A 52-year-old woman in emergency department with ac pain epi

Discussion in 'USMLE STEP 2 CS' started by Ann-, Jun 10, 2006.

  1. Ann-

    Ann- Guest

    A 52-year-old woman presents to the emergency department with an acute onset of diffuse and colicky abdominal pain accompanied by nonprojectile vomiting and a feeling of being bloated. She states that she has had no flatus in the last 2 days. She has no history ac.painof fever, lightheadedness, syncope, or previous abdominal surgeries. She takes only takes metoprolol for hypertension.

    On physical examination, her vital signs are a temperature of 37.2°C, a heart rate of 110 beats per minute, and a blood pressure of 138/92 mm Hg. Her abdomen is noticeably distended, with diffuse tenderness to palpation and focal tenderness, which is greatest in the epigastrium. No rebound or guarding is observed. Bowel sounds are present but hypoactive, and the shake and heel-tap findings are negative. No Murphy sign is noted, and no fluid thrill is elicited. Her cardiovascular and respiratory findings are normal. What is the diagnosis?
  2. star

    star Guest

    pseudocolonic obstruction, ogilvy syndrome?
  3. Guest

    Guest Guest

    Explanation

    Small-bowel obstruction (SBO): The supine abdominal radiograph (see Image 1) demonstrates several loops of dilated, air-filled small bowel in the upper abdomen. If an upright image were obtained, it would likely show air-fluid levels in the dilated bowel loops. The abdominal CT scan (see Image 2) likewise demonstrates the dilated loops of small bowel with air-fluid levels.

    SBO is relatively common among patients presenting to emergency departments. An SBO can be partial or complete and simple or strangulated. As many as 40% of obstructions are strangulated; this is a surgical emergency, and urgent release and decompression is required to prevent vascular compromise and resultant bowel ischemia.

    About 60% of SBOs result from adhesions secondary to a previous abdominal surgery. Other causes of obstruction include gallstone ileus, incarcerated hernia, tumor, and inflammatory bowel disease (Crohn disease). On clinical examination, patients present with colicky abdominal pain accompanied by vomiting and abdominal distension. They often have a history of no bowel movement or no flatus, which they may interpret as constipation. Bowel sounds are hyperactive in the early stages of the condition but are absent in the late stages.

    If a hernia is the suspected etiology of SBO, examination of any known or suspected hernial orifices may reveal the cause. Hernial orifices should always be checked for abnormal bowel loops. Inguinal hernias account for approximately 90% of all hernias in men and women. Inguinal hernias can be either direct or indirect and are usually above and medial to the pubic tubercle.
    Femoral hernias account for 5-10% of all groin hernias and are more common in women (80%) than in men. Femoral hernias are due to herniation of a bowel loop through the femoral ring into the femoral canal, which is a continuation of the femoral sheath medial to the femoral vein and below the level of the inguinal ligament. Unlike an inguinal hernia, a femoral hernia is usually inferior and lateral to the pubic tubercle. The femoral ring is a narrow structure, and any herniation through it can easily lead to the incarceration with resultant obstruction and strangulation of the trapped bowel. Factors predisposing individuals to hernial incarceration include conditions that increase intra-abdominal pressure, such as chronic constipation, prostatic problems, and chronic lung diseases.

    Plain abdominal radiography is the initial imaging modality of choice, and radiographs may show dilated loops of small bowel with several air-fluid levels and an absence of air in the large bowel. Plain radiographs are only 75% sensitive for SBO, and further imaging should be considered if the patient's clinical presentation is consistent with SBO. An abdominal CT scanning has increased sensitivity (approximately 90%) and can help in delineating the etiology of the SBO (eg, adhesions, hernia, neoplasm, Crohn disease). CT can also depict other associated complications (eg, abscess, associated inflammatory process, mesenteric ischemia) and evidence of strangulation (eg, serrated beak at transition point, bowel wall thickening, portal venous gas, pneumatosis).

    All SBOs should initially be managed with continuous nasogastric low wall suction, intravenous fluid resuscitation, pain and anti-nausea medication, and strict bowel rest. Depending on the patient's clinical condition, the etiology of the obstruction, and the likelihood of strangulation, surgical repair to relieve the obstruction may be needed on an urgent basis.

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