Patient details
- Name
- Mr A.D.
- Age / sex
- 58-year-old man
- Occupation
- Farmer
- Marital status
- Married
- Admitted
- Emergency department, 16:20
- Clerked
- Surgical ward, 17:30
- Source
- Patient himself, reliable
- Referred by
- Family doctor
Presenting complaint
“Cramping pain in my tummy and vomiting for two days.”
History of presenting complaint
Mr A.D. was well until two days before admission, when he developed pain in the centre of the abdomen that came on gradually. The pain comes in waves, each lasting about a minute and returning every four to five minutes, reaching 8 out of 10 at its peak, and he is free of pain between the waves. It does not spread anywhere and nothing he has tried relieves it. A few hours after the pain began he started to vomit, first food and then green bile; he has vomited more than six times in the last day, in large amounts, and each vomit eases the pain for a short while. Since yesterday his abdomen has become swollen and his trousers no longer fasten. He last opened his bowels two days ago, with a normal stool, and has not passed wind for 24 hours. He is very thirsty and has passed only a small amount of dark urine today. He had one similar but milder attack two years ago, which settled in hospital after two days with a tube in the nose and a drip. The pain has remained in waves and has not become constant, and he has had no fever. He has not noticed a lump in either groin or at his scar. Before this illness there was no blood in his stool, no change in his bowel habit and no weight loss. He has had no burning on passing urine and no jaundice.
Past medical history
Hypertension for six years. No diabetes, no heart disease.
Past surgical history
Midline laparotomy in 2014 for a perforated duodenal ulcer. Recovery was uneventful. No hernia repairs.
Drugs and allergies
Amlodipine 5 mg once daily. Omeprazole 20 mg once daily. No opioid painkillers and no other regular drugs.
No known drug allergies.
Family history
No family history of bowel cancer.
Social history
Smokes 20 cigarettes a day for 30 years (30 pack-years). No alcohol. Lives with his wife and works on his own land.
Last ate two days ago; has taken only sips of water since, last at 15:00.
Systems review
Cardiovascular, respiratory, neurological and musculoskeletal systems: no symptoms.
General examination
A man who looks unwell and tired, with bouts of pain during the examination. Alert and orientated. Tongue dry, eyes sunken, skin fold over the sternum slow to return. Not pale, not jaundiced.
Urine dark and concentrated. No enlarged lymph nodes in the neck.
Abdominal examination
Inspection
Abdomen distended, symmetrically and mainly in the centre. Healed midline scar with no bulge on coughing. Visible peristalsis across the upper abdomen during a wave of pain.
Palpation
Soft, with mild tenderness throughout. No guarding, no rebound and no area of localised tenderness. No mass felt.
Percussion
Drum-like note throughout. No shifting dullness.
Auscultation
High-pitched, tinkling bowel sounds coming in rushes that coincide with the pain.
Hernial orifices
Both inguinal and both femoral orifices examined: no lump and no cough impulse. Scrotum normal.
Rectal examination
Performed with consent and a chaperone. Rectum empty. No mass. No blood on the glove.
Other systems
Chest: equal air entry, no crackles.
Heart: first and second heart sounds normal, no murmurs.
Legs: calves soft, no swelling.
Summary
Provisional diagnosis
Small bowel obstruction due to adhesions, with dehydration and no clinical sign of strangulation.
Initial plan
- Nil by mouth. Nasogastric tube on free drainage. Intravenous fluids with potassium replacement guided by results.
- Urinary catheter and hourly urine output. Analgesia and antiemetic.
- Bloods: full blood count, urea, creatinine and electrolytes, lactate and blood gas.
- Abdominal X-ray, then CT of the abdomen and pelvis with intravenous contrast.
- Senior surgical review. Re-examine the abdomen every few hours and record it.
- Operation if signs of strangulation appear or the obstruction does not settle.
Differential diagnosis of intestinal obstruction
First decide whether it is mechanical or functional, then small or large bowel, then the cause.
| Diagnosis | Points to it in the history | Points to it on examination | In this patient |
|---|---|---|---|
| Small bowel, mechanical | |||
| Adhesions | Previous abdominal operation; earlier attacks that settled | Abdominal scar, soft distended abdomen | Most likely |
| Strangulated groin or incisional hernia | Lump that has become painful and will not go back | Tense, tender lump with no cough impulse | All orifices and the scar are normal |
| Crohn's stricture | Years of diarrhoea, weight loss, earlier milder attacks | Thin, mass in the right iliac fossa | No bowel history |
| Small bowel tumour | Weight loss, anaemia, attacks getting more frequent | Often nothing | CT will show |
| Gallstone ileus | Elderly woman with known gallstones | Signs of obstruction, no scar and no hernia | He has a scar and a better explanation |
| Large bowel, mechanical | |||
| Cancer of the colon | Weeks of change in bowel habit, bleeding, weight loss; distension before vomiting | Great distension around the edges of the abdomen, mass, empty rectum | No earlier bowel symptoms |
| Sigmoid volvulus | Elderly or bedbound, sudden great distension, earlier episodes | Very tense drum-like abdomen | Not the pattern |
| Functional | |||
| Paralytic ileus | Recent operation, peritonitis, low potassium; little pain | Silent distended abdomen | Bowel sounds are loud |
| Pseudo-obstruction | Elderly, unwell in hospital, on opioids | Great distension with gas in the rectum | Fit man at home |
| Mimics | |||
| Gastroenteritis | Vomiting with diarrhoea; others affected | No distension | No stool or wind |
| Acute pancreatitis | Constant epigastric pain through to the back | Epigastric tenderness | Pain is colicky |
| Mesenteric ischaemia | Elderly with atrial fibrillation; severe constant pain out of proportion to the signs | Few signs at first, then peritonitis | Pain comes in waves |
Clinical signs related to this case
The signs you should look for in any patient with suspected intestinal obstruction. For each one, know how to elicit it and what a positive result means.
| Sign | How to elicit it, or what you see | What it means |
|---|---|---|
| Signs of obstruction | ||
| Distension | Central in small bowel obstruction; around the flanks and upper abdomen in large bowel obstruction | Gas and fluid held up above a blockage |
| Visible peristalsis | Waves seen crossing the abdomen, best during a pain | Bowel contracting against an obstruction |
| Drum-like percussion note | Resonant throughout | Gas-filled bowel. Dull flanks that shift suggest fluid. |
| Tinkling bowel sounds | High-pitched, in rushes, with the pain | Mechanical obstruction |
| Silent abdomen | No sounds after listening for a full minute | Ileus, or late obstruction with dead bowel |
| Succussion splash | Splashing heard when the abdomen is rocked, hours after a meal | Stomach full of fluid: gastric outlet obstruction or high obstruction |
| Empty rectum | No stool on rectal examination | Obstruction higher up. A mass or impacted stool gives the cause. |
| Signs of the cause | ||
| Abdominal scar | Any scar, including laparoscopic ports and old groin scars | Adhesions |
| Groin or scar lump without cough impulse | Tense, tender, irreducible | Strangulated hernia |
| Signs of strangulation | ||
| Constant pain | The colic stops coming in waves and stays | Bowel wall is ischaemic |
| Fever and rising pulse | Temperature above 38 °C, pulse climbing on repeated checks | Dead or dying bowel |
| Localised tenderness, guarding, rebound | One area clearly more tender than the rest | Peritonitis over the affected loop |
| Signs of fluid loss | ||
| Dry tongue and slow skin fold | Pinched skin over the sternum returns slowly | Significant dehydration |
| Capillary refill over two seconds | Press on the sternum or fingertip for five seconds and time the return of colour | Poor perfusion |
| Low urine output | Less than half a millilitre per kilogram per hour | Kidneys under-filled; guides fluid replacement |
Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.