Run to the operation room!

Clinical Scenario

A 70 yo woman is brought to the ED by ambulance.

She’s suffering from vomit, lach of flatus and abdominal pain since 24 hours says the nurse. 

She’s pale, the abdomen shows a midline scar. There is diffused tenderness with rebound.

Abdomen US and X rays show abnormal distended loop of small bowel.

Ok, Ok I saw the images, there’s an occlusion says the surgeon at phone but, you know, I need a CT!

Are there CT findings that identify patients requiring a run to the operation room? 

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Plain X ray in suspected bowel obstruction. Is that all?

Clinical Scenario

A 67 y/o woman arrives in the ED at 5pm because of diffused abdominal pain since 2 hours. She has nausea and she refers costipation from the day before. 

She has a history of hysterectomy 5 years before because of fibroma.

Vital signs are normal, she presents pale and sufferer for pain, the abdomen is distendend and palpation cause pain all over it. 

Bowel movements are present but abnormal. 

Plain x ray shows 2 little fluid levels without the evidence of dilated loops of bowel, so radiologist describe it as negative.

Has plain x ray changed your previous clinical judgment about the suspect of bowel obstruction?

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Bowel obstruction and physical examination

A 75 y/o man arrives in ED from a nursing. 

He complains abdominal pain. 

No fever, no jaundice, abdomen presents distended. 

Inspection shows a midline old scar,

there is diffuse rigidity, 

increased bowel sounds and vomit on the sheets. 

Can history and clinical examination contribute to diagnosis of bowel obstruction?

Conclusion 

Medical history and physical examination are a good method in evaluation of a patient with a suspected bowel obstruction. Age > 50 years, distended abdomen, increased bowel sounds, vomit, history of costipation,  previous abdominal surgery  alone can increase the probability of bowel obstruction. The combination of three of this has a very high LR+ from 19 to infinity! Although in some case clinical examination could be diagnostic of bowel obstruction without any other investigation, the practice of plain radiography is still very diffused….what about it?

Bibliography 

H Bohner, Q Yang et al:

Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. 

Eur J Surg 1998; 164:777-784

to be continued...

Ciro Paolillo and Ilenia Spallino

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