|Case of the Week - Patient Summary 13808|
Peer Reviewed and Certified -
|Demographics: 53 y.o. woman|
|History & Chief complaint:|
| 53 y.o. woman complaining of abdominal pain and nausea. |
|Physical exam and Laboratory:|
| unavailable |
|Summary of Findings:|
|Scout shows gas filled transverse colon, loops of contrast filled small bowel and paucity of gas in the right side of the abdomen.
CT images show dilated cecum, colon and small bowel. There is propulsion of bowel contrast through the ileocecal valve mimicking intussusception. There is omental caking with multiple peritoneal poorly defined, contrast enhancing soft tissue masses throughout the pelvis. The uterus and ovaries are not clearly identified. The rectum is encased by a soft tissue mass and represents the transition point in dilation of the bowel.
|• Large bowel obstruction
• Ovarian cancer
• Colon cancer
• Endometrial cancer
• Pertoneal carcinomatosis
| Colon Obstruction, Metastatic ovarian adenocarcinoma |
|Confirmed by: Exploratory laparotomy|
|Treatment and Followup:|
|Patient was diagnosed with metastatic ovarian adenocarcinoma. She had a colostomy to alleviate the obstruction acutely.|
|Patient Specific Discussion: (Also Read the Disease Discussion)|
|Bowel contrast in the setting of obstruction may be used to differentiate bowel from abscess, assess bowel wall thickness, or even to characterize bowel masses or causes for the obstruction. It is known that oral contrast takes anywhere from 2.5 to 10 hours to reach the rectum in an obstructed individual. In this case, the bowel contrast clearly is flowing through the ileocecal valve. This mimics a target lesion seen in intussusception. The patient received urgent surgery but did not have an intussusception.|
|Large bowel obstruction is a common diagnosis and accounts for approximately 25% of all bowel obstructions. Regardless of the cause, obstruction is mechanical in nature. They can range from partial obstructions to complete obstruction. Depending on the cause of the obstruction, surgical management may vary from immediate surgery to 2-3 days of bowel rest and watchful waiting. The most common cause of bowel obstruction in the US is adhesions, predominantly from previous surgery. Other important causes include volvulus, which in adults is concerning for underlying malignancy. In the elderly population, fecal impaction is potentially a source.
The typical symptoms of patients are lower abdominal pain, nausea, vomiting, and constipation/obstipation. Obstipation is unreliable as it may not be complete even in the setting of full obstruction as colonic flora distal to the obstruction may continue to make some amount of gas.
Imaging findings on radiograph typically include dilated loops of bowel filled with fluid, gas (may have multiple air-fluid levels in loops of bowel) and/or stool. The 3, 6, 9 rule is easy to remember for criteria for bowel obstruction. On radiograph:
Small bowel is considered dilated when it measures over 3 cm in diameter.
Colon is considered dilated when the diameter exceeds 6 cm.
The cecum is not considered dilated until 9 cm.
Cecum over 10 cm in diameter is at increased risk for rupture/perforation. It is important in the setting of dilated colon to assess the cecum as (according to Laplace's Law) it should be the most dilated in the setting of obstruction. If it is not dilated along with the distal portions of the colon, it is possible that the patient has pseudo-obstruction, which would be managed clinically in a completely different way. Additional findings include a transition point in dilation of the colon with stool and gas proximal to the obstruction and normal colon distally. Remember that haustra folds
are incomplete rings seen around the large bowel wall and these are what differentiates large bowel from small bowel (small bowel lines are complete rings around the bowel).
Another sign of obstruction is lack of visualized bowel in the abdomen. This is termed paucity of gas and it results from lack of interface between different radiographic densities such as air and fluid. This will, however, be picked up on CT.
Once a large bowel obstruction is suggested on radiograph, CT may be indicated to find the source of the obstruction and guide clinical management. The differential diagnosis here is extensive and management will vary depending on what is the cause.