2. 65 year old White male presents complaining of diffuse, crampy abdominal pain. He began vomiting a few hours ago and feels very nauseated. His last bowel movement was yesterday. He has a history of an open- cholecystectomy and open - appendectomy. T: 98.9 P 110 R 16 BP 120/80 Gen: elderly male in NAD, HEENT: PERRL, NCAT, Oropharynx clear CV: mildly tachycardic, No m/r/g Pulm: CTAB Abd: active, high-pitched bowel sounds; mild TTP diffusely, No rebound/guarding; mild distention Ext: 2+ pulse, no c/c/e

4. 1.Air Fluid Levels 2.String of Pearls Sign 1.small, round air pockets trapped in plicae circulares (valvulae conniventes) of small intestine 3.Dilated Bowel >3cm 1.Rule of 3,6,9 4.Coiled Spring Sign 5.Plicae Circulares (Valvulae Conniventes) 1.Indicates Small Bowel involved 6.No gas in colon 1.Indicates Small Bowel involved

5. Most common causes: (1) surgical adhesions (2) Hernia (3) Tumor (4) Inflammatory Bowel Disease (5) Intussusception (6) Gallstone Ileus Rule of 3,6,9: suspect obstruction if small bowel dilated >3cm; large bowel >6cm, cecum >9cm. “Never Let the Sun Rise or Set on a Small Bowel Obstruction”

6. IV & IVFs NG Decompression Analgesics and Antiemetics Surgery Consult Approximately one-quarter of patients admitted for small bowel obstruction will require operation. Patients suspected of having complete or closed-loop obstruction with fever, leukocytosis, tachycardia, metabolic acidosis, continuous pain or peritonitis warrant prompt exploration Antibiotics are suggested if surgery planned. Admission to hospital Medical service is reasonable disposition if patient does not have significant risk factors for surgical managment

7. String of Pearls Sign = obstruction Small Bowel: air pockets trapped in valvulae of small intestine, smaller, rounder Large Bowel: air pockets trapped in haustra; larger, and have flat underside Large Bowel Small Bowel

8. Coiled Spring Sign: Dilated coils of small bowel that appear stacked Indicates SBO Slit sign: Caused by small amounts of air caught in the valvulae of fluid-filled bowel that appear as “slits of air” Similar to string of pearls sign Indicates SBO

9. Greenberg, Michael. Greenberg’s Atlas of Emergency Medicine. http://learningradiology.com/radsigns/radsignsphotos /string%20of%20beads--cu.jpg Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th edition. Vol 2. pg 1440-1444. Schwartz, David. Emergency Radiology. 2000. pg 523- 525. Tintanelli’s Emergency Medicine: A Comprehensive Study Guide. Chapter 97 Intestinal Obstruction