# data[].attributes.body
1. Admit patient.

2. NPO, IV fluids, consult with surgery, NG tube if needed, pain management. Antibiotics if infection is present.

# data[].attributes.body
1. Admit

2. IV fluids, NPO, NG tube abx if there is an infection, zofran, pain management, Surgery if the complete obstruction

# data[].attributes.body
1. Tympany/dullness to percussion

2. Acute abdomen series X-Ray (stacked coin appearance), CT of the abdomen, Barium enema

3. CBC – if concern for perforation can assess leukocytosis (peritonitis), CMP -check liver functions & electrolytes to see how they are compensating

# data[].attributes.body
1. Admit because this patient likely has a full obstruction due to the presence of air fluid levels and his full lack of any BM in the past 3 days. Additionally, the cause is probably due to the adhesions, which can only be treated through surgical management.

2. Surgical intervention because likely due to adhesions from the surgery he had in the past.

# data[].attributes.body
1. Decreased bowel sounds, tender and distended abdomen. Dullness to percussion.

2. Abdominal xray and CT. X-ray is done for air fluid levels and CT is done to determine the cause and extent of the obstruction.

3. CMP, CBC

# data[].attributes.body
1. Can you toot? (partial vs complete obstruction),

2. Colectomy secondary to perforated diverticulitis >10 years ago, h/o of this happening 3x in the past, obesity, DM, HTN

3. Is his diverticulitis managed, hx of previous x can increase adhesions, previous diagnosis for when he had similar symptoms, personal/family hx of malignancy?

# data[].attributes.body
1. Large bowel obstruction vs. small bowel obstruction, Partial vs. complete (obstipation) obstruction

2. Outside the bowel: adhesions, incarcerated hernia, malignancy.

Bowel problem: intussusception, Crohn, malignancy, foreign body

# data[].attributes.body
1. Is he passing gas still? Does vomiting occur after consuming both solids and liquids?

2. Previous history of colectomy secondary to perforated diverticulitis. Diabetes and HTN.

3. History of abdominal surgeries

# data[].attributes.body
1. Abdominal tenderness in SBO are typically more focal rather than diffuse. abdominal distention and firmness is also a significant finding that may indicate obstruction due to backup in the bowels. Also, looking for hernia can be a significant indicator.

2. Xray and then CT scan. US is also a conisderation, but the sensitivity of CT is significantly than US in BO.

3. CMP, CBC, electrolytes

# data[].attributes.body
1. Imaging Modality #1: Upright PA & Stacked coins

2. Imaging modality #2: CT (some type of view)

# data[].attributes.body
1. Small bowel obstruction 2/2 adhesions from previous colectomy

2. NPO, IV fluids, Surg (lyse adhesions) if unstable incomplete or stable complete

# data[].attributes.body
1. Physical exam, large bowel tends to have diffuse tenderness as opposed to focal in small bowel obstruction. If he is still passing gas. Emesis after meals is an indication that an obstruction may indeed be present.

2. 2. The patient has had a colectomy secondary to diverticulitis in the past, this puts him at risk of adhesions which may be the cause of his obstructions. The patient is also obese which is another risk factor

3. The surgical history puts the highest risk for obstruction due to the potential of adhesions.

# data[].attributes.body
1. Admit! Has a complete small bowel obstruction

2. Surg (Exploratory laparoscopy) → lysis of adhesions, resection of necrotic bowel, or hernia repair

# data[].attributes.body
1. PE findings

1. Abd distention

2. Dry mucous membranes d/t vomiting

3. bowel sounds, tenderness

4. ascites

2. Imaging

1. Abd XR (“plain film”; always 1st) → dilated loops of small bowel w/ air-fluid levels before obstruction

2. Barium enema: if unclear if SBO or large

3. Upper GI series w/ follow thru = last resort

4. Poss abd CT

3. Labs: CBC, CMP(check metabolites for dehydration), Spec grav (dehydration)

# data[].attributes.body
1.  Cause of prior similar events? passing gas? Relieving/aggravating factors? trouble urinating? Is the vomit greenish/yellow (have bile in it)? Vomit digested or chunky? Does vomit have fecal matter in it? Onset of pain?

2. See #3?

1. Risk factors for bowel obstructions:

1. Prior hx → risk for bowel obstruction d/t adhesions (scar tissue)

2. “Remote” Colectomy secondary to perforated diverticulitis >10 years ago

3. h/o of this happening 3x in the past

4. Is it entire colon? If only partially removed → could be at risk for colon CA

5. Obesity, DM, HTN

# data[].attributes.body
1. Admit, NPO, IV fluids, IV hypertensive meds, pain management

2. Surgical consult

# data[].attributes.body
1. Dullness to percussion, abd distention, TTP, guarding, rebound, dry mucus membranes, decreased turgor

2. Abd XR

Barium enema or Upper GI series if unsure

3. CBC to look for signs of inflammation/infection

CMP to check for metabolic disturbances

# data[].attributes.body
1. Categories are defined as partial vs. complete and open vs. closed.

2. Adhesions, intussusception, incarcerated hernia, malignancy, Crohn's disease, foreign body.

# data[].attributes.body
1. Admission

2. Ex lap (surgical consult), NPO, antiemetics, pain management, IV fluids, correct metabolite disturbances (+/- NG, ABX)

# data[].attributes.body
1. Distention, tenderness to palpation, hyper resonance over air filled bowel, dullness over obstruction, N/V

2. Abdominal plain film to see air fluid levels, move onto CT if inconclusive

3. CBC (to see leukocytosis), metabolic disturbances (metabolic alkalosis), electrolyte imbalances (from vomiting)

# data[].attributes.body
1. Small Bowel vs Large Bowel, intra or extra bowel cause. Based on pain, imaging, tenderness quadrants, type of vomit. Based on the history of surgery, possibly adhesions.

2. Adhesions, hernia, intra abdominal abscess, malignancy, intussusception, FB, IBD

# data[].attributes.body
1. functional vs physical vs. extrinsic (e.g. hernias, malignancy, adhesions). Partial vs full obstruction. Proximal vs distal

2. adhesions, incarcerated hernia, malignancy. IBS

# data[].attributes.body
1. Is vomit bilious (small bowel) or feculent (large bowel)? Or coffee ground vomit (upper GI bleed)?

2. Colectomy -> adhesions

3. HTN, DM, Obesity, AMAB

# data[].attributes.body
1. Tympani to percussion, hyperactive → absent bowel sounds, distended abdomen

2. Abdominal XR, CT

3. CBC, electrolytes

# data[].attributes.body
1. Admit - to get the IV, NPO and removal of obstruction (if it is complete)

2. If it turns out to be a complete blockage we will be performing sx.

# data[].attributes.body
1. Admit because pt is unstable and has risky hx w/ high potential for complications

2. NPO, IV fluids, IV Zofran, pain management with opiates, NG tube, surgery consult

# data[].attributes.body
1. Hypoactive bowel sounds

1. Lack of fluid

2. Tympanic over air and dullness over obstruction

3. Tender to palpation

2. Plain film first

1. If unable to distinguish barium enema

2. Upper GI series with small bowel follow through

3. CT

3. TSH, CBC, CMP, UA

1. TSH looking for metabolic/endocrine causes

2. CBC - determines if infection

3. CMP - electrolyte imbalances

4. UA- hydration/dehydration level

# data[].attributes.body
1. Categories: Extrinsic or due to bowel, functional or structural, complete or incomplete, large bowel or small bowel

2. Adhesions, incarcerated hernia, malignancy, IBD, intussusception, foreign body

# data[].attributes.body
1. Ask about flatus, ask about if it's bilious, feculent, or bloody emesis

2. Prior surgery increases risk factor for adhesions, obesity, DM, HTN

3. IBD, hx of bowel disease, chronic constipation, hernias, diet (low fiber, Western diet), hx of malignancy

# data[].attributes.body
1. Flatus?, trouble urinating?, characteristics of diarrhea (bloody, mucus) and emesis (bilious, bloody)

2. Hx of remote colectomy 2° to perforated diverticulitis

3. Trauma, surgery, diverticulitis

# data[].attributes.body
1. Distended abdomen, +/- vomiting, obesity, assess for abdominal pain, dullness to percussion

2. Order: Start with upright Abd X-ray, then order CT w/ contrast. Do not order: Barium enema (if unclear small vs. large), US (good for serial tests but not diagnostic), MRI (not pregnant or pediatric)

3. CBC (look at WBC count), CMP (BUN:Cr ratio to assess for dehydration, assess for metabolic abnormalities/electrolyte abnormalities), lactic acid (assess for dehydration)

# data[].attributes.body
1. Does he have a history of hernias?

1. Any B symptoms (cancer)

2. Heavy lifting (hernias)

3. Family history of cancer

4. Is the pain considered to colic?

2. Hx of colectomy s/p 10 years

1. Diabetes and HTN meds

3. Adhesions (prior surgery)

1. Heavy lifting

2. Cancer

3. Inflammatory Bowel Disease

# data[].attributes.body
1. Partial: flatus, complete: obstipation

External to the bowel (adhesion, hernia, volvus, abscess)

Within the wall of the bowel (tumor, strictures)

Luminal defect preventing passage (intussusception, foreign body)

2. Adhesions (post-op scar tissue), hernia, cancer

# data[].attributes.body
1. +/- flatus? Blood present in stool or vomit? Causes and reliefs of previous episodes? Any known complications from surgery or diverticulitis?

2. Perforated diverticulitis, colectomy, initial cause of diverticulitis

3. Previous abdominal surgeries, previous inflammatory bowel conditions, smoking, ETOH

# data[].attributes.body
1. Incomplete (flatus) v. complete (no flatus), location (small v. large)

2. Incarcerated hernias, adhesions, intussusception, ileus, IBD (Crohn's), foreign body, malignancy

# data[].attributes.body
1. Is he flatus?

1. Abdominal X-ray

2. Outside the bowel:

1. Adhesions

2. Incarcerated hernia

3. Malignancy

3. Inside the bowel

1. Intussusception

2. IBD

3. Malignancy

4. Foreign body

# data[].attributes.body
1. Small bowel vs. large bowel, physical/functional, external/internal, partial/complete, open/closed based on imaging

2. Adhesions, hernia, malignancy, Crohn, intussusception

# data[].attributes.headline
Answer the following questions in your group posts below.

# data[].attributes.subject
Answer the following questions in your group posts below.

# data[].attributes.body
1. What is your disposition for this patient?

2. Based on the physiologic problem, what is your treatment strategy for this patient?

# data[].attributes.attachment_caption
Case courtesy of Ian Bickle, Radiopaedia.org, rID: 85382

# data[].attributes.body
Published answers not required, but what study is this? What view is this? What are notable findings here?

# data[].attributes.attachment_caption
Case courtesy of Ian Bickle, Radiopaedia.org, rID: 85382

# data[].attributes.body
Published answers not required, but what is this image? How would you order it? What is your interpretation?

# data[].attributes.headline
Answer the following questions in your group posts below.

# data[].attributes.subject
Answer the following questions in your group posts below.

# data[].attributes.body
1. Given his primary concern during his visit today, what characteristics of the history of present illness would be important to identify or ask to increase the likelihood of a bowel obstruction?

Be specific here - for example, what is the significance of vomiting that occurs shortly after oral intake that could be either bilious or feculent?

2. What medical and surgical risk factors does our patient have that would put him at risk for bowel obstruction?

3. What risk factors do you want to identify in a patient that you were concerned about having a bowel obstruction?

# data[].attributes.headline
Answer the following questions in your group posts below.

# data[].attributes.subject
Answer the following questions in your group posts below.

# data[].attributes.body
1. What are important physical exam findings to evaluate for if you suspect small bowel obstruction?

2. Describe your approach to imaging diagnosis of small bowel obstruction. Include what you wish to order, along with what you considered but did not choose to order, and explain why.

3. What laboratory studies do you want to order? Be specific and explain your reasoning.

# data[].attributes.headline
Answer the following questions in your group posts below.

# data[].attributes.subject
Answer the following questions in your group posts below.

# data[].attributes.body
Bowel obstructions are essentially an inability to progress material through the bowel lumen.

1. What is your strategy for classifying bowel obstructions and how would you define your categories?

2. What are the most common causes of small bowel obstruction?

# data[].attributes.headline
These are the questions to think about before our session.

# data[].attributes.subject
These are the questions to think about before our session.

# data[].attributes.body
If applicable, actual values and data will be provided on the day of, once you're in your groups.

# data[].attributes.headline
This is a space for your group to work on the cases. 

# data[].attributes.subject
This is a space for your group to work on the cases. 

# data[].attributes.body
Answer the prompts, one post per group per section. To publish a segment, click the "+" below each header. Make the subject line your group number, and put your answer in the text box!

# data[].attributes.body
A 55 year old male presents by EMS from the urgent care to the emergency department for three days of vomiting and abdominal pain. His pain is acute onset, gradually worsening, with intermittent episodes of severe cramping and generalized abdominal pain. He is unable to qualify where the pain is located and generally gestures to the entire abdomen. Every time he eats, he vomits shortly after. He says his abdomen feels bloated. He initially had some diarrhea but has not had a bowel movement in two days. This has happened to him three times in the last ten years and presented almost identically to today. He is concerned for a bowel obstruction.

By chart review he has a history of hypertension and diabetes. He takes lisinopril and metformin, but has not been able to take his medications since he started vomiting. He has history of remote colectomy secondary to a perforated diverticulitis >10 years ago.

He does not smoke. He drinks one drink per week. He denies any drug use.

Vital signs

HR: 125 bpm

BP: 170/110

RR: 25

Temp: normal

SpO2: 99% RA

Physical exam

General: Obese male. Writhing in the wheelchair. Unable to get comfortable but sitting upright and conversant between spasms of pain.

HEENT: Unremarkable.

CV: Rapid rate. Regular rhythm. No murmurs.

R: Rapid, shallow breaths. CTAB.

Abd: Distended, firm abdomen. No bruising. No rash. Tender to deep palpation in all quadrants. No fluid wave. No flank tenderness.