A 45 yo female with a hx of Crohn's disease and multiple abdominal surgeries presents to the ED complaining of gradually worsening right sided abdominal pain with nausea and vomiting for the past one day.  The patient appears uncomfortable and is tender on exam with guarding.  CT of the abdomen is shown.  What's the diagnosis?

Answer:  Small bowel obstruction

• Most commonly associated with adhesions after abdominal surgery; also may be associated with hernia/incarceration, intussusception, stricture, lymphoma, adenocarcinoma, polyps, gallstones, bezoars
• Presents with abdominal pain, crampy, intermittent, periumbilical or diffuse
• Vomiting- bilious in proximal obstruction, feculent in distal obstruction
• Constipation, not passing flatus
• Distention (most reliable sign), tenderness, peritonitis, rebound
• Labs with elevated WBC (>20k) or left shift could suggest bowel gangrene, abscess or peritonitis, labs may also reveal hemoconcentration (elevated BUN, hematocrit), metabolic alkalosis from GI losses, elevated lactate (suggests bowel ischemia)
• Flat and upright abdominal x-rays - distended loops of bowel with air fluid levels
• CT abdomen and plevis with oral and IV contrast is the imagaging of choice
• Treatment involves IV fluids, antiemetics, analgesia, NG tube if complete or high grade obstruction
• Complications involve strangulation, perforation, peritonitis, shock

References: Price TG, Orthober RJ. “Bowel Obstruction”. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 538--41.