(1) 78 year old white female presents with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. She has a history of chronic constipation. (2) X-ray findings include dilated colon over 6cm, effacement of haustrae peripherally located, and multiple air fluid levels consistent with large bowel obstruction. (3) Treatment includes IV fluids, analgesics, NG tube, antibiotics, and surgery consult with emergency laparotomy if signs of peritonitis, free air, or sepsis are present.

2.  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

4. What is Diagnosis?
(1) Dilated Colon >6cm
(2) Effacement of Haustrae
Peripherally located
(3) Multiple Air Fluid Levels
Large Bowel Obstruction

5.  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

6.  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.

7.  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%)

8.  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

9.  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