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Small bowel obstruction

Case contributed by Tom O'Graphy
Diagnosis certain

Presentation

Abdominal pain and distension. Dark vomiting. No shock. No fever.

Patient Data

Age: 90 years
Gender: Female

Abdominal radiograph

x-ray

Abdominal radiograph showing dilated bowel in the lower abdomen. Crosstable projection further demonstrates multiple gas-fluid levels.

Bedside ultrasound

ultrasound

Bedside ultrasound performed demonstrates anechoic area with particles and air bubbles with a back and forth movement (not visible on this still image) typical of small bowel obstruction on ultrasound. No free fluid identified within the Pouch of Douglas or Morison pouch.

CT-scan

ct

Marked dilatation of the stomach and small bowel loops. Bowel wall thickening in left lower quadrant, at the transition area of dilated and collapsed small bowel.

Mesenteric hyperemia and fluid infiltration of surrounding fat.

Small foci of gas around the bladder, and also under peritoneum inside the bladder. This is not typical for gastrointestinal perforation.

No abnormalities in the pancreas, spleen, kidneys, adrenal glands or liver. No peritoneal effusion. The large bowel is not dilated. There is uncomplicated diverticulosis of the ascending and sigmoid colon.

Case Discussion

The findings are compatible with fibrous abdominal adhesion from an older surgical intervention.

This woman was operated 10 years ago for another small bowel obstruction. She didn't remember if the last time she had similar pain she had similar dark-brown (possibly fecaloid) vomiting.

This patient was been hospitalized and placed under aspiration precautions while waiting for surgical intervention.

CT scan was ordered by the surgeon for preoperative evaluation (she has a normal renal function so IV contrast was used). As with many older people, the patient didn't complain very much about the pain even though her abdomen was tense.

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