A13) Abdominal pain and bilious vomiting

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with nausea and vomiting.
  2. Review the DDx considerations in a patient with nausea and vomiting.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with nausea and vomiting.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
This patient presenting with a known, now irreducible hernia, with new onset vomiting, obstipation, and abdominal distension is most likely presenting with a bowel obstruction secondary to that hernia.
Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

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The patient requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

An abdominal X-ray is an appropriate first diagnostic test to assess for bowel obstruction.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

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Second Imaging Study

What is the next imaging study you will order?

CT has high diagnostic accuracy for SBO and can identify the cause of obstruction.
View ACR Appropriateness Criteria
Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

Watch our video

View the full study if you'd like to like a look yourself

Third Imaging Study

What is the next imaging study you will order?

No further imaging is required as the diagnosis is made with the CT scan.

What is your Diagnosis now that you have seen the imaging results?

The physical exam demonstrated that the hernia is non-reducible, or incarcerated. The imaging findings suggest blood supply compromise and strangulation, which can be confirmed intraoperatively.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient requires urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 75-year-old male presenting with a small bowel obstruction secondary to a strangulated hernia. An NG tube should be placed for decompression. Surgery should be consulted for surgical evaluation if they find that the hernia is non-reducible.

Lessons Learned:
- Small bowel obstruction may occur secondary to post-operative abdominal adhesions, hernias, tumors, foreign bodies, volvulus, intussusception, and inflammatory or infectious processes. 
- In some cases, like with bowel obstruction secondary to abdominal adhesions, patients may undergo a trial of conservative treatment with NPO, bowel decompression with a nasogastric tube, and fluid and electrolyte administration.
- Adhesions are the most common cause of small bowel obstructions in the U.S.
- A KUB may differentiate a mechanical versus adynamic ileus and assess for complications like free abdominal air.
- The cause of the small bowel obstruction can be assessed for using a CT scan.

Socioeconomic Factors: Patients with lower socioeconomic status or without private insurance are more likely to present to the emergency department with uncomplicated hernias, likely secondary to a lack of access to outpatient surgical care.

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