A 65-year-old man presented with diffuse abdominal pain and vomiting for a few hours. He has a history of cholecystectomy and appendectomy. On exam, his abdomen was actively tender with mild distention and high-pitched bowel sounds. Imaging showed small bowel dilation and the "string of pearls" sign, indicating a small bowel obstruction. Non-surgical management was recommended given his stable condition, with surgery as an option if his condition deteriorates.

2.  65 year old White male T: 98.9 P 110 R 16 BP 120/80
presents complaining of Gen: elderly male in NAD,
HEENT: PERRL, NCAT,
diffuse, crampy abdominal Oropharynx clear
pain. He began vomiting a CV: mildly tachycardic, No m/r/g
few hours ago and feels very Pulm: CTAB
Abd: active, high-pitched bowel
nauseated. His last bowel sounds; mild TTP diffusely, No
movement was yesterday. rebound/guarding; mild
He has a history of an open- distention
cholecystectomy and open - Ext: 2+ pulse, no c/c/e
appendectomy.

4. 1. Air Fluid Levels
2. String of Pearls Sign
1. small, round air pockets
trapped in plicae circulares
(valvulae conniventes) of
small intestine
3. Dilated Bowel >3cm
1. Rule of 3,6,9
4. Coiled Spring Sign
5. Plicae Circulares
(Valvulae Conniventes)
1. Indicates Small Bowel
involved
6. No gas in colon
1. Indicates Small Bowel
involved

5.  Most common causes: (1) surgical adhesions (2)
Hernia (3) Tumor (4) Inflammatory Bowel Disease
(5) Intussusception (6) Gallstone Ileus
 Rule of 3,6,9:
 suspect obstruction if small bowel dilated >3cm; large bowel >6cm,
cecum >9cm.
 “Never Let the Sun Rise or Set on a Small Bowel
Obstruction”

6.  IV & IVFs
 NG Decompression
 Analgesics and Antiemetics
 Surgery Consult
 Approximately one-quarter of patients admitted for small
bowel obstruction will require operation.
 Patients suspected of having complete or closed-loop
obstruction with fever, leukocytosis, tachycardia, metabolic
acidosis, continuous pain or peritonitis warrant prompt
exploration
 Antibiotics are suggested if surgery planned.
 Admission to hospital
 Medical service is reasonable disposition if patient does not
have significant risk factors for surgical managment

7.  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

8. • Coiled Spring Sign: • Slit sign:
•Dilated coils of small bowel • Caused by small amounts
that appear stacked of air caught in the valvulae
•Indicates SBO of fluid-filled bowel that
appear as “slits of air”
• Similar to string of pearls
sign
• Indicates SBO

9.  Greenberg, Michael. Greenberg’s Atlas of Emergency
Medicine.
 http://learningradiology.com/radsigns/radsignsphotos
/string%20of%20beads--cu.jpg
 Rosen’s Emergency Medicine: Concepts and Clinical
Practice, 6th edition. Vol 2. pg 1440-1444.
 Schwartz, David. Emergency Radiology. 2000. pg 523-
525.
 Tintanelli’s Emergency Medicine: A Comprehensive
Study Guide. Chapter 97 Intestinal Obstruction