A 65-year-old man presents with diffuse abdominal cramping and vomiting. His abdomen is distended and tender. Imaging shows small bowel obstruction with dilated bowel loops and the "string of pearls" sign. He has a history of prior abdominal surgeries. Based on the history and imaging, this patient likely has a small bowel obstruction requiring further management including IV fluids, decompression, and surgery consultation given his risk factors.

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

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
Bowel
Small
Bowel

8. • Coiled Spring Sign:
•Dilated coils of small bowel
that appear stacked
•Indicates SBO
• Slit sign:
• Caused by small amounts
of air caught in the valvulae
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