rady 401 case presentation charlotte story july 22,...

Charlotte Story July 22, 2019

RADY 401 Case Presentation

Chief complaint: Epigastric pain

• Patient 44 year old male

• Chief complaint: Excruciating epigastric abdominal pain• Sudden onset while sleeping, sharp, 10/10 • No nausea, vomiting, chest pain, SOB• No BM in 12 hours prior to presentation

• Medical/Surgical History: Ulcerative Colitis, status post total abdominal colectomy and diverting loop ileostomy (now with J-pouch)• Usually has 4-5 loose stools/day

• Social: No alcohol use

• Medications: Loperamide 2mg four times per day, probiotic

• Vitals: T: 98 HR: 75 BP: 112/61 RR: 19 SpO2: 95%

• Exam: Mild epigastric tenderness to palpation. Otherwise abdomen is soft with no rebound or guarding. Abdomen is non-distended. Patient BMI 22

Work-up and inpatient course

• Lipase 868

• Triglycerides 106

• LFTs, bilirubin, Alk Phos, WBC, ESR, CRP normal

• RUQ ultrasound without stones or biliary dilation

• Patient treated with continuous IV, PCA pump for pancreatitis of unclear origin

• Hospital day 2: patient looks a little better• Lipase 233• Multiple episodes of emesis, still with abdominal pain improved with pain medication, but

worsening into the evening hours

• Hospital day 3: • In the early AM, abdominal pain is severe, patient now with guarding/rebound• Day 5 without BM in patient who normally has 4-5 stools or more per day

What would you do?

• 44 male with UC and multiple surgeries, inpatient with diagnosis of pancreatitis who developed severe abdominal pain with guarding, rebound and stable vital signs. He has had no bowel movement in 5 days, and has been vomiting for 3.

• What would you order?

• Was the appropriate imaging study ordered in this patient?• CT abdomen and pelvis with IV contrast only

List of all imaging studies during inpatient stay

• 07/15/19 • CT abdomen and pelvis with IV contrast only

• Abdominal pain in ED• Ultrasound of the abdomen RUQ

• Looking for gallstones

• 07/16/19• X ray abdomen 1 view

• Still vomiting • X ray chest portable

• Brief desaturation of unclear origin

• 07/17/19• CT abdomen and pelvis with IV contrast only

• Acute abdominal pain• X ray abdomen

• NGT placement confirmation

Imaging studies from PACS 1

Imaging type: CT AP with IV contrast only

View: Coronal

Day of admission: 7/15/19

Imaging studies from PACS 2

7/16/19Imaging type: X ray abdomen, supine

View: Coronal

Indication: Worsening abdominal pain

Imaging studies from PACS 3Imaging type: CT AP with IV contrast only

View: Coronal

7/17/19 7/15/19


View: AxialImaging studies from PACS 4

Note mesenteric fluid and bowel wall enhancement


View: AxialImaging studies from PACS 4

Treatment

• Patient was diagnosed with small bowel obstruction with a closed loop configuration on CT

• NGT placed

• General Surgery Consulted and patient taken to OR for exploratory laparotomy

• In the OR, significant ascites and large section of ischemic bowel that had volvulized multiple times around adhesive bands. Surgeons de-torsed the volvulized bowel, but about 30 cm did not appear viable and was resected. They re-anastomosed the remaining bowel.

• Post Op: patient starts having BM post op day 2.

• Post Op day 4, hospital day 7: patient discharged with GI follow-up

What would you do?

• 44 male with UC and multiple surgeries, inpatient with diagnosis of pancreatitis who developed severe abdominal pain with guarding, rebound and stable vital signs. He has had no bowel movement in 5 days, and has been vomiting for 3.

• What would you order?

Emergent Imaging for Bowel Obstruction

What would you order?• Ultrasound

• $500-1500• No radiation• Evidence of obstruction is indirect: poor peristalsis, thickened bowel wall, intra-abdominal free fluid• Gasless abdomen can be caused by high grade SBO or SBO with ischemia

• X ray abdomen • ~50-80% sensitive• ~0.5-1.0 mSv• Price: ~ $100-400• Fast, lower radiation dose than CT, upright can quickly demonstrate intraperitoneal air• Relies heavily on bowel gas pattern

• CT AP with IV contrast• ~80-94% sensitive in general for SBO, 90-94% sensitive, 96% specific, 95% accurate for high grade-SBO per

Uptodate• Price: ~ $1000 - 5000• ~10 mSv• More radiation, more money, more time

Evaluating for Bowel obstruction on CT

• 3-6-9 rule • To remember cutoffs for bowel distention - measured outer to outer

• small bowel: <3 cm• large bowel: <6 cm• cecum: <9 cm

• On CT, small bowel obstruction should be suspected when• Dilated small bowel proximal to an area of decompressed small bowel• Signs of ischemia may be present: thick or hypoattenuated wall, mesenteric

fluid (ascites)• Signs of closed loop obstruction: whirl sign, beak sign (next slide)

• Oral contrast not typically needed and may limit evaluation of intestinal ischemia

The “Signs” of Small Bowel Obstruction

• Small Bowel Feces sign• Seeing what looks like the typical appearance of stool in colon - except in the

small bowel (particulate fecal matter with air bubbles)

• Whirl Sign• Whirling pattern of mesenteric fat and vessels caused by volvulus, should be at

or near transition point

• Beak Sign • Sharp narrowing of lumen of bowel at transition point (this sign is used to

describe GI tract luminal narrowing in many diseases, most classically achalasia)

Closed Loop Obstruction

• A volvulus forms, due to adhesions in this patient.

• Bowel continues to secrete fluid, causing luminal distention that prevents good mesenteric venous outflow. Bowel and mesenteric edema increases to point that mesenteric arterial flow is disrupted, which can lead to ischemia.

• CT findings: whirl sign, signs of ischemia, C-shaped or U-shaped dilation of bowel around the transition point

• Small bowel obstruction can sometimes be medically managed but when there is concern for closed loop obstruction - the OR is the answer.

Whirl Sign

Wrap Up

• What is the most sensitive imaging test for urgent diagnosis of bowel obstruction?

Wrap Up

• What is the most sensitive imaging test for urgent diagnosis of bowel obstruction?• CT abdomen and pelvis

Wrap Up


• How do we measure bowel wall dilation?

Wrap Up


• How do we measure bowel wall dilation?• Outer wall to outer wall

Wrap Up



• What are some signs of bowel ischemia on CT ?

Wrap Up

• What is the most sensitive imaging test for bowel obstruction?• CT abdomen and pelvis


• What are some signs of bowel ischemia on CT ?• Bowel wall thickening (most common), ascites, portal venous gas, bowel

dilation, absent or poor attenuation of bowel wall (most specific)

Wrap Up



• What are some signs of bowel ischemia on CT ?• Bowel wall thickening (most common), ascites, portal venous gas, bowel

dilation, absent or poor attenuation of bowel wall (most specific)

• What is the 3-6-9 rule?

Wrap Up



• What are some signs of bowel ischemia on CT ?• Bowel wall thickening (most common), ascites, portal venous gas, bowel dilation,

absent or poor attenuation of bowel wall (most specific)

• What is the 3-6-9 rule?• Normal small bowel: < 3 cm• Normal large bowel: < 6 cm• Normal cecum: < 9 cm

Thank you!

References

• Bordeianou, Liliana and Dante Y, Daniel. (June, 2019) Chen, Wenliang (Ed.). Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults. Uptodate. Retrieved June 22, 2019.

• Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins. (2007)

• McGinty, Katrina. (2018) Right image for the right patient (PowerpointPresentation). Retrieved from: http://msrads.web.unc.edu/files/2019/06/Abdominal-ImagingLecture-Dr-McGinty.pdf

• Paulson, E.K., Thompson, W.M. Review of small bowel obstruction: the diagnosis and when to worry. Radiology. 2015;275:332–342

• Rha SE, Ha HK, Lee SH, et al. CT and MR imaging features of bowel ischemia from various primary causes. RadioGraphics 2000; 20:29-42. Accessed at: https://www.ajronline.org/doi/full/10.2214/ajr.176.5.1761105

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