Obstruction or Ileus ? Jim Lamphear Pediatric GI Fellow

1. Obstruction or Ileus ?Jim LamphearPediatric GI Fellow

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

3. 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

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

5. “AIM” • Adhesions • Appendicitis • Intussusception • Incarceratedinguinal hernia • Malrotation • Meckel's • Masses

6. 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

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

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

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

11. 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

12. 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

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

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

15. Example #1

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29. Example #15

30. 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: T36.5, P118, Wt 50%, non-toxic appearing, well perfused, abdomen soft, flat, active bowel sounds, no masses, testes descended bilaterally, non-tender, no fissure, heme-positive

32. 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