WhiteCoat

What’s The Diagnosis #14

A patient in her late 60’s comes in with vomiting and some vague abdominal pain over the previous 24 hours. Her husband states that her stomach looks swollen. It does. X-rays below can be clicked upon to give you a higher resolution image if you want one.

What is wrong with the patient? What’s the treatment?

I’ll post the answer in the comments section in a couple of days.

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22 Responses to “What’s The Diagnosis #14”

  1. Moshe says:

    Small bowel obstruction?

  2. ER Jedi says:

    Is this another of those “obstructions” secondary to “I slipped a fell doc, I don’t know how that thing got in my rectum” post? ;)

  3. except the answer is all over the hyperlink and the enlarged photos.

  4. Melissa says:

    Massive SBO (even without enlarging you can see the dialated bowel). NG tube to suction and a massive dose of zofran. Probably an enema or two as well.

  5. Roberto says:

    Large bowel obstruction. Pte needs a CT scan w/ PO-enema-IV contrast and DRE/Lactic Acid to r/o ishemic bowel, perforation.

  6. Nate says:

    Yep, totally an SBO (actually recognized it BEFORE looking at the hyperlink).

    NPO, IV hydration and NG-tube decompression. Admit to Sx to monitor for improvement vs deterioration.

  7. dirtridndoc says:

    SBO it is but the real question is, even with this obvious radiograph, will the surgeon STILL request a CT before agreeing to come and see the patient????

  8. oldocmom says:

    looks like may have free air on upright film overlying a SBO. Free air would be surgical emergency, can’t tell because the xrays arent clear. My facility surgeons would insist on CT.

    Treatment is fluids and expectant management. NG if needed.

  9. Canuck says:

    What’s the belly like clinically ? Acute ? If so, there’s a good chance that in addition to the SBO there’s a perforation : looks like free air under the diaphragms. If so, laparotomy, not drip ‘n suck…

  10. DocHolliday says:

    Not enough history. Prior abdominal surgery would most likely be adhesions. No prior abdominal surgery would most likely be tumor.
    Initial work up is similar with IV hydration, strict NPO, NG decompression, admit to Surgery.
    While you are waiting for daylight, and the arrival of the Surgeon, get a much better history. Also, start thinking about disimpacting her rectum as I see dilated large bowel as well. The lost FB comment above requires investigation.

  11. JT says:

    I think you can see both sides of the bowel (“double bowel wall sign”) so it may be pneumoperitoneum (with all of it’s related causes)and ileus.

  12. Snarky Scalpel says:

    large bowel obstruction, and bad. so bad, in fact, her valvula bauchini is gonegonegone.

  13. Hp123 says:

    I see dilated large bowel as well? LBO.
    I think that pneumoperitoneum might be hepatic flexure actually.

  14. Tom says:

    Large bowel obstruction. NG tube and CT to look for cause. Surgical consult

  15. JAMES MEADE says:

    Gallstone Ileus

  16. Hueydoc says:

    “It’s just blockage , by Gumption ! Give her a dose of salts and don’t call me again !”
    (old surgeon)

  17. overhilldoc says:

    Sigmoid Volvulus with Obstruction

  18. anon says:

    near dead

  19. Gump says:

    Cecal volvulous causing obstruction

  20. WhiteCoat says:

    The small bowel obstruction was the easy part. However, there was more to the xrays than just a small bowel obstruction.

    The patient also had free intraperitoneal air on the upright film.

    Management of the patient involves not only nasogastric decompression, but also broad spectrum antibiotics, fluid resuscitation, and almost always a trip to the operating room.

    Remember that some studies have showed that 30-40% of elderly patients with abdominal pain require operative repair of their underlying condition.

    Ultimately, according to the surgeon, this patient had a colonic mass that had caused an obstruction and perforation.

  21. pratiba says:

    Rigler`s sign is very obvious along with both small and large bowel obstruction!

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