84984907 case-analysis-final

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CASE ANALYSIS
I. BACKGROUND OF IDENTIFIED CASE
-What is the most likely cause of this patient’s problems?
INTESTINAL/ BOWEL OBSTRUCTION
The patient has abdominal pain that is cramping and intermittent which is more
prevalent in simple obstruction. Usually, pain that occurs for a shorter duration of time
and accompanied by vomiting may be more proximal. Pain that lasts as long as several
days, is progressive in nature, and is accompanied by abdominal distention may be
typical of a more distal obstruction. Our patient here vomited twice.
The patient also has previous abdominal surgery which is for the resection of right colon
carcinoma. A history of colonic malignancy. Past history of colon cancer points to the
possibility that recurrent cancer may be the cause of obstruction.
(http://books.google.com.ph/books?id=Q64UTEkul7gC&pg=PA189&lpg=PA189&dq=hemoccult+positive+stool%2C+mildl
y+distended+abdomen%2C+diminished+bow el+sounds%2C+empty+rectal+vault&source=bl&ots=dil00uJDib&sig=KUp3
WhBvmOZCkhgzhBdGC8iMuHU&hl=tl&sa=X&ei=-
Y8NT6bYD8mbiQfp0uiZBg&ved=0CC0Q6AEw Ag#v=onepage&q=hemoccult%20positive%20stool%2C%20mildly%20dist
ended%20abdomen%2C%20diminished%20bow el%20sounds%2C%20empty%20rectal%20vault&f=false)
Upon physical examination, abdominal distention is present. Hyperactive bowel sounds
occur early as GI contents attempt to overcome the obstruction; hypoactive bowel
sounds occur late. This is compatible with mechanical obstruction.

Proper genitourinary and pelvic examinations are essential. Look for the following during
rectal examination:
 Gross or occult blood, which suggests late strangulation or malignancy
In here, our patient has hemoccult-positive stool.
Empty rectal vault is also revealed. This may indicate recurrence of colorectal
cancer. This also indicates high-grade small bowel obstruction.
EPIDEMIOLOGY
 Bowel obstruction is a common and distressing outcome in patients with
abdominal or pelvic cancer.
 Patients may develop bowel obstruction at any time in their clinical
history, with an incidence ranging from 5.5% to 42% in ovarian carcinoma
and from 10% to 28.4% in colorectal cancer. The causes of the
obstruction may be benign postoperative adhesions, a focal malignant or
benign deposit, relapse or diffuse carcinomatosis. The symptoms which
are almost always present are intestinal colic (reported in 72%–76% of
patients), abdominal pain due to distension, hepatomegaly or tumor
masses (in 92% of patients) and vomiting (68%–100%) of cases.
http://annonc.oxfordjournals.org/content/4/1/15.abstract
 Bowel obstruction arises most commonly as a complication of ovarian or
colon cancer. In one series 42% of patients with ovarian cancer
developed obstruction.31
Primary presentation of colon cancer with
obstruction is usually treated with surgical resection. The incidence of
obstruction in colorectal cancer as a late complication is approximately
10%.http://w ww.palliative.org/PC/ClinicalInfo/NursesNotes/BowelObstructions.html
ETIOLOGY
Obstruction of the bowel may due to:
 A mechanical cause, which simply means something is in the way
 Ileus, a condition in which the bowel doesn't work correctly but there is no
structural problem
Mechanical causes of intestinal obstruction may include:
 Abnormal tissue growth
 Adhesions or scar tissue that form after surgery
 Foreign bodies (ingested materials that obstruct the intestines)

 Gallstones
 Hernias
 Impacted feces (stool)
 Intussusception
 Tumors blocking the intestines
 Volvulus (twisted intestine)
http://www.mayoclinic.com/health/intestinalobstruction/DS00823/DSECTION=causes
Brunner and Suddarth’s Textbook of Medical-SurgicalNursing 11th
ed. pg. 1264
Risk factors
Diseases and conditions that can increase your risk of intestinal obstruction include:
 Abdominal or pelvic surgery, which often causes adhesions — a common cause of
intestinal obstruction
 Crohn's disease — an inflammatory condition that can cause the intestine's walls to
thicken, narrowing its passageway
 Cancer within your abdomen, especially if you've had surgery to remove an abdominal
tumor or radiation therapy
http://www.mayoclinic.com/health/intestinalobstruction/DS00823/DSECTION=risk-factors
ed. pg. 1264
II. WHAT ARE THE NEXT STEPS IN THIS PATIENT’S EVALUATION?
Abdominal Series.
Tests that show obstruction include:
* Abdominal CT scan
* Abdominal x-ray
* Barium enema
* Upper GI and small bowel series
Abdominal series
These x-rays will help to distinguish partial obstruction from high-grade, complete
obstruction. The abdominal series would delineate the level of obstruction. The
presence of stool or air in the rectal vault may suggest a partial obstruction,
whereas the presence of air and fluid levels in the small intestine, with the
absence of stool and air throughout the colon, indicate a high grade, small bowel
obstruction.
Supine and upright abdominal x-rays should be obtained and are usually

adequate to diagnose obstruction..Although only laparotomy can definitively
diagnose strangulation, careful serial clinical examination may provide early
warning. Elevated WBCs and acidosis may indicate that strangulation has
already occurred.
On plain x-rays, a ladderlike series of distended small-bowel loops is typical of
small-bowel obstruction but may also occur with obstruction of the right colon.
Fluid levels in the bowel can be seen in upright views. Similar, although perhaps
less dramatic, x-ray findings and symptoms occur in ileus differentiation can be
difficult. Distended loops and fluid levels may be absent with an obstruction of the
upper jejunum or with closed-loop strangulating obstructions (as may occur with
volvulus). Infarcted bowel may produce a mass effect on x-ray. Gas in the bowel
wall (pneumatosis intestinalis) indicates gangrene.
In large-bowel obstruction, abdominal x-ray shows distention of the colon
proximal to the obstruction. In cecal volvulus, there may be a large gas bubble in
the mid-abdomen or left upper quadrant. With both cecal and sigmoidal volvulus,
a contrast enema shows the site of obstruction by a typical “bird-beak” deformity
at the site of the twist.
III. Trace schematically the pathophysiology
Cause: Tumor (recurrence of metastatic colon carcinoma asevidendenced by patient’s history
of right colectomy 8 months ago)
Within the intestine, extends into the intestinal lumen;outside the intestine, pressureon the
wall of the intestine; intestinal lumen becomes partially or completely obstructed.
Mechanical Obstruction
Gases and fluids
accumulatein
the area
Bacterial
activity
Distention of
intestine
BorborygmiContractions of
proximal intestines
Severe colicky
abdominal pain
Intraluminal
pressure
Abdominal
series
Tumor invasionMicrocapillary
rupture/ bleeding
Hemoccult- positive stool
FOBT

Late:Metabolic
acidosis
Persistent
vomiting
Early:Metabolic
alkalosis
Compression of
veins
ECF volume
Plasma vol.
CVP
Hemoconcentration
Tachycardia
Capillary permeability
(fluid loss to peritoneum)
Bacterial
translocation
Compression of
terminal branches
of mesenteric
artery
Arterial
blood supply
Ischemia
Anoxia
Necrosis
Cell death
Release of
prostaglandin
Abdominal
Pain
Gangrenous
intestinal wall
Perforation of
necrotic segments
Bacteria or toxins leak
into:
Hypovolemia
Abdominal
distention
Nausea and vomiting
Food intake
Nutrient absorption
Carbohydratereserves
Ketosis
Gastric content analysis
Risk for deficient
fluid volume
Acute pain
Edema of the
intestine
Abdominal series
Ineffective
tissueperfusion
ABG analysis
H & H
F & E
imbalance
Risk for
imbalanced
nutrition less
than body
requirements

LEGEND:
--clinical findings
--laboratory/diagnostic
--nursingdiagnosis
Ref: http://www.slideshare.net/reynel89/pathophysiology-of-intestinal-obstruction
Huether-McCance Understanding Pathophysiology 4th
ed., pg. 946
Doenges, Marilyn. Nurse’s Pocket Guide 11th
ed.
ed. pg. 1265
NURSING MANAGEMENT:
ACUTE PAIN:
1. Teach patient non-pharmacological pain management methods such as DBE,
diversional activities
2. Environmental comfort management manipulation of the patient’s surrounding
for promotion of optimal comfort
3. Evaluate client’s response to prescribed pain medications
Ref: Doenges Nurses Pocket Guide,11th
ed
Doenges, Nursing Care Plans Guidelines for Individualizing Client Care across the Life Span, 7th
ed
RISK FOR DEFICIENT FLUID VOLUME
1. Monitor intake and output
2. Control nausea/ emesis as prescribed
3. Assist in venoclysis establishment and fluid & electrolyte replacement
ed
ed
Bowel
sounds
Peritoneal
cavity
Blood
supply
Peritonitis Bacteremia
Septicemia
Fever
Empty
rectal vault
Rectal exam
WBC count
Hyperthermia
Altered elimination
pattern: Constipation

RISK FOR IMBALANCED NUTRITION LESS THAN BODY REQUIREMENTS
1. Establish baseline parameters- baseline body fat and muscle mass and
anthropometric measurements
2. Establish nutritional plan that meets individual need as appropriate, but is low
in fiber.
3. Evaluate nutritional status, noting current intake, weight changes, and
problems with oral intake
ed
ed
INEFFECTIVE TISSUE PERFUSION:GASTROINTESTINAL
1. Monitor perfusion as appropriate (nausea & vomiting, balanced intake and
output; free of abdominal pain/ discomfort)
2. Measure abdominal girth; investigate reports of pain out of proportion to
degree of injury to detect early development of abdominal compartment syndrome
3. Review laboratory studies (e.g., ABGs)
ed
ed
ALTERED ELIMINATION PATTERN:CONSTIPATION
1. Palpate abdomen for presence of distention
2. Determine usual pattern of elimination
3. Assess current pattern of elimination to provide baseline for comparison,
recognition of changes
ed
ed

IV. NCP PROPER
Nursing Problem(Actual): Abdominal pain
Nursing Diagnosis: Acute Pain related to distention/ edema and ischemia of intestinal tissue
S> intermittent pain throughout the abdomen for the past 8-10 hours
O> vomited twice
>obese abdomen, mildly distended and tender
>guarding noted
>diminished bowel sounds, occasional high-pitched sounds
>rectal exam reveals decreased tone, empty rectal vault
> hemoccult-positive stool
Explanation of the
Problem
OBJECTIVES Nursing Intervention Rationale
Expected Nursing
Outcome
Pain is unpleasant
sensory and emotional
experience arising
from actual/ potential
tissue damage. In this
case, pain arises from
the increase
contractions of
proximal intestine in
attempt for
compensatory
mechanism that leads
LTO: Reported pain is
absent and does not
recur during the entire
hospitalization
STO: During the shift,
the patient will
verbalize relief from
pain as manifested by
lowering of pain rating
>After 4 hours of
Dx>Assess
characteristics of pain
>Observe for non-
verbal cues of pain
>Monitor and record
vital signs
>To know what kind of
pain the pt. is feeling
and how severe it is
>Gives a clue on how
severe the pain
>Serves as baseline
data for comparison;
any rise could mean
the patient is in
>Pain does not recur
the entire
hospitalization stay
>The patient expressed
feelings of comfort;
reported pain has been
relieved/ controlled.
>The patient utilized
3/5 non-
pharmacological pain

to severe colicky
abdominal pain.
Furthermore, due to
the distention of
intestine that
eventually leads to
decrease blood supply
causing ischemia
wherein cell death
occurs and in the
process, prostaglandin
is released therefore
aggravating pain.
nursing intervention,
the patient will be able
to identify 3/5 non
management method
effectively.
>After 4 hours of
nursing intervention,
to demonstrate and
utilize 3/5 non
management method
effectively.
>Assess general
status
>Assess patient’s
response to
medication
Tx> Perform DBE with
the patient/ offer music
therapy/ suggest
diversional activities
>Provide rest and
comfort
distress brought by the
pain
>To see how client is
coping up with the
present condition
>This is to evaluate
client’s response to
pain and medications
for the health care
providers to consider
worsening/
improvement of
underlying condition
>An independent
nursing intervention for
the client to manage
pain aside from
pharmacologic
treatment
>For the patient to
conserve energy, more
activities would
demand for more
oxygen therefore
aggravating cell
hypoxia in the affected
area
management and
identify methods that
provided relief

>Ensure safety
especially if patient
has altered mobility
due to guarding
behaviors
>Assist patient in
assuming comfortable
position
>Give pain medication
as prescribed
Edx:
>Encourage to
continue DBE
>Advise to report any
progressive pain
>Reinforce diversional
activities such as
watching TV, listening
to music and the like
>Stress importance of
low-fiber diet
>So the patient would
not have further injury
>To prevent further
pain and difficult
breathing to patient
>For pain relief
avoiding further stress
to the body
>Decreases pain and
to manage pain
independently
>To facilitate early
notification of the
health care provider of
the possible worsening
condition of the patient
>To divert attention
away from pain
> So as not to
stimulate bowel for
increase peristalsis

>Stress importance of
following treatment
regimen as ordered by
the physician
that could further
contribute to pain
>Alleviates pain and
facilitates possible
shorter hospital stay
ed
ed
ed. pg. 1265
http://onlinelibrary.wiley.com/doi/10.1111/j.1349-7006.1999.tb00791.x/pdf

Nursing Problem: Persistent vomiting
Nursing Diagnosis (Potential): Risk for deficient fluid volume related to active fluid loss [vomiting and possible NG
decompression of distended bowel]
Risk for imbalanced nutrition less than body requirements related to decrease absorption
S>
O> vomited twice
>obese abdomen, mildly distended
>weight loss
Explanation of the
Problem
OBJECTIVES Nursing Intervention Rationale
Expected Nursing
Outcome
Risk for deficient fluid
volume exists because
of the active loss of
fluid, electrolytes and
nutrients due to
vomiting further
aggravated by
decreased absorption
inherent to intestinal
obstruction. There is
vomiting because of
the distention of the
intestines and
abdominal pain alone
triggers the feeling of
nausea and vomiting.
LTO:
During hospitalization,
the patient will not
develop this
complication
Maintain fluid volume
at a functional level all
throughout the
hospitalization
The patient will
maintain his weight.
STO
:During the entire shift,
the patient is able to
Dx> Monitor vital signs
compare with client’s
normal/ previous
readings
>Evaluate laboratory
findings such as
electrolytes and gastric
contents, H & H,
specific gravity of urine
>Monitor intake and
>Changes in blood
pressure and pulse
rate characteristics
may be used for rough
estimate of circulating
blood volume
>Part of vomitus is not
only fluid but also the
electrolytes and gastric
contents. This is for
prevention of fluid and
electrolytes imbalance
as well.
>Provides guidelines
The patient’s fluid
volume will remain
within normal
parameters
Patient demonstrates
no further weight loss.

maintain adequate
urinary output, stable
vital signs, moist
mucous membranes,
good skin turgor
: During the entire shift,
to maintain adequate
caloric intake
output
>Note color and
characteristics of
vomitus
>Monitor weight
changes
Tx> Initiate trial of
clear fluids/high
caloric foods as
indicated or as oral
intake is resume once
symptoms have been
contolled
>Assist in venoclysis
>Control emesis by
administering
antiemetic as
for fluid replacement
>Gastric content
analysis such as in the
case of undigested
food particles provides
a picture of the
intestinal obstruction
as well as its level of
obstruction
>This also provides
guidelines for fluid
replacement as well as
it shows the nutritional
intake of the patient.
>For immediate fluid
replacement and
caloric foods to sustain
energy requirement
>For fluid resuscitation
and prevention of
dehydration
>This is to reduce fluid
loss through vomiting

prescribed
>Assist in draining GI
contents
Edx> Discuss to
patient some ways to
prevent dehydration
>Reinforce eating
high-caloric foods
>Educate patient to
limit fiber/ bulk
>To relieve distended
bladder, decreasing
pain. Note for the
amount and
characteristics of fluid.
>For the patient to
initiate ways to prevent
deficient fluid volume
independently, such as
trying to replace oral
fluid intake, and
>For nourishment of
the client since the
body is physiologically
stressed, it needs to
cope up with increased
metabolic rate
>This may lead to
early satiety, and the
patient won’t be able to
get his energy
requirement
ed
ed
ed. pg. 1265
http://onlinelibrary.w iley.com/doi/10.1111/j.1349-7006.1999.tb00791.x/pdf

Nursing problem: PERSISTENT VOMITING
Nursing Diagnosis: <POSSIBLE> ELECTROLYTE IMBALANCE related to possible loss of H+
ions and potassium
S>
O> vomited twice
Explanation of the
problem
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALE
EXPECTED
OUTCOME
This is an imbalance
that occurs when
hydrogen ions and
potassium is excreted
excessively through
active losses, as in this
case, through vomiting.
At early stages, with
the loss there is
metabolic alkalosis,
and after exhausting
the compensatory
mechanism of the
body, the activity leads
to lactic acid build-up
causing acidosis.
LTO: The patient
maintains normal
ABGs values during
the entire hospital stay
STO:
:During the shift, the
patient will not
manifest any
electrolyte imbalance
as manifested in
laboratory findings
Dx:> Monitor vital
signs
>Watch out for atony
(Hypo K)
>Review laboratory
findings
>Establishment of
baseline data as a
basis for comparison
from client’s current
condition
>So the condition is
still easy to reverse if
detected at very early
stage –this is life-
threatening
>For early detection
even at the slightest
change in electrolytes,
while still the patient is
asymptomatic of the
said imbalance, the
NOD will be able to
know what to
anticipate and knows
when to notify
physician for
immediate appropriate
action.

>Monitor I& O
Tx>Anticipate for
possible electrolyte
replacement
>Provide safety and
security by assisting
patient
Edx>Teach patient to
eat foods high in
potassium as the diet
for the patient allows
>Advise to report any
feelings of fatigue,
muscle weakness
> Provides guidelines
for fluid & electrolytes
replacement
>For replacement of
lost electrolyte and
correct the imbalance
brought by it
>Because patient may
experience weakness
suddenly due to HypoK
>To prevent HypoK
>For the NOD to be
prompted, because
this warrants
assessing serum K
concentration.
Ref:Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th
ed. pg. 309, 322

V. MANAGEMENT
MEDICAL:
Diagnostic tests for Intestinal Obstruction
Various tests help to establish the diagnosis and pinpoint complications. For example,
 Abdominal X-rays.
 CT scan- A computer creates separate images of the belly, called slices to see
size of the tumor
 Barium enema In large-bowel obstruction reveals a distended, air-filled colon or a
closed loop of sigmoid with extreme distention
 Serum sodium, chloride, and potassium levels may decrease because of
vomiting.
 White blood cell counts may be normal or slightly elevated if necrosis, peritonitis,
or strangulation occurs. Serum amylase level may increase, possibly from
irritation of the pancreas by a bowel loop.
 Hemoglobin concentration and hematocrit may increase, indicating dehydration.
 Sigmoidoscopy, colonoscopy, or a barium enema may be used to help determine
the cause of obstruction.
Ref.:http://nurse-thought.blogspot.com/2011/04/ncp-nursing-care-plans-for-intestinal.html
Huether-McCance Understanding Pathophysiology 4th
ed., pg. 946
 Hyperbarric oxygen therapy
http://onlinelibrary.w iley.com/doi/10.1002/cncr.23502/pdf
PHARMACOLOGIC:
Octreotide
The most important drug in the therapy of bowel obstruction is octreotide. An analogue
of the hormone somatostatin, it significantly reduces secretion into the gut. Octreotide is
generally well tolerated. It appears to have minimal effects on motility. Doses range from
100 mcg BID to 200 mcg TID IV or SC. Octreotide can result in significant improvements
in nausea and vomiting. However, because this appears to be due to decreased
secretion of fluid into the gut, it usually takes 24 to 48 hours for this effect to become
apparent. Octreotide was superior in reducing intestinal secretions.
Promotility agents
Promotility agents can be used if cramping is not present and if the intention is to
normalize and use the proximal gut. Traditionally, clinicians have believed that
promotility agents are contraindicated in bowel obstruction because increased motility

could worsen cramping and theoretically result in gut perforation. However, reports of
the beneficial effects of promotility drugs are beginning to appear in the literature.
Metoclopramide is the drug of choice for this purpose. Metoclopramide works by binding
5HT4 receptors and releasing acetylcholine, which in turn binds cholinergic receptors
and results in increased motility. Understanding this is important, as concomitant use of
drugs with anticholinergic effects, such as scopolamine, promethazine, or amitriptyline,
may antagonize this action and reduce efficacy. Dosing is usually begun at 10 mg TID
AC PO and gradually increased. Promotility drugs should not be used in complete bowel
obstruction
Direct antiemetics
If cramping is present or if the intent is to rest the bowel, as with patients no longer
capable of eating or drinking, anticholinergic and antihistaminic antiemetics such as
promethazine may be used. Glyco-pyrrolate, a more locally acting anticholinergic drug,
can be given orally or parenterally. It can reduce cramping, intestinal secretion, and
nausea.
If the goal is to normalize gut function, anticholinergic agents should be avoided,
because they both inhibit motility and block the use of metoclopramide. Many experts
use haloperidol as a first-line agent in part because it does not affect motility. However, a
pharmacologic rationale for this is lacking, as it is unclear that dopamine receptors are
significantly involved in the pathophysiology of obstructive nausea
Hyoscine butylbromide helps reduce GI secretions and peristalsis.
Simethicone
Simethicone is given in order to encourage burping of stomach and intestinal gas. One
cause of intestinal dilatation is intestinal gas (largely nitrogen) that cannot be disposed of
"the old-fashioned way" via flatus..
Opioids
Opioids are very effective in dealing with the cramping of bowel obstruction and are
usually needed for pain management associated with advanced malignant disease.
However, they can have undesirable effects on motility if one is trying to normalize gut
function. As a general rule, pain management trumps motility management. That is, if a
patient needs an opioid for pain, give it.
Dexamethasone
High dose dexamethasone may help reduce the obstruction by decreasing the swelling
and inflammation on the site. The dose is tapered over time to the lowest effective dose.
This is also a powerful anti-nauseant.

SURGICAL:
 Surgical bypass
 Ostomy
 Bowel Resection
 NG/venting gastrostomies
It can be very helpful for initial gut decompression. Venting gastrostomies have been
used, much like PEG tubes for feeding, as a long-term alternative to NG tubes for
decompression. Although certainly less uncomfortable than NG tubes, there is minimal
evidence that they result in less nausea or distention
 Early surgical intervention is indicated in patients with no known
recurrence or long interval to the development of SBO. In patients with
carcinomatosis, ascites, or palpable masses, more prolonged course of
nonoperative treatment is justifiable. Surgical intervention is indicated if
nasogastric decompression fails or if re-obstruction develops after
removal of nasogastric tube. Selection of surgical procedure, resection,
bypass, gastrostomy, or tube jejunostomy is based on extent of the
disease. Used selectively, percutaneous gastrostomy can improve quality
of life. http://www.palliative.org/PC/ClinicalInfo/NursesNotes/BowelObstructions.html
PREVENTION
Prevention depends on the patient’s case. Since the patient’s case is a recurrence of
cancer. The prevention of this should have been the prevention of recurrence of cancer.
PreventColonCancerRecurrenceby:
Healthy diet:
o 1
Yogurt: Yogurt contains healthy bacteria which can help to work in the colon to create a
healthy environment that can prevent tumor growth. Add yogurt to your daily diet, and
opt for more natural, plain and organic yogurts. Make sure it's yogurt that is labeled as
either live or active.
o 2
Bromelain: Bromelain is an enzyme in pineapple that is known for being anti-cancer. It
helps to break down tumors and prevents them from growing. Eating it in pineapple isn't
enough to make a drastic difference, so it's best to take it in supplemental form.
o 3
Colostrum: Colostrum is a substance found in some female mammals. It's been studied
multiple times, and has been proven to help prevent the recurrence of colon cancer.
http://www.ehow.com/how_5555643_prevent-colon-cancer-recurrence.html

To reduce risk of colon cancer:
1. Get Screened
2. Exercise Regularly
3. Eat Right
4. Maintain a Healthy Body Weight and Shape
5. Avoid Tobacco and Don't Smoke
http://coloncancer.about.com/od/preventionandrecurrence/a/prevoverview.htm
SCREENING AND DETECTION:
Upper GI and small bowel series
An upper GI and small bowel series is a set of x-rays taken to examine the esophagus,
stomach, and small intestine. Patient is given an injection of a medication that will
temporarily slow bowel movement, so structures can be more easily seen on the x-rays.
Before the x-rays are taken, instruct to drink 16 - 20 ounces of a millkshake-like drink
that contains a substance called barium. An x-ray method called fluroscopy tracks how
the barium moves through the esophagus, stomach, and small intestine. Pictures are
taken with in a variety of positions. The test usually takes around 3 hours. However, in
some cases, it may take up to 6 hours to complete.
A GI series may include this test or a barium enema.
Barium enema
Barium enema is a special x-ray of the large intestine, which includes the colon and
rectum.
Lie flat on back on the x-ray table and a preliminary x-ray is taken then to lie on side.
The health care provider will gently insert a well-lubricated tube (enema tube) into the
rectum. The tube is connected to a bag that holds a liquid containing barium sulfate. It is
placed in the rectum. The liquid is a type of contrast. Contrast highlights specific areas in
the body, creating a clearer image. The barium flows into the colon, and eventually
passes out of the body with the stools.
A small balloon at the tip of the enema tube may be inflated to help keep the barium
inside the colon. The health care provider monitors the flow of the barium on an x-ray
fluoroscope screen, which is like a TV monitor.
There are two types of barium enemas:
 Single contrast barium enema uses barium to highlight your large intestine.
 Double contrast barium enema uses barium, but also delivers air into the colon to
expand it. This allows for even better images.

The enema tube is removed after the pictures are taken.
DETECTION
The diagnosis of majority of cases of bowel obstruction can be made based on clinical
presentation and initial plain radiograph of the abdomen.
1. Luminal contrast studies, computed tomography (CT scan), and
ultrasonography (US) are utilized in select cases. Once the diagnosis of
bowel obstruction is entertained, location, severity and etiology are to be
determined. Most importantly is the differentiation between simple and
complicated obstruction.
Computed tomography (CT scan) is emerging as a valuable tool in the management of
bowel obstruction. It confirms the diagnosis, differentiates between mechanical and
functional obstruction, provides information about cause and site of obstruction, and
helps differentiate between simple and complicated SBO (Stage C). Furthermore, CT
scan can diagnose other disease states. Hence CT scan helps in decision making for
early surgical intervention, and prevents delay in treatment. CT scan may give false
positive results and may be difficult to interpret when colonic abnormalities cause
predominantly SB dilatation. CT scan is unable to identify location and cause of
obstruction accurately in 18% of cases. Furthermore, CT scan cannot predict who will
benefit from conservative treatment in cases of partial SBO. In these situations SBFT or
enteroclysis are more helpful.
Past surgical and medical history may shed light on etiology of SBO. In the absence of
prior surgery and any apparent cause, or in presence of clinically confusing clinical
picture, intussusception, MD, gall stone ileus, and neoplasms are suspects. The four
cardinal symptoms of bowel obstruction are pain, vomiting, obstipation/absolute
constipation, and distention. Obstipation, change in bowel habits, complete constipation,
and abdominal distention are the predominant symptoms in LBO.
Vomiting occurs late in the course of the desease. On the other hand, pain, vomiting,
and distention are commonly seen in SBO. The pain is colicky in nature and becomes
dull late in the course of SBO. Vomiting is a pronounced symptom in high SBO. The
vomitus is bilious or semi-indigested food in high SBO, and feculant in low SBO.
Obstipation and constipation are present to a variable degree.
“Tumbling SBO” describes intermittent symptoms of obstruction seen in patients with
gallstone ileus. These episodes correspond to stone impaction, subsequent release, and
reobstruction. Biliary symptoms are present before the onset of obstruction in 20–56% of
cases. Intermittent partial bowel obstructive symptoms are also suggestive of
intussusception.
2. Plain radiograph of the abdomen is the most valuable initial diagnostic
test in acute SBO. This imaging method gives information diagnostic of
SBO in 50–60% of cases and provide enough information needed for

clinical decision making . The typical air fluid levels seen in the dilated
bowel proximal to the obstruction may be absent in high SBO, closed loop
obstruction or late obstruction. Low grade obstruction is difficult to assess
with plain radiograph of the abdomen.
Intraluminal contrast studies (small bowel follow-through, enteroclysis, barium enema)
are utilized in certain clinical situations. Small bowel follow - through (SBFT) is indicated
when: 1) clinical presentation of bowel obstruction is confusing; 2) plain radiograph of
the abdomen is non-diagnostic, and 3) response to nonoperative management is
inadequate, and more diagnostic accuracy is needed to aid in decision making i.e. to
continue with nonoperative treatment or resort to surgical intervention. The study is
particularly indicated when a trial of medical treatment is warranted: postoperative or
adynamic ileus, partial SBO, malignant SBO (carcinomatosis, intraabdominal recurrent
or metastatic cancer), radiation enteritis, recurrent adhesive SBO, and SBO in Crohn's
disease.
3. Small bowel follow-through (SBFT) differentiates adynamic ileus from
mechanical SBO. In adynamic ileus oral contrast moves to colon in 4–6
hrs. In complete mechanical SBO contrast shows dilated SB and stops at
site of obstruction in one hour or less, and in partial SBO transit time of
the dye is prolonged. In carcinomatosis multiple points of obstruction with
pooling of contrast is noted. In gallstone ileus, SBFT detects the biliary
enteric fistula and filling defect (corresponding to the impacted gall stone)
in the small bowel. A beak-like point of obstruction or a mass is
suggestive of intussusception.
4. Enteroclysis (small bowel enema) is a barium infusion study that allows
close examination of mucosal pattern, distensibility, and motility of
individual bowel loops. Enteroclysis is used when SBFT is inconclusive
for partial SBO and is valuable in the diagnosis of tumors,
intussusception, strictures, radiation enteritis, and occasionally Crohn's
disease. A “stretched spring” appearance with intermittent large thick
concentric rings as opposed to fine rings in close proximity suggest the
presence of vascular compromise in intussusception. Enteroclysis can
suggest whether a lead point is benign (causing longer and permanent
intussusception) or malignant (short and transient intussusception). A
combination of thickened valvulae conniventes mucosal folds measuring
greater than 2 mm, mural thickening (wall thickness greater than 2 mm
when adjacent bowel loops are parallel for at least 4 cm under
compression) are the commonest features noted in radiation enteritis.
Other findings include, single or multiple stenoses of variable lengths, stenoses at site or
origin of sinus or fistula, and adhesions as evidenced by constant angulation of bowel
loops and relative fixity within the pelvis. There is also pooling of barium that represent
barium-filled, matted loops of terminal ileum in which individual loops are not
distinguishable nor are mucosal folds discernable. In Crohn's disease there is a

combination of thickened valvulae conniventes, stenoses, sinuses, fistulae, discrete
fissure ulcers, longitudinal ulcers, cobblestoning, skip lesions, and asymmetrical
involvement.
5. Barium enema is not sensitive in the diagnosis of SBO except in distal
SBO where LBO masquerades as SBO. Barium (or gastrografin, a water
soluble hyperosmolar contrast) enema is utilized more frequently in LBO
to differentiate pseudo-obstruction from mechanical obstruction, confirm
the diagnosis of volvulus, and intussusception, and accurately determine
site of obstruction.
6. Ultrasonography (US) is a valuable diagnostic tool in the evaluation of
acute abdomen when used selectively. It is useful in the diagnosis of
gallstone ileus, intussusception, pelvic disease, and gallbladder disease,
and can aid in the exclusion of SBO. In gallstone ileus, US reveals
diseased gall bladder (GB), gas in the GB or bile ducts or both, and fluid
filled bowels that can be followed to the stone in the intestine. The
presence of stones in the GB will modify the planned operative procedure
in the treatment of gallstone ileus. In intussusception, US reveals the
diagnostic “target sign”, a mass with sonolucent periphery (due to
edematous bowel) and a strongly hyperechoic center (from compressed
center of intussusception). Paralytic ileus is differentiated from
mechanical SBO by the presence of peristaltic movement that is easily
observed by US. The location of obstruction is determined by analysis of
dilated bowel loops in terms of location and valvulae conniventes.
Adhesion is considered the cause of SBO when there is no apparent
cause of obstruction.
http://www.palliative.org/PC/ClinicalInfo/NursesNotes/BowelObstructions.html
http://www.ehow.com/how_5555643_colon-cancer.html
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