A 64-year-old man presents to the emergency department with abdominal pain and distention, as well as constipation of 8 days’ duration. He denies vomiting, fever, diarrhea, or dysuria. Except for hypertension, he is otherwise healthy with no prior surgeries.

His vital signs are normal except for a borderline pulse of 99 bpm. His physical examination is unremarkable except for his abdomen, which is large, rotund, and tympanitic. There is diffuse tenderness everywhere in the abdomen, but the left lower quadrant seems to be significantly more tender, and you think that you may feel a mass there.

A plain film of the patient’s abdomen is shown below.

What does the image show? What should you do next?

Answers

The kidney, ureter, and bladder (KUB) X-ray demonstrates a large bowel obstruction. You should order a CT scan and consult a surgeon.

The KUB shows no distal air in the rectum and dilated loops of large intestine >6 cm. These findings are concerning for a large bowel obstruction. Initial management should include a CT scan of the abdomen and pelvis, nasogastric (NG) tube placement, and surgical consultation. The CT image slice below shows a Spigelian hernia in the left abdominal wall, which was the cause of the bowel obstruction. Interestingly, hernias causing obstruction are not always focally painful, especially in the elderly. The hernia was not reducible, and so the patient was taken urgently to the OR for definitive treatment.

Discussion

Large bowel obstructions are much less common than small bowel obstructions, primarily because adhesions do not usually cause large bowel obstructions. The presentation usually includes generalized or lower abdominal pain. Vomiting is rare, especially if the ileocecal valve is competent. Because adhesions are seldom the cause, large bowel obstructions rarely resolve spontaneously and typically require urgent surgery or colonoscopy. See the table for more details on causes and treatment of large bowel obstructions.

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Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Table 1. Large bowel obstruction

Clinical Pain generalized or in lower abdomen, vomiting late if at all (if ileocecal valve competent)
Causes Tumor, 65%; diverticulitis, 20%; volvulus, 5%; impaction, adhesion, ulcerative colitis, foreign body, hernia
Treatment IV fluid, NG tube, OR vs unprepped colonoscopy. If diameter >10 cm, can perforate

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Reference

Pregerson B. Emergency Medicine1-Minute Consult Pocketbook. 5th ed. EMresource.org; 2017.

This article originally appeared on Clinical Advisor