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.

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

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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.


  1. 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

  2. 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

  3. 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

  4. apple core sign - ca with obstruction.

  5. I believe the patient swallowed a mallard duck.


  6. Adenocarcinoma, secondary bowel obst.

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

  8. LBO secondary to colon ca

    PGY 3 EM

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

  10. 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?

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

  12. 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.

  13. 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.


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