78 year old white female
presents from nursing
home with increasing
abdominal pain, and 3
days of constipation. Pt
has a history of chronic
T: 99.0 P 115 R 16 BP 110/75
Gen: Elderly white female with
chronic debilitation, actively
vomiting in room.
HEENT: PERRL, NC/AT,
CV: mildly tachycardic, no m/r/g
Abd: abdominal distention,
decreased bowel sounds,
diffuse TTP, hyperressonance to
Ext: 2+ pulses, no c/c/e
What is Diagnosis?
(1) Dilated Colon >6cm
(2) Effacement of Haustrae
(3) Multiple Air Fluid Levels
Large Bowel Obstruction
IV & IVFs
Analgesics & Antiemetics
Antibiotics for Gram (-) Aerobes & Anaerobes (ie.
Flagyl, Cipro, Zosyn, Clindamycin)
Admission for all LBO
Emergency Laparotomy if:
(1) Peritonitis (2) Peritoneal Free Air (3) Sepsis (4)
Cecal Distention >12cm
How to Differentiate Large from Small Bowel
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.
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%)
String of Pearls Sign = obstruction
Small Bowel: air pockets trapped in valvulae of small intestine, smaller,
Large Bowel: air pockets trapped in haustra, larger, and have flat
Greenberg, Michael. Greenberg’s Atlas of Emergency
Ginzberg, Leon. “X-Ray Diagnosis of Acute Intestinal
Instruction Without the Use of Contrast Media”
Annals of Surgery
Lifeinthefastlane.com “Abdominal X-Ray
Schwartz, David. Emergency Radiology. 2000. pg 527-
Tintanelli’s Emergency Medicine: A Comprehensive
Study Guide. Chapter 79 Intestinal Obstruction