Abdominal pain and vomiting

Question 1

abdo pain, vomiting, BNO

How would you assess this patient?

Answer 1

Concern re bowel obstruction
ABCDE (expand) +
- Auscultate for “tinkling” bowel sounds
- Percuss for hyperresonance
- examine external genitalia, hernia orifices
- PR
- insert NGT to decompress stomach “drip and suck method”
- pt kept NBM
- urinary catheter
- order abdo XR or CT
- d/w registrar

Question 2

Differential diagnosis?
50-year-old female from A&E. She has a one-day history of abdominal distension, severe central colicky abdominal pain, and persistent vomiting. During the last 12 hours, she has not opened her bowels or passed flatus. She has a past surgical history of total abdominal hysterectomy, performed 5 years ago.

Answer 2

SBO, LBO, pseudo-obstruction, ileus
small bowel more like as vomiting before constipation
likely due to adhesions bc prev hysterectomy

Confirm with AXR, consider CT AP

Question 3

What can be seen on AXR for SBO?

Answer 3

• dilated small bowel loops >3cm in diameter
• prominent valvulae conniventes

Question 4

What can be seen on AXR in LBO?

Answer 4

• larger pouch-like haustrae
• faeces give mottled appearance
• > 6cm dilation

Question 5

How would you manage likely SBO?

confirmed on AXR

Answer 5

• reassess A-E
• “drip and suck” NGT
• IV fluids adjusted to electrolyte disturbances
• dietician input
• NBM
• senior review
• monitor pt and pain, rpt bloods/VBG/lactate if worsening
• consider further imaging
• consider gastrograffin
• Abx as per trust guidelines
• analgesia and anti-emetics (not metoclopramide)
• surgical management may be indicated

Question 6

What is the most common cause of small bowel obstruction?

Answer 6

Adhesions

Question 7

What are the features of acute strangulation?

Answer 7

• Severe constant pain
• Peritonitis: guarding, rigid abdomen, absent/ reduced bowel sounds
• Tachycardia
• Pyrexia
• Raised lactate
• Leukocytosis