A 70 year male who has never before been hospitalized, is admitted with signs and symptoms typical of a small-bowel obstruction. Which of the following clinical findings would give the most help in ascertaining the diagnosis?
|A||Coffee-grounds aspirate from the stomach|
|C||A leukocyte count of 40,000/μ L|
|D||A pH of 7.5, Pco2 of 50 Kpa, and paradoxically acidic urine|
a. The diagnosis of intestinal obstruction is often immediately evident after a thorough history and physical examination.
b. Therefore, plain radiographs usually confirm the clinical suspicion and define more accurately the site of obstruction.
c. The accuracy of diagnosis of the small intestinal obstruction on plain abdominal radiographs is estimated to be about 60%, with an equivocal or a nonspecific diagnosis obtained in the remainder of cases.
d. Characteristic findings on supine radiographs are dilated loops of small intestine without evidence of colonic distention.
e. Upright radiographs demonstrate multiple air-fluid levels, which often layer in a stepwise pattern .
f. Plain abdominal films may also demonstrate the cause of the obstruction (e.g., foreign bodies or gallstones).
g. Early in the course of bowel obstruction, peristaltic waves can be observed, particularly in thin patients, and auscultation of the abdomen may demonstrate hyperactive bowel sounds with audible rushes associated with vigorous peristalsis (i.e., borborygmi).
h. Late in the obstructive course, minimal or no bowel sounds are noted. Mild abdominal tenderness may be present with or without a palpable mass; however, localized tenderness, rebound, and guarding suggest peritonitis and the likelihood of strangulation.
i. CT is particularly sensitive for diagnosing complete or high-grade obstruction of the small bowel and for determining the location and cause of obstruction.
j. In addition, CT is helpful if an extrinsic cause of bowel obstruction (e.g., abdominal tumors, inflammatory disease, or abscess) is suggested.
k. CT has also been described as useful in determining bowel strangulation. Unfortunately, CT findings associated with strangulation are those of irreversible ischemia and necrosis.