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Free air under the diaphragm on upright abdominal radiograph
6%
1/16
Apple core defect after lower GI series
0%
0/16
Multiple punctate mucosal outpouchings through the serosa on lower GI series
Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph
88%
14/16
Loss of haustral markings and "lead pipe" appearance to the descending colon on lower GI series
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This patient with prior abdominal surgery presenting with a painful, distended abdomen and history of obstipation is highly suggestive of an acute small bowel obstruction. Abdominal radiograph is most likely to show Ladder-like series of distended bowel loops with air-fluid levels (Illustration A). Small bowel obstructions account for around 15% of all surgical admissions in the United States. Adhesive disease, typically secondary to previous surgery, accounts for around 75% of all small bowel obstructions, with malignancy and hernias accounting for another total 16%. Conservative management with nasogastric suction, IV fluid hydration, and bowel rest is an appropriate first strategy for patients who present without evidence of peritonitis and who are hemodynamically stable. Patients who fail conservative management or who present with more advanced disease require immediate surgical management. Jackson et al. discuss the diagnosis and management of intestinal obstructions in adults. They conclude that in the hemodynamically stable patient, IV fluid hydration, nasogastric intestinal decompression, and bowel rest is an appropriate first strategy to attempt to resolve the obstruction. However, hemodynamically unstable patients, patients with perforations or ischemic gut, and patients who fail conservative management require surgical intervention. Maung et al. discuss the diagnostic approach to patients with small bowel obstructions. They conclude that the use of helical computed tomography plays a central role to the diagnosis of small bowel obstructions, as it provides incremental clinically relevant information over plain films that may lead to changes in management. Illustration A shows a partially upright abdominal radiograph with dilated loops of small bowel and air fluid levels, consistent with a small bowel obstruction. Incorrect Answers: Answer 1: Free air under the diaphragm is characteristic of hollow viscus perforation. This is unlikely given this patient's abdominal exam and vital status. Answer 2: This is a characteristic finding of colon cancer, this patient's presentation is more consistent with a small bowel obstruction. Answer 3: This is a characteristic finding in diverticulosis, not small bowel obstruction. Answer 5: This is a characteristic finding in ulcerative colitis.
4.2
(5)
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