Tag: Bowel & GI

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Case 50: Ventral Hernia Pain

Bradley Phillips

A 47-year-old female with a medical history of right nephrectomy complicated by incisional “Swiss cheese” ventral hernias with recurrent incarceration and bowel strangulation presented to the ED with acute abdominal pain localized to the ventral hernia, nausea, and vomiting.

About three years earlier, the patient had undergone an exploratory laparotomy while admitted for peritonitis, which revealed an ischemic segment of small bowel and incarcerated omentum within a ventral hernia. She then underwent omentectomy, small bowel resection with primary anastomosis, and ventral hernia repair.

Following this surgery, the patient had recurrence of the hernia and frequent admissions for small bowel obstruction (SBO), all managed nonoperatively with nasogastric tube decompression and small bowel follow-through. She was discharged from the last such admission the day before presentation, and at that time was tolerating a liquid diet, passing flatus and having bowel movements. She believed that advancing her diet at home had triggered her symptoms, which included 6-7 episodes of non-bloody, non-bilious emesis following a solid meal.

Vitals: BP 128/83 mmHg | Pulse 103 | Temp 98.7 °F (37.1 °C) | Resp 16 | SpO2 93%

On physical examination, the patient was in acute distress and tachycardic. Abdominal exam revealed distension, tenderness in the periumbilical area, and guarding without rebound, as well as a large ventral hernia adjacent to a well-healed midline scar. The right side of the hernia was firmer than the left side but was mostly reducible.

A focused bedside ultrasound exam of the bowel was performed using the curvilinear transducer.

Figure 1. A dilated loop of small bowel, shown here in long axis, measures 3.78 cm in diameter. Bowel wall distension increases the visibility of the plicae circulares.

Figure 2: A loop of small bowel shown in long axis with bidirectional intraluminal content flow, also known as to-and-fro peristalsis.

Computed tomography of the abdomen showed dilated loops of small bowel measuring up to 3.9 cm with fecalization of the internal contents and a transition point at the anastomotic site at the hernia mouth, confirming SBO. There was no radiographic evidence of ischemia or perforation. General surgery was consulted. It was thought that the obstruction was likely due to adhesions or stenosis at the prior anastomosis and unrelated to the large ventral hernia.

The patient was admitted and treated conservatively with intravenous fluids and nasogastric tube decompression. Small bowel follow-through showed delayed passage of contrast and slow return of bowel function. She was discharged on a full liquid diet with planned follow-up with minimally invasive surgery for complex hernia repair.

Discussion

SBO is a significant cause of morbidity and hospital admissions. In the United States, the annual incidence of SBO is approximately 350,000 cases [1,2]. Prolonged obstruction can cause intestinal ischemia and necrosis of the bowel wall [3]. Combined with increased intraluminal pressure from the obstruction, this can lead to bowel perforation, peritonitis, and sepsis. The overall mortality rate for SBO is approximately 10%, but it can increase to 30% in cases complicated by bowel necrosis or perforation [1].

Adhesions are the most common cause of SBO, responsible for 65-74% of cases, and typically result from previous abdominal or pelvic surgeries. Other risk factors for SBO include hernias, neoplasms, Crohn disease, radiation enteritis, volvulus and foreign bodies [1,4].

Patients with SBO typically present with abdominal pain (often colicky and centrally located), nausea and vomiting, and constipation or obstipation. On physical examination, there may be abdominal distension. Early in the course of the obstruction, bowel sounds may be high-pitched and hyperactive. Advanced SBO can present with hypoactive or absent bowel sounds as well as severe abdominal tenderness with signs of peritoneal inflammation [1,5-6]. An elevated lactate supports clinical concern for bowel ischemia [7-8]. This patient’s lactate was normal at 1.1 mmol/L, although at the time of her episode of bowel strangulation and ischemia three years earlier, it was 2.5 mmol/L (elevated).

The differential diagnosis of SBO includes the myriad non-obstructive causes of nausea, vomiting, and abdominal pain; functional small bowel obstruction (adynamic ileus, pseudo-obstruction); and large bowel obstruction.

If SBO is suspected, the American College of Radiology recommends early imaging, particularly abdominal CT, to evaluate the severity of the obstruction, identify the etiology, and detect complications such as volvulus, strangulation, closed-loop obstruction, and ischemia [5]. However, point-of-care ultrasound (POCUS) has been shown to have a sensitivity of 83% to 92% and specificity of 93% to 96% in the evaluation of SBOs, and its use can save time and reduce radiation exposure [9,10].

When performing a POCUS exam for SBO, the curvilinear probe should be used for adult patients. The exam can be started at the patient-identified point of maximum tenderness, with the examiner applying graded compression to slowly and gently displace air out of the way of the probe. Segments of small bowel should be inspected in both long and short axis for dilation (diameter greater than 2.5 cm), absent or to-and-fro peristalsis, the presence of a transition point, free fluid, and bowel wall edema. Once an area of interest is identified, examiners can switch to the linear probe to increase image resolution [11].

The presence of a transition point is highly specific for SBO, as it is not seen in ileus. On ultrasound, a transition point will appear as an area of dilated bowel adjacent to an area of decompressed bowel. In the duodenum and jejunum, bowel wall distension can increase the visibility of the plicae circulares. An edematous bowel wall appears thickened on ultrasound with decreased echogenicity [11].

Management of small bowel obstruction (SBO) involves both nonoperative and operative strategies, depending on the patient's clinical presentation and response to initial treatment. Surgical intervention is indicated in cases of generalized peritonitis or signs of bowel ischemia (e.g., fever, leukocytosis, tachycardia, metabolic acidosis, or evidence of ischemia on imaging) or if the obstruction fails to resolve after 3 days of nonoperative management [2,12].

The risk of recurrence of adhesive small bowel obstruction is higher in patients who are managed nonoperatively compared to those who undergo surgical management, with recurrence rates ranging from 13% to 29% over long-term follow-up periods. The risk of recurrence also increases with the number of prior SBO episodes [13-15].

References

1. Rami Reddy SR, Cappell MS. A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep. 2017 Jun;19(6):28. doi: 10.1007/s11894-017-0566-9.

2. van Veen T, Ramanathan P, Ramsey L, Dort J, Tabello D. Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction. Surg Endosc. 2023 Nov;37(11):8628-8635. doi: 10.1007/s00464-023-10282-9.

3. Scaglione M, Galluzzo M, Santucci D, Trinci M, Messina L, Laccetti E, Faiella E, Beomonte Zobel B. Small bowel obstruction and intestinal ischemia: emphasizing the role of MDCT in the management decision process. Abdom Radiol (NY). 2022 May;47(5):1541-1555. doi: 10.1007/s00261-020-02800-3.

4. Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel obstruction. Am J Surg. 2000 Jul;180(1):33-6. doi: 10.1016/s0002-9610(00)00407-4.

5. Expert Panel on Gastrointestinal Imaging; Chang KJ, Marin D, Kim DH, Fowler KJ, Camacho MA, Cash BD, Garcia EM, Hatten BW, Kambadakone AR, Levy AD, Liu PS, Moreno C, Peterson CM, Pietryga JA, Siegel A, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. J Am Coll Radiol. 2020 May;17(5S):S305-S314. doi: 10.1016/j.jacr.2020.01.025.

6. Jackson P, Vigiola Cruz M. Intestinal Obstruction: Evaluation and Management. Am Fam Physician. 2018 Sep 15;98(6):362-367.

7. Tanaka K, Hanyu N, Iida T, Watanabe A, Kawano S, Usuba T, Iino T, Mizuno R. Lactate levels in the detection of preoperative bowel strangulation. Am Surg. 2012 Jan;78(1):86-8.

8. Ambe PC, Kang K, Papadakis M, Zirngibl H. Can the Preoperative Serum Lactate Level Predict the Extent of Bowel Ischemia in Patients Presenting to the Emergency Department with Acute Mesenteric Ischemia? Biomed Res Int. 2017;2017:8038796. doi: 10.1155/2017/8038796.

9. Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. Am J Emerg Med. 2018 Feb;36(2):234-242. doi: 10.1016/j.ajem.2017.07.085.

10. Shokoohi H, Mayes KD, Peksa GD, Loesche MA, Becker BA, Boniface KS, Lahham S, Jang TB, Secko M, Gottlieb M. Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis. Am J Emerg Med. 2023 Aug;70:144-150. doi: 10.1016/j.ajem.2023.05.039.

11. Damewood S, Finberg M, Lin-Martore M. Gastrointestinal and Biliary Point-of-Care Ultrasound. Emerg Med Clin North Am. 2024 Nov;42(4):773-790. doi: 10.1016/j.emc.2024.05.006.

12. Azagury D, Liu RC, Morgan A, Spain DA. Small bowel obstruction: A practical step-by-step evidence-based approach to evaluation, decision making, and management. J Trauma Acute Care Surg. 2015 Oct;79(4):661-8. doi: 10.1097/TA.0000000000000824.

13. Behman R, Nathens AB, Mason S, Byrne JP, Hong NL, Pechlivanoglou P, Karanicolas P. Association of Surgical Intervention for Adhesive Small-Bowel Obstruction With the Risk of Recurrence. JAMA Surg. 2019 May 1;154(5):413-420. doi: 10.1001/jamasurg.2018.5248.

14. Medvecz AJ, Dennis BM, Wang L, Lindsell CJ, Guillamondegui OD. Impact of Operative Management on Recurrence of Adhesive Small Bowel Obstruction: A Longitudinal Analysis of a Statewide Database. J Am Coll Surg. 2020 Apr;230(4):544-551.e1. doi: 10.1016/j.jamcollsurg.2019.12.006.

15. Fevang BT, Fevang J, Lie SA, Søreide O, Svanes K, Viste A. Long-term prognosis after operation for adhesive small bowel obstruction. Ann Surg. 2004 Aug;240(2):193-201. doi: 10.1097/01.sla.0000132988.50122.de.

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Case 48: The Gut Feeling Was Right

Kanchi Mehta

A 38yo male with history of diverticulitis complicated by sepsis presented to the ED with lower quadrant abdominal pain. He noted that the pain started 2 weeks ago and became worse. He reported normal bowel movements in the morning, denied fever/chills, nausea, vomiting, or genitourinary symptoms. A recent colonoscopy was notable for moderate sigmoid diverticulosis and a 4mm sessile sigmoid polyp that was resected.

Past medical history: Diverticulitis, ADHD, eczema, insomnia, loose stools

No past surgical history.

Vitals: BP 107/65 | Pulse 73 | Temp 98 °F (36.7 °C) | Resp 18 | BMI 25.35 kg/m²

A bedside ultrasound was performed, and the following image was obtained:

Figure 1: Diverticula with bowel wall edema

Uncomplicated acute diverticulitis characteristics on ultrasound are:

  • thickened bowel wall >5mm
  • presence of diverticula with focal outpouching or bowel wall discontinuity
  • noncompressible pericolic fat inflammation with hyperechogenic halo around bowel serosa
  • sonographic tenderness with compression

Outcome:

General surgery was consulted for possible surgical evaluation, which was deferred after findings on CT noted to be non-surgical. Patient was sent home with ciprofloxacin 500mg BID for 7 days and metronidazole 500mg TID for 7 days. Patient was also educated on return precautions.

References:

  1. Nazerian P, Gigli C, Donnarumma E, et al. Diagnostic accuracy of point-of-care ultrasound integrated into clinical examination for acute diverticulitis: a prospective multicenter study. Ultraschall der Med 2021;42(6):614–22. English.
  2. Cohen A, Li T, Stankard B, et al. A prospective evaluation of point of care ultrasonographic diagnosis of diverticulitis in the emergency department. Ann Emerg Med 2020;76(6):757–66.
  3. Damewood, Sara et al. “Gastrointestinal and Biliary Point-of-Care Ultrasound.” Emergency medicine clinics of North America vol. 42,4 (2024): 773-790. doi:10.1016/j.emc.2024.05.006
  4. https://www.ultrasoundcases.info/cases/abdomen-and-retroperitoneum/gastrointestinal-tract/diverticulosis-and-diverticulitis/
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Case 47: Abdominal Wall Perforation

Cloie June Chiong

A 37 year old male with a past medical history of ulcerative colitis, now status-post total abdominal colectomy with a creation of end ileostomy, left-sided ureteral lysis due to retroperitoneal fibrosis, robotic-assisted proctectomy with creation of an ileoanal pouch and diverting loop ileostomy, extensive lysis of adhesions and right-sided ureterolysis, and ileostomy takedown in 2024 presents to the ED with diffuse abdominal pain that began this morning and sweats beginning last night. The pain was 4/10 with rest, 7/10 with standing, and 8/10 with ambulation. The pain radiated to the right shoulder this morning while lying in bed. He denied nausea and vomiting. He endorsed intermittent testicular pain, reduced oral intake, and decreased voids, but urinated and defecated without pain. Did not report any abnormal concerns with stool input through anastomosis.

Vitals: BP: 122/78 | Pulse: 78 | Temp: 98.6°F | Resp: 16 | SpO2: 100%

Physical Exam showed a soft, flat, non-distended abdomen. A surgical scar was present. There was generalized abdominal tenderness and guarding throughout the abdomen with palpation, without rebound or rigidity. He had tenderness in the lower quadrants > upper quadrants, left > right. There was no hernia present. The remainder of the physical exam was unremarkable.

Labs: WBC 16.9

A bedside ultrasound was performed on the abdomen:

Figure 1: Pneumoperitoneum

Figure 2: Pouchitis

Discussion:

Pneumoperitoneum, a critical condition marked by the presence of free air in the abdominal cavity, typically arises from a perforated hollow viscus and is a rare yet serious cause of acute abdominal pain1,2. This condition requires immediate surgical intervention due to its potential for high mortality. Detecting serious conditions based on abdominal pain alone during physical examinations is challenging due to low sensitivity. Differential diagnoses for acute abdominal pain may include inflammatory bowel disease complications, intra-abdominal abscesses, perforations, bowel obstructions, mesenteric ischemia, and pancreatitis.

While abdominal X-ray and computed tomography of the abdomen are considered as more conventional standards for imaging, ultrasound also serves as a rapid, radiation-free diagnostic tool for detecting gastrointestinal perforations3. The diagnostic performance of ultrasonography for pneumoperitoneum has shown to have a sensitivity of 93%, accuracy of 90%, specificity of 64%, and positive predictive value of 97%, versus plain radiography (79%, 77%, 64%, and 96%, respectively)4.

One key ultrasonographic finding in cases of gastrointestinal perforation is the presence of the peritoneal stripe sign, which shows equidistant, horizontal or vertical reverberations posterior to the abdominal wall and can extend to the lower edge of the monitor, creating a striped pattern of alternating dark and light hyperechoic lines. A “comet tail” appearance may also be present as a result of reverberation artifacts caused by pockets of free air, which acts as a barrier to ultrasound waves2,5.

An additional technique used in ultrasound for detecting a pneumoperitoneum is the "shifting phenomenon." This involves repositioning the patient to observe the movement of air and the peritoneal stripe sign within the peritoneal cavity, confirming the presence of free air6. The "scissors maneuver" further confirms this technique by placing a linear probe in the right epigastric region without abdominal compression; reverberation artifacts are observed and manipulated by pressing and releasing the caudal end of the probe, showing movement of the free air and reverberation artifacts away from the anterior liver5.

The use of ultrasound not only confirmed the presence of pneumoperitoneum, but also allowed for immediate surgical intervention, underscoring its high sensitivity and the crucial impact of rapid assessment capabilities in emergency settings. Point-of care ultrasound should be considered as a potential first-line form of diagnostic imaging for abdominal perforation.

References:

  1. Nazerian, P., Tozzetti, C., Vanni, S. et al. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study. Crit Ultrasound J 7, 15 (2015). https://doi.org/10.1186/s13089-015-0032-6
  2. Chao, A., Gharahbaghian, L., & Perera, P. (2015). Diagnosis of pneumoperitoneum with bedside ultrasound. The western journal of emergency medicine, 16(2), 302. https://doi.org/10.5811/westjem.2014.12.24945
  3. Jiang L, Wu J, Feng X. The value of ultrasound in diagnosis of pneumoperitoneum in emergent or critical conditions: A meta-analysis. Hong Kong Journal of Emergency Medicine. 2019;26(2):111-117. doi:10.1177/1024907918805668
  4. Bacci, M., Kushwaha, R., Cabrera, G., & Kalivoda, E. J. (2020). Point-of-Care Ultrasound Diagnosis of Pneumoperitoneum in the Emergency Department. Cureus, 12(6), e8503. https://doi.org/10.7759/cureus.8503
  5. Taylor, M.A., Merritt, C.H., Riddle, P.J. et al. Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound. Ultrasound J 12, 52 (2020). https://doi.org/10.1186/s13089-020-00195-2
  6. Yum, J., Hoffman, T., & Naraghi, L. (2021). Timely Diagnosis of Pneumoperitoneum by Point-of-care Ultrasound in the Emergency Department: A Case Series. Clinical practice and cases in emergency medicine, 5(4), 377–380. https://doi.org/10.5811/cpcem.2021.4.52139
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Case # 20: Right Lower Quadrant Pain

A 40 year old male presented with a 4 day history of right lower quadrant pain. He reported that the pain was at its worse when it started but gradually improved. When in the ED he noted only minimal discomfort without the help of analgesics.  He denied ever having anorexia, fever, chills, nausea, vomiting, GU complaints. During examination, he had moderate tenderness to palpation in the right lower quadrant without rebound or guarding. 

Vitals:  T 97.7F    BP 130/77    HR 66    RR 16   SP02 100%

An abdominal ultrasound of the RLQ was performed and the following images were seen. What do you see and what is your most likely diagnosis? 

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Answer and Learning Points

Answer

In both the longitudinal and transverse views, you see a tubular structure in the right lower quadrant that is non- compressible, greater than 6mm (measures 15.6 mm), and lacks peristalsis. You can also appreciate some dependent free fluid around the appendix. These findings are consistent with the diagnosis of acute appendicitis.

CT abdomen/pelvis showed a retrocecal appendix with finding of acute uncomplicated appendicitis. No bowel obstruction or intra-abdominal/pelvic abscesses. Labs showed a slight leukocytosis to 14, otherwise were reassuring. Patient was given a dose of Zosyn in the emergency department and take to the OR for appendectomy by general surgery.

Learning Points

    • Appendicitis is the most common abdominal surgical emergency that presents to the ED in western countries [1]. 
    • The sensitivity and specificity of ultrasound for the diagnosis of appendicitis appears to be around 86% and 81%, respectively, based on results from older studies [2]. 
    • Ultrasound can be used to diagnosis acute appendicitis and may be the imaging modality of choice in certain patient populations such as pregnant women and children [3]. 
    • To obtain images you can use either the linear or curvilinear probe. Ask the patient to point where exactly they hurt and place the probe there. If you don’t see it you can use the landmark of the iliac crest (most lateral), psoas muscle (posterior), and iliac artery (most medial). Move superior and inferior along the iliac artery and the appendix should be just anterior to iliac artery. If you still haven’t found it, “lawnmower” along the right lower quadrant. Look for a tubular, blind ended pouch that has no peristalsis. It should be compressible and measure <6mm in AP diameter [4]. 

References

    1. Caterino, S., et al. Acute abdominal pain in emergency surgery. Clinical epidemiologic study study of 450 patients. Ann Ital Chir. 1997; 68: 807-817.
    2. Lim H, Bae S, Seo G: Diagnosis of acute appendicitis in pregnant women: value of sonography. AJR Am J Roentgenol 1992;159(3): 539–542.
    3. Excerpt From: Mike Mallin & Matthew Dawson. “Introduction to Bedside Ultrasound: Volume 2.” Emergency Ultrasound Solutions, 2013. Apple Books. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/id647356692Mallin, M, Dawson, M. Introduction to Bedside Ultrasound: Volume 2. Emergency Ultrasound Solutions, 2013. Apple Books. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/id647356692. Accessed April 18th, 2020.
    4. www.5minsono.com

 

The following authors contributed to this post:

Amir Aminlari, MD; Danika Brodak, MD; Michael Macias, MD

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