NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Case 8.3 Crampy Abdominal Pain with Signs of Small Bowel Obstruction You are asked to see a 46-year-old patient in the emergency department who has the signs and symptoms of a small bowel obstruction.

Q: How would each of the following radiographs influence your decision-making? Case Variation 8.3.1. Closed loop obstruction (Fig. 8-6)

◆ ◆ Typically, an adhesive band occludes the inlet and outlet of a loop of bowel, allowing se- cretions and air to accumulate in the loop and distend it. The loop can become ischemic due to blood flow obstruction from twisting either the blood supply or the adhesive band obstructing the blood supply. The loop can also perforate. The patient should be urgently explored after resuscitation. On exploring the patient in Case Variation 8.3.1, you find a single loop of bowel that has twisted around an adhesion, causing an obstruction of the loop. You untwist the loop and cut the adhesion. On reinspection of the previously twisted segment of bowel, you note that it appears viable but edematous and obviously injured.

Figure 8-6: Closed loop small bowel obstruction. A: Upright abdominal radiograph in a patient with abdominal pain and vomiting showing dilated small bowel loops with multiple air–fluid levels. There is a paucity of colonic bowel gas. B: Contrast-enhanced axial CT image showing dilated, fluid-filled small bowel loops (arrows) and decompressed distal small bowel (arrowheads) consistent with a small bowel obstruction. The dilated loops demonstrate relative hypoenhancement of the bowel wall, suspicious for ischemia. At surgery, the patient was found to have a closed-loop obstruction with necrotic bowel due to an adhesion from prior appendectomy. (From Klein J, Brant WE, Helms CA, Vinson EN. Brant and Helms’ Fundamentals of Diagnostic Radiology , 5th ed. Wolters Kluwer Health; 2018, Fig. 69-19.) SAMPLE