78 year old white female T: 99.0 P 115 R 16 BP 110/75 presents from nursing Gen: Elderly white female with chronic debilitation, actively home with increasing vomiting in room. abdominal HEENT: PERRL, NC/AT, distention, vomiting, cra Oropharynx clear, mping abdominal CV: mildly tachycardic, no m/r/g pain, and 3 days of Pulm: CTAB constipation. Pt has a Abd: abdominal distention, decreased bowel sounds, history of chronic diffuse TTP, hyperressonance to constipation. percussion Ext: 2+ pulses, no c/c/e
What is Diagnosis?(1) Dilated Colon >6cm(2) Effacement of Haustrae Peripherally located(3) Multiple Air Fluid LevelsLarge Bowel Obstruction
IV & IVFs Analgesics & Antiemetics NG decompression Antibiotics for Gram (-) Aerobes & Anaerobes (ie. Flagyl, Cipro, Zosyn, Clindamycin) Surgery Consult 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 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.
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, rounder Large Bowel: air pockets trapped in haustra, larger, and have flat underside Large Small Bowel 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