29yo female presented yesterday with epigastric pain of 2/7 and vomitting. Her only PMHx was intussusception as a child for which she had had surgery.
She had opened her bowels yesterday. She stated she hadn't passed flatus today.
OE she was tachycardic HR 100, but otherwise stable and afebrile. Her abdomen wasn't distended and she was tender epigastrically without guarding.
BHCG was negative.
High on the differential was SBO.
On US, her GB and pancreas were normal. Aorta was 2 cm, nil flap.
However she became very tender on examination of the pelvis:
RIF: dilated loop of SI (note place circulars in video below); free fluid around the loop. Loop is dilated (>3cm) and completely filled with fluid.
No peristalsis in this dilated loop of bowel
LIF showed further distended loops of bowel with faecalised (grainy and faeces like: ie has been in the bowel a while) content and significant free fluid.
two videos showing washing machine (to and fro) movement of content due to bowel obstruction
CT showing the same as the US.
Important to note in this case: the patient had been seen the previous evening with vomiting and epigastric pain. Her ED US was deemed normal due to a normal GB, normal CBD and lack of hydronephrosis. Remember to keep an open mind if the ED US is negative and go searching for other pathology with US or perform a different diagnostic test if concerned.
Signs of bowel obstruction on US:
dilated loops of SI: >2.5cm
ineffective to and fro movement of contents
features suggestive of bowel ischaemia:
hyper echoic gas within the bowel wall with reverberation artefact (dirty shadowing)
absence of peristalsis
thick bowel wall >3mm
In a case of bowel obstruction always check for herniae
hyperechoic gas in within thickened bowel wall
Incidentally we had an elderly patient last night with vomitting and distended abdomen. This was her AXR (I don't know why we do these anymore)
On ED US, she had dilated SI loops, washing machining and free fluid. I know many of you would go straight to CT in this patient, but if you want extra reassurance before calling EGS, ordering the CT and booking a bed: have a look with US: it's really EASY!