18 January 2009

Sticking with a theme

A sixty-seven year old man on chronic high-dose narcotics with subacute onset of constipation and bloating presents with abrupt onset of severe pain, which is poorly localized and comes in waves. He reports no bowel movements in six days, and is uncertain whether he is passing flatus. There is no vomiting. Vital signs are normal, and exam shows a protuberant abdomen, tense and minimally tender to palpation, with normal bowel tones. Rectal exam shows an empty vault.

Uploaded with plasq's Skitch!

What does this abdominal x-ray show? What are the most common causes of this condition?

Uploaded with plasq's Skitch!

What is the indicated finding on this CT, and what is the likely diagnosis?

Put your answers in the comments. As usual, Vijay is ineligible, and the first correct answer will win my everlasting respect.


WongML said...

Imaging shows differential air-fluid levels consistent with bowel obstruction and the pt's hpi.

The most common cause of bowel obstruction is adhesions from previous surgery. The second most common cause is hernia with bowel entrapment.

MLW, Second Year Med Student

ERnursey said...


Anonymous said...

What the...
My standard answer, looks bad, call somebody (anybody) stat.
Bowel obstruction, not a new one, not a pretty one. Malrotation/volvulus? Intussusception around a lead point?
Call someone.
~your children's pediatrician who does not miss dealing with old people

gtg595 said...

Multiple air-fluid levels with pain/distension/absolute constipation = bowel obstruction (looks like large bowel to me)

Volvulus near IC valve?

Large BO : CRC or volvulus
Small BO : adhesions or incarcerated hernia

Anonymous said...

apple core sign - ca with obstruction.

Matt Dick said...

I believe the patient swallowed a mallard duck.


cynic said...

Adenocarcinoma, secondary bowel obst.

Anonymous said...

I agree with apple core lesion, causing one heck of a bloated colon.

Brian and Jennifer said...

LBO secondary to colon ca


Mary Sue said...

Jiminy Christmas! The man's got two giant red arrows in his tummy! No wonder it hurts!

CountyRat said...

Does anyone share my curiosity about the fact that the patient is, "on chronic high-dose narcotics"? Why? Me thinks that a crucial bit of history has been witheld to make the diagnosis appear more difficult than it really is.

Ya think?

artillerywifecq said...

I agree with volvulus. Obviously an obstruction. Maybe he swallowed too much gum.

Cranky Student Nurse said...

I'm going to guess fecal impaction related to long term use of narcotics?

First thing that came to my mind, but mind you I'm only a second-semester nursing student.

seticat said...

Very clear air-fluid levels, deff. an abrupt narrowing of the bowel. With his current Hx of chronic narc. use with no reason why given, onset of pain, no BM, etc., I'm putting bowel obstruction d/t colon ca on top of my r/o list.