature and with abdominal distention, may be typical of a more distal obstruction.
- Changes in the character of the pain may indicate the development of a more serious complication (ie, constant pain of strangulated or ischemic bowel).
- Nausea
- Vomiting, which is associated more with proximal obstructions
- Diarrhea (an early finding)
- Constipation (a late finding) as evidenced by the absence of flatus or bowel movements
- Fever and tachycardia - Occur late and may be associated with strangulation.
4. What would you find on the physical exam?
- Abdominal distention (Duodenal or proximal small bowel has less distention when obstructed than the distal bowel has when obstructed.)
- Hyperactive bowel sounds occur early as GI contents attempt to overcome the obstruction. (Hypoactive bowel sounds occur late.)
- Look for the following during rectal examination :(Gross or occult blood, which suggests late strangulation or malignancy)
Check for symptoms commonly believed to be more diagnostic of intestinal ischemia, including the following:
- Fever (temperature >100°F)
- Tachycardia (>100 beats/min)
- Peritoneal signs
5. Management would include?
- Aggressive fluid resuscitation
- Initial decompression can be performed by placement of a nasogastric (NG) tube for suctioning GI contents and preventing aspiration.
- Antibiotics are used to cover against gram-negative and anaerobic organisms
- Monitor airway, breathing, and circulation (ABCs).
- Blood pressure monitoring
- Cardiac monitoring in selected patients (especially elderly patients or those with comorbid conditions)
- Consultation with general surgery. (Early and without delay)
Irish Trivia: U2 made their first appearance on "The Simpsons" in 1997, in an episode entitled "Trash of the Titans." Which of their own songs was the band seen performing at a concert crashed by Homer Simpson?
- Answer: Pride (In the Name of Love).
- In the show, the band members were seen as pawns in Homer's attempt to become Springfield's Sanitation Commissioner. Although Bono was impressed with Homer's commitment to the environment, the Simpson family left a less-than-favorable impression on U2.
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