Small Bowel Obstruction

Dilated loops of small bowelCC:

Consultation for bowel obstruction

HPI:

The patient is a 40yo male with a history of alcohol abuse, and seizure disorder secondary to traumatic brain injury who was admitted to this hospital 4d ago after an altercation with law enforcement officials. On arrival, the patient was reported to be acutely intoxicated with ecchymosis and bleeding from left lateral/posterior head and ear. No other significant injuries were found and the patient underwent CT imaging of head and c-spine, with notable findings of left occipital epidural hematoma, subarachnoid hemorrhage, but no significant midline shift. Neurosurgery was consulted and no emergent surgical intervention was required, the patient underwent serial imaging to monitor the bleed which was found to be stable and the patient slowly returned to baseline mental status.

On HOD4, the patient developed nausea/vomiting and abdominal pain, a nasogastric tube was placed with feculent output. CT abdomen/pelvis showed high grade SBO and possible mesenteric ischemia/infarct, and general surgery was consulted for further evaluation. The patient reported experiencing some abdominal pain since the altercation, but could not recall if he was hit in the abdomen.

PMH:

  • Alcohol abuse
  • Seizure disorder

PSH:

  • Tibia fracture
  • No prior abdominal surgery

FH:

  • Non-contributory

SHx:

  • Current alcohol, marijuana use, no tobacco use
  • History of homelessness

Medications:

  • Norco PRN
  • Ativan PRN
  • LISS, SQH, Thiamine
  • NKDA

Physical Exam:

  • VS:  T 99.5°F    HR 108    RR 16    BP 128/82    O2 99% RA
  • Gen: NAD
  • HEENT: PERRL, EOMI, sclera clear, anicteric
  • CV: RRR, normal S1/S2
  • Lungs: CTAB
  • Abd: Distended, diffuse tenderness to palpation, no rebound tenderness, no ecchymoses or signs of trauma
  • Ext: Warm, well-perfused
  • Neuro: AAOx4, appropriate

Assessment/Plan:

40M w/hx alcohol abuse, TBI and seizure disorder, presented initially with evidence of head trauma which was stabilized. However, the development of abdominal pain, N/V, and finding of distension on exam associated with copious output of feculent material from NGT suggests bowel obstruction. This patient has no history of abdominal surgeries to suggest adhesions as a possible cause. Though the patient cannot recall any abdominal trauma, and there was no e/o trauma on exam, findings on CT abdomen/pelvis are suggestive of traumatic cause (hematoma causing obstruction or ischemia resulting from mesenteric injury). The patient was monitored for several days, continuing NGT to suction and with serial abdominal films. However, abdominal pain persisted, abdominal radiographs showed worsening obstruction and the patient developed leukocytosis and on HOD7 the patient was taken to the OR for exploratory laparotomy. Upon entering the peritoneal cavity, there was obvious blood and very distended small bowel which was run distally with finding of a mesenteric laceration in the distal ileum which was walled off by omentum. Additionally, a grade 2 splenic laceration was found. Ultimately, a small bowel resection with primary anastomosis along with a repair of the splenic laceration was performed.

Imaging:

CT abdomen/pelvis

CT abdomen/pelvis

Moderate abdominal and pelvic ascites which has Hounsfield unit attenuation is greater than simple fluid suggestive of blood products.

CT abdomen/pelvis

CT abdomen/pelvis

Fluid dilated small bowel

CT abdomen/pelvis

CT abdomen/pelvis

Complex transition point in the central mid abdomen.
Segment of bowel at the transition point has circumferential mural thickening and surrounding complex attenuation mesenteric fluid and mesenteric stranding.

Abdominal X-Ray

Abdominal X-Ray

Small bowel distention
Nasogastric tube is seen coiled in the gastric fundus

CT Head

CT Head

Left occipital extracranial soft tissue hematoma
Left occipital epidural hematoma subjacent to the fracture site in addition to subarachnoid hemorrhage within the sulci of the left temporal lobe and interpeduncular cistern
Extra-axial fluid collection along the right frontal convexity, tracking down the anterior falx, compatible with a subdural hematoma

Differential Diagnosis for bowel obstruction: 1, 2, 3

A System for Bowel Obstruction

Types of Abdominal Pain: 4

Types of Abdominal Pain

References:

  1. Kulaylat MN, Doerr RJ. Small bowel obstruction. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6873/
  2. Jackson, P. G., & Raiji, M. T. (2011). Evaluation and management of intestinal obstruction. American family physician, 83(2), 159–165.
  3. Maung, A. A., Johnson, D. C., Piper, G. L., Barbosa, R. R., Rowell, S. E., Bokhari, F., Collins, J. N., et al. (2012). Evaluation and management of small-bowel obstruction. Journal of Trauma and Acute Care Surgery, 73, S362–S369. doi:10.1097/TA.0b013e31827019de
  4. Stabile, Bruce. “The Acute Abdomen.” Chairman’s Hour. Harbor UCLA Department of Surgery Student Lecture Series. 5/17/13. Lecture.

Abdominal Wall Hernias

Inguinal hernia CTHPI:

23M w/no known medical history presenting with abdominal “ball” x10d. Patient denies pain, and is tolerating regular diet w/o N/V. Reports lifting weights.

PMH/PSH/FHx/SHx:

None, non-contributory, no t/e/d.

Meds:

Acetaminophen, NKDA

PE:

  • VS:     T N/A      HR 86     RR 18       BP 116/64      O2 N/A
  • Gen: Well-appearing young male, no acute distress
  • HEENT: PERRL, MMM no lesions
  • CV: RRR, normal S1/S2, no murmurs
  • Lungs: CTAB, no crackles/wheezes
  • Abd: +BS, soft, NT/ND, 3cm bulge in right inguinal region with valsalva, above inguinal ligament, ~7cm lateral to symphysis, non-tender, reduces spontaneously after valsalva GU: uncircumcised penis, testes descended b/l, normal size, non-tender, no herniation through inguinal canal palpated with valsalva
  • Ext: Warm, well-perfused, 2+ peripheral pulses
  • Neuro: Alert and oriented, appropriate

Assessment/Plan:

23M ċ inguinal hernia, currently asymptomatic with no evidence of incarceration/strangulation. Recommend follow-up at city hospital for evaluation and possible surgical repair. Advised to refrain from strenuous activity, heavy lifting.

Physical Examination Techniques: 1

Physical Examination Techniques

  • Observation: Best performed with patient standing and physician seated on a stool facing the patient
  • Palpation: place hand over patient’s groin (see figure), with two fingers each superior and inferior to the inguinal ligament. Have the patient cough and feel for a palpable bulge or impulse.
  • GU: With a finger in the inguinal canal, bulges felt against the side of the examining finger are direct hernias, while those felt at the tip of the finger are indirect.

Types of Abdominal Wall Hernias: 2

Types of abdominal wall hernias

Name Location Etiology/Epidemiology
1. Umbilical Linea alba through weakened umbilical ring.Paraumbilical hernias through linea alba in the region of the umbilicus. Congenital or acquired due to increased intra-abdominal pressure (obesity, pregnancy, ascites, PD)
2. Epigastric Linea alba between umbilicus and xiphoid process Congenital weakness of linea alba (lack of decussating fibers)
3. Spigelian Semilunar line: along the lateral borders of rectus abdominus. Herniation typically occurs caudally (below arcuate line) due to absence of posterior rectus sheath.
4. Incisional Site of prior incision Poor fascial healing possibly due to: infection (increased risk in wound dehiscence), obesity, smoking, immunosuppression excess wound tension, CT disorders.
5. Inguinal Indirect: internal (deep) inguinal ring, lateral to inferior epigastric vessels.Direct: external (superficial) inguinal ring, medial to inferior epigastric vessels. Indirect > direct.
6. Femoral Inferior to the inguinal ligament, through empty space medial to femoral sheath. F > M, increased likelihood of incarceration/strangulation (40%)
7. Lumbar 3 Arise in two anatomical triangles:Superior lumbar triangle – lateral border internal oblique, medial border erector spinae, superior border 12thrib.Inferior lumbar triangle – lateral border external oblique, medial border latissimus dorsi, inferior border iliac crest. (See figure) Associated with surgery (incisional), typically urologic.
8. Obturator Protrusion of peritoneal sac through obturator foramen. Rare, occur primarily in elderly women (high predisposition for incarceration).

Locations of Abdominal Wall Hernias:

Locations of abdominal wall hernias

Layers of the Anterior Abdominal Wall:

abdominal_wall

Differential diagnosis for groin masses: 4

Category Inguinal 5 Scrotal 6 Vulvar 7 Perineal 8
Vascular Varicocele extension Varicocele Vulvar varicocity

Hemangioma
Infectious, Inflammatory Lymphadenopathy
Abscess
Inflammatory joint process (hip, related bursae)
Thrombophlebitis
Epididymitis
Epididymo-orchitis
Condyloma
Molluscum
Bartholin’s cyst
Neoplastic Benign (lipoma)
Lymph node metastatsis
Testicular malignancy Malignant skin lesions Soft-tissue malignancy
Anal SCC
Rectal GIST
Metastasis (commonly anorectal, prostatic)
Congenital, Anatomic Hernia
Testis (undescended, retracted)
Epididymal cyst
Spermatocele
Hydrocele
Embryological remnants (mucocele)
Traumatic Hematoma
Aneurysm (complication of catheterization)
Hematoma Hematoma

Locations of Groin Masses: 9

Locations of groin masses

References:

  1. Amerson JR. Inguinal Canal and Hernia Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 96. Available from: http://www.ncbi.nlm.nih.gov/books/NBK423/
  2. Aguirre, D. A., Casola, G., & Sirlin, C. (2004). Abdominal Wall Hernias: MDCT Findings. American Journal of Roentgenology, 183(3), 681–690. doi:10.2214/ajr.183.3.1830681
  3. Guillem, P., Czarnecki, E., Duval, G., Bounoua, F., & Fontaine, C. (2002). Lumbar hernia: anatomical route assessed by computed tomography. Surgical and radiologic anatomy : SRA, 24(1), 53–56.
  4. Roberts, J. R., & Hedges, J. R. (2010). Clinical procedures in emergency medicine. (5th ed., Vol. section 7, p. Ch. 44). W B Saunders Co. Retrieved from http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-3623-4.00044-4
  5. Shadbolt, C. L., Heinze, S. B., & Dietrich, R. B. (2001). Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics : a review publication of the Radiological Society of North America, Inc, 21 Spec No, S261–71.
  6. Eyre, RC. Evaluation of nonacute scrotal pathology in adult men. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2013.
  7. Foster, D. C. (2002). Vulvar disease. Obstetrics and gynecology, 100(1), 145–163.
  8. Tappouni, R. F., Sarwani, N. I., Tice, J. G., & Chamarthi, S. (2011). Imaging of unusual perineal masses. American Journal of Roentgenology, 196(4), W412–20. doi:10.2214/AJR.10.4728
  9. Collins, R. (2008). Differential diagnosis in primary care. Philadelphia: Lippincott Williams & Wilkins.

Skull Fracture

Frontal bone fractureID:

14 year-old female, previously healthy, brought in by ambulance s/p auto vs. pedestrian.

HPI:

Incident unwitnessed, paramedics report no LOC with GCS 15 at scene. GCS 10 upon arrival to ED, with 2min GTC seizure. Patient intubated for airway protection and CT head showed non-displaced frontal bone fracture and small frontal SAH. Patient self-extubated, returned to baseline mental status and was transferred to PICU.

PE:

  • VS: 128/76mmHg, 120bpm, 22 R/min, 100% RA, 37.6°C
  • General: Alert and responsive young female with multiple bandages on extremities
  • HEENT: Right frontal hematoma, no bony defect palpated, multiple facial abrasions, no otorrhea, no rhinorrhea, TM clear b/l, no other ecchymosis.
  • CV: RRR, normal S1/S2, no M/R/G
  • Lungs: CTAB
  • Abdomen: +BS, soft, NT/ND, no rebound/guarding, no flank ecchymoses
  • Neuro: AAOx3, CN II-XII intact, sensation/motor/reflexes symmetric and intact.
  • Extremities: Well-perfused with good pulses, no focal bony tenderness, no joint effusions, multiple abrasions on extensor surfaces of all four extremities.

Assessment & Plan:

14yo female, previously healthy, s/p auto vs. peds followed by GTC seizure and CT head showing small SAH and non-displaced frontal bone skull fracture. No evidence of basilar skull fracture on examination or imaging. Seizure likely 2/2 irritation from SAH. Patient was followed closely in PICU with q1h neuro checks with low threshold for repeat CT if change in mental status or more seizures occurred. The patient was eventually transferred to the general ward and was discharged with neurology follow-up and Keppra for seizure prophylaxis for 6mo.

Types of Skull Fractures:

A system for skull fractures

Sore Throat

Oropharynx AnatomyID:

17 year-old female presenting to the pediatric ED with sore throat for 2 days.

HPI:

The patient reports steadily worsening sore throat over the past 2 days, associated with a sensation of swelling. The pain is described as sharp, 4/10 in severity, located on the left side of her throat, and worsened with swallowing. She denies inability to swallow or difficulty breathing, she also denies fever, cough, new skin rashes or genital lesions.

She has no PMH/PSH, takes no medications, denies t/e/d use and is not currently sexually active.

PE:

  • VS: 111/65mmHg, 80bpm, 97.8°, 16/min, 100% RA
  • Gen: Well-appearing, NAD
  • HEENT: PERRL, no conjunctival injection, TM clear b/l, minimal pharyngeal erythema on left with 6mm white circular lesion on left tonsil, no tonsillar enlargement, no uvular deviation, no cervical LAD, neck supple no masses, normal neck ROM
  • CV: RRR, no M/R/G, Lungs: CTAB
  • Abdomen: +BS, soft, NT/ND
  • Ext: Warm, well-perfused, normal peripheral pulses

Assessment & Plan:

17yo female with no significant PMH with acute pharyngitis for 2 days. The most likely cause of the patient’s symptoms is viral pharyngitis, potentially herpangina (given the appearance of the tonsillar lesion). A more serious viral/bacterial pharyngitis is less likely given the absence of fever or significant erythema/exudate. There was no uvular deviation to suggest peritonsillar abscess and no evidence of airway obstruction to suggest other acute processes (epiglottitis, retropharyngeal abscess). The plan is to recommend supportive care and ibuprofen for symptomatic relief. The patient will be discharged home in good condition with precautions to return if symptoms worsen or she begins to have difficulty swallowing/breathing.

Differential Diagnosis of Acute Pharyngitis:

Acute Pharyngitis

 

Evaluation (history):

  • Respiratory distress: epiglottitis, retropharyngeal abscess, peritonsillar abscess, EBV (obstruction in or near pharynx)
  • Fatigue: infectious mononucleuosis
  • Abrupt onset: epiglottitis

Evaluation (physical examination):

  • Vesicles anterior: herpetic stomatitis, SJS, Behcet
  • Vesicles posterior: herpangina (± involvement of extremities)
  • Asymmetry: peritonsillar abscess
  • Stridor, drooling, respiratory distress: airway obstruction
  • Generalized inflammation: Kawasaki