Obstruction or Ileus Jim Lamphear Pediatric GI Fellow

Obstruction or Ileus ? Jim Lamphear Pediatric GI Fellow

Outline • • Obstruction versus ileus How to read an abdominal film 15 Examples 1 Case

What Does It Matter? • Abdominal pain is common • Difficult to distinguish • Obstructions tend to be surgical emergencies • Maintain a high index of suspicion if clinical or radiographic data are unclear

Mechanical Obstruction • Impedance of air or intestinal contents due to mechanical forces • Examples: – – – Incarcerated hernia Instussusception Volvulus Intestinal atresia Extrinsic compression Intraluminal mass

“AIM” • • Adhesions Appendicitis Intussusception Incarcerated inguinal hernia Malrotation Meckel's Masses

Adynamic Ileus • Temporary impedance of air or intestinal contents due to uncoordinated or decreased peristalsis • Examples: – – – Gastroenteritis Abdominal/spinal/pelvic surgery Inflammation (sepsis, pneumonia, UTI) Metabolic (hypokalemia, hypothyroid) Pseudoobstruction

Patterns • • • Fixed anatomy Gas distribution Degree of bowel distension Air-fluid levels Arrangement of bowel loops

Fixed Anatomy • Relatively fixed structures – Stomach, duodenum, hepatic/splenic flexures, rectum • Solid organs – Liver, spleen, kidneys, bladder, psoas muscle • Lungs and diaphragm • Bony structures

Gas Distribution • Obstruction – Poor gas distribution or gasless – More air proximal to obstruction • Ileus – Air distributed throughout abdomen – Incompetent ICV or early obstruction

Bowel Distension • Obstruction – Smooth bowel walls (“sausages”) – Dilation proximal to obstruction • Ileus – Dilation remains proportional • Colon is larger than the small intestine – “Sentinel loops” • Short segment of bowel dilation adjacent to inflammation

Air-fluid Levels • Obstruction – Many dilated air-fluid levels in both limbs of a given loop at different heights (“candy canes”) • Ileus – Fewer/smaller air-fluid levels scattered throughout the abdomen

Arrangement of Bowel Loops (supine view only) • Obstruction – Orderly – “Bag of sausages” • Ileus – Disorderly – “Bag of popcorn”

Examples • HPI: Emesis and abdominal pain • PE: VSS, mildly tender Supine Upright

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Case #1 • HPI: 11 month male, stomach flu 2 wks ago, now with NB NB emesis x 5 and intermittently fussy over 12 hrs, no stool • PE: T 36. 5, P 118, Wt 50%, non-toxic appearing, well perfused, abdomen soft, flat, active bowel sounds, no masses, testes descended bilaterally, nontender, no fissure, heme-positive

Intussusception • 2: 1 male to female • 3 -12 mo of age • Triad: a) episodic pain, b) emesis, c) passage of bloody/mucoid stools • An abdominal mass may be present • Plain films may be normal up to 12 hours after symptom onset