Ultrasound
Case of the Week
01/27/2014
56 year old male with history of HTN, GERD and alcohol abuse
and 5 day s/p bilateral L4 laminectomy presented to ED with nausea and vomiting
for past five days. Patient had poor appetite, limited PO intake since the procedure
and endorsed 2 episodes of non-bloody bilious vomiting accompanied by abdominal
soreness. Had no bowel movements for past four days. He was taking Norco for
past 3-4 months for back pain and had recently taken it about q6 hours at home
since his surgery. Denied any hematemesis, melena and hematochezia. Had history
of large bowel resection 4 years ago for a colonovesicular fistula and was
immunosuppressed (on enbrel).
Vital signs: 96.4°F/ P 80 / RR 18 / 98% sat
Exam: Patient was in NAD, A & O x3; heart, lung, head
and neck, and extremity exam unremarkable. Abdomen was mildly obese and
distended with hypoactive bowel sounds, nontender with no rebound pain or
guarding. Three healed scares appreciated.
Labs: Lactate 1.2; Na 123; anion gap 17; BUN 91; Cr 4.83;
U/A neg; lipase 48
Xray abdomen: Dilated small bowel loops with multiple air-fluid
levels most likely due to partial distal small bowel obstruction.
IMAGES:
Wrap Up:
56yo M presented with SBO like symptoms, most likely due to
post op ileus due to Norco use vs adhesions. Nausea and vomiting improved with
NG placement, IVF and NPO status. Surgery performed a LOA during ex-lap, which
resolved the SBO.
Review/Discussion:
SBO can be due to a mechanical cause or due to a pseudobstruction
(aka ileus).
Possible causes of mechanical obstructions include adhesions,
hernias, tumors, Crohns disease, intussuception, volvulus, or gallstone ileus. Possible
causes of ileus include narcotics, viral infections, mesenteric ischemia,
surgery, and longstanding diabetes.
The general treatment of an SBO following imaging is: IVF,
NPO, NG tube, enema, surgery if need be.
U/S findings of an SBO: Dilated bowel >25mm, increased
intraluminal fluid, alternating peristalsis, Keyboard sign (due to plicae
circulares)
X ray findings of an SBO: air fluid levels, dilated loops of
bowel
Finding of a recent study: EP-performed ultrasound compares favorably
to x-ray in the diagnosis of SBO. (1)
Sources and More Resources:
(1) http://www.ncbi.nlm.nih.gov/pubmed/20732861
http://www.youtube.com/watch?feature=player_detailpage&v=MoZx-EV3Aso
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