PHYSICAL DIAGNOSIS OF SMALL BOWEL OBSTRUCTION

A middle aged man presented with worsening bloating, cramping abdominal pain, nausea, and vomiting. He had been in the ED the day before for similar symptoms, his x-rays were normal, and he had been diagnosed with gastroenteritis. With vomiting and cramping pain, you wonder about a bowel obstruction. Can physical diagnosis help?

LIMITATIONS OF RADIOGRAPHS

This is a very important topic because plain films have a sensitivity for small bowel obstruction approximately 50% and even noncontrast CT scan has limitations in sensitivity (Ros J Am Coll Radiol 2006).

DISTENSION IS HUGE!

The first thing is to recognize that intestinal obstruction is a heterogenous event, and presents differently according to the level of obstruction, whether proximal or distal. In general the more proximal obstructions present with dominant vomiting, and the distal obstructions present with prominent distension. This is huge (literally). When you see distension, pursue this finding, as it has high discriminatory value.(Eskelinen 1994)

SCARS OUTSIDE PREDICT SCARS INSIDE

The majority of patients (85%) with bowel obstruction have a history of previous abdominal surgery.(Eskelinen Scand J Gastroenterol 1994) In the poor historian, an abdominal scar is a useful proxy.

BOWEL SOUNDS

Diminished bowel sounds indicate ileus and increased bowel sounds indicate bowel obstruction, though there is overlap and these are neither sensitive nor specific.(Gu Dig Surg 2010) Listen for an increase in loudness, faster cycle times, and a higher pitch of sound. SBO can make everything higher: volume, frequency, pitch. If the radiologist says it is SBO vs ileus then the presence of bowel sounds is helpful in arguing against ileus. Gastroenteritis will cause increased bowel sounds.

OTHER FINDINGS

A history of constipation is present in only 37% but is 90% specific. Relief with vomiting is not common (19% sensitive) but very specific for bowel obstruction (93%) .

Take home points

-Note the history of abdominal surgeries or look for a scar

-Distension is huge! (sensitive and specific)

-Auscultation may have some value in ileus vs gastroenteritis vs SBO

“ACUTE FEBRILE ERYTHEMATOUS SYNDROME” – T KAWASAKI, 1967

A child presents with a fever and systemic constitutional symptoms. Could this be Kawasaki disease?

 

Many of the diagnostic features of Kawasaki disease are nonspecific, and indeed, in one study 46% of patients who met criteria for Kawasaki disease were actually found to have a different disease.(Burns J Pediatrics 1991)

 

Kawasaki disease is a systemic vasculitis of medium sized arteries.(Takahashi Clin Exp Immunol 2011) Coronary arteritis begins day 6-8 and the monocyte/macrophage damage continues for several weeks.

 

The first alert is prolonged fever. In the first few days of illness the disease is often not distinguishable from many viral illnesses. After five days of fever, Kawsaki disease should be considered.(Newburger Circulation 2004)

 

Consider the original case description. Tomisaku Kawasaki introduced the disease in 1967, describing it as an “acute febrile erythematous syndrome.”(Kawasaki Pediatric Infect Dis J 2002, translation)

 

Erythema affects the eyes, lips, and oral mucosa. The conjunctivitis is classically limbus-sparing, meaning a halo of white sclera surrounds the iris. The erythema of the lips and oral mucosa is deep and colorful. Kawasaki writes “in our cases we noted only dryness, redness, erosion and cracking of lips and diffuse injection of whole oral mucosal membrane, which never formed aphthae, ulcers or pseudomembrane.”

 

As for the other classic signs, they are either nonspecific (cervical lymphadenopathy) or occur late, after we would like to have already made the diagnosis (desquamation). Focus on the erythema and the fever as means of “triggering” you to consider the diagnosis.

 

TAKE HOME POINTS:

Prolonged fever prompts the clinician to consider Kawasaki disease

The vasculitis produces a deep erythema of the conjunctivae and lips/oral mucosa.