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Case of the Month 07/10

This 44-year-old female with anoxic brain injury with associated motor dysfunction only presented to the ED with two days of abdominal pain and distention. Since the symptoms began, she had been vomiting several times per day and had not had any bowel movements or flatus.

Question 1: What's wrong with this picture?

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Answer 1:

There are several loops of dilated large bowel. Large bowel can only be reliably differentiated from small in on plain film by the presence of solid stool (not seen well here). Another (less reliable but still helpful) way to differentiate large from small bowel radiologically is by the presence of haustra (which do not go all the way across the bowel) instead of valvulae conniventes (which do go all the way across the bowel). The arrow below points to one of the few visible haustra on this image and the double arrow points to the valvulae conniventes on another one of her abdominal images.

Question 2: What are some possible next steps to help clarify the exact cause of these findings?

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Answer 2:

It may be impossible (as in this case) to radiologically differentiate pseudo-obstruction (also known as Ogilvie’s syndrome) from actual large bowel obstruction. Options to help make the correct diagnosis include barium enema, colonoscopy or abdominal CT. This patient underwent an abdominal CT which was read as small bowel obstruction. She was taken to the OR where she was actually found to have a cecal volvulus. This case demonstrates the difficulty we often see in differentiating exact cause of bowel obstruction with imaging in the ED.