2.  78 year old white female
presents from nursing
home with increasing
abdominal distention,
vomiting, cramping
abdominal pain, and 3
days of constipation. Pt
has a history of chronic
constipation.
T: 99.0 P 115 R 16 BP 110/75
Gen: Elderly white female with
chronic debilitation, actively
vomiting in room.
HEENT: PERRL, NC/AT,
Oropharynx clear,
CV: mildly tachycardic, no m/r/g
Pulm: CTAB
Abd: abdominal distention,
decreased bowel sounds,
diffuse TTP, hyperressonance to
percussion
Ext: 2+ pulses, no c/c/e

4. What is Diagnosis?
(1) Dilated Colon >6cm
(2) Effacement of Haustrae
Peripherally located
(3) Multiple Air Fluid Levels
Large Bowel Obstruction

5.  IV & IVFs
 Analgesics & Antiemetics
 NG decompression
 Antibiotics for Gram (-) Aerobes & Anaerobes (ie.
Flagyl, Cipro, Zosyn, Clindamycin)
 Surgery Consult
 Admission for all LBO
 Emergency Laparotomy if:
 (1) Peritonitis (2) Peritoneal Free Air (3) Sepsis (4)
Cecal Distention >12cm

6.  How to Differentiate Large from Small Bowel
Obstruction:
 Gas in the Large Bowel is usually situated peripherally.
 Gas in the small bowel is usually centrally located.
 Large intestine has haustrae, which are blunter,
thicker, and do not completely transverse intestine.
 Small Intestine has valvulae conniventes that transverse
width of intestine, giving it a ribbed appearance.
 Feces are only found in Large Intestine.

7.  Rule of 3,6,9:
 suspect obstruction if small bowel dilated >3cm; large bowel
>6cm, cecum >9cm.
 Causes of LBO:
 Carcinoma (60%), Diverticulitis (20%), Volvulus (10%)

8.  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

9.  Greenberg, Michael. Greenberg’s Atlas of Emergency
Medicine.
 Ginzberg, Leon. “X-Ray Diagnosis of Acute Intestinal
Instruction Without the Use of Contrast Media”
Annals of Surgery
 Lifeinthefastlane.com “Abdominal X-Ray
Interpretation”
 Schwartz, David. Emergency Radiology. 2000. pg 527-
529.
 Tintanelli’s Emergency Medicine: A Comprehensive
Study Guide. Chapter 79 Intestinal Obstruction