Case 13 - Poo and Fro
Author: Gokul Sagar Bailur Reviewer(s): Nick Mani, Nish Cherian
A 35-year old female presents with a few days of intermittent abdominal pain which suddenly worsened. She has not had bowel movements or passed flatus, and has vomited multiple times. She has a surgical history of a previous appendicectomy but is otherwise fit and healthy. On examination, her vitals are stable and she appears dehydrated with a diffusely tender and distended abdomen. Her VBG shows a lactate of 3. Urine hCG is negative and labs are pending.
The department is crowded and there is a long wait for X-ray and CT. The Surgical team are reluctant to admit the patient without imaging, the charge nurse and flow coordinator are pushing for a disposition. You elect to perform a focused ultrasound of the bowel to enhance your clinical assessment:
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Dilated small bowel loops filled with fluid and small amount of free fluid between bowel loops - “Tanga Sign”
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Prominent Valvulae Conniventes. This also suggests edematous bowel wall- “Keyboard Sign”
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Abnormal peristalsis showing to and fro movement of bowel contents- “To and Fro Sign”
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Small bowel obstruction.
Bowel POCUS has good sensitivity and specificity for SBO in patients with a reasonable pre-test probability.
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XR
Abdominal XR has a low sensitivity, specificity, NPV, PPV and likelihood ratios for small bowel obstruction. Supine x-rays poorer than erect.
POCUS -Dilated bowel loops >3 cm- Specificity 83.7%
Abnormal or no peristalsis - Specificity 97%
A systematic review of 11 studies comprising of 1178 patients (Gottlieb M et al. 2018) showed that Ultrasound had Sensitivity 92% and Specificity 96.6%
Image 1. Dilated fluid filled bowel loop measuring 3cms.
Image 2. AXR (erect) demonstrates an isolated/non-specific air fluid level in LUQ
Image 3. Abdo/Pelvis CT scan demonstrates multiple fluid filled dilated small bowel loops.
Case Resolution
The patient was was eventually admitted to the surgical assessment unit facilitated by the POCUS findings. She was initially managed non-operatively, but due to worsening symptoms and rising lactate underwent an emergency laparoscopic adhesiolysis. She made a good post-operative recovery and was discharged.
