ER Case Presentation

40 Years old Gentleman, no known

co-morbids, R/O Karachi, brought to
the E.R with complaints of:
Abdominal Pain 4-5 days
Constipation
3 days
Vomiting
2 days

 Pain
Epigastric, sudden onset, Diffuse, crampy,
intermittent. Non radiating. Worsening with time.
Vomiting. 5-6 episodes daily. Food particles.
Everything he eats or drinks. Non bilious, Non
bloody. Non projectile

Stool
-constipated- Not able to pass stool since last
3 days despite straining
-able to pass flatus

 ROS: No hx of trauma, no fever, no hx of

eating out, Urine-N, Sleep-disturbed,
appetite- decreased, Weight loss- none
PMH/PSH: Right Inguinal Hernia repair
2013
F.H: Unremarkable
D.H: NSAIDs for Pain Management
S.H: Banker, married, with 2 kids, no known
allergies or addictions

General Physical:
Middle aged gentleman, lying in distress
Appears Pale, No signs of Jaundice,
Clubbing, Edema, Lymphadenopathy
Vitals :
B.P 138/75
Pulse 109/min
Temp: Afebrile
02 sats : 99%
Resp. Rate: 19/min

Abdominal Exam:
Marked abdominal distension with
midline abdominal fullness
Mild tenderness to palpation,
hyperactive bowel sounds
throughout
No palpable masses
Other systems unremarkable

Differentials

Bowel obstruction
Paralytic Ileus
Gastroenteritis
Diverticular Disease
Ischemic Bowel Disease

Hb: 12
Hct :37.1
WBC 8.4
Plt 245
Amylase : 10
Lipase: 11
BUN: 8
Cr: 0.9

Na: 142
K: 4.5
Cl: 99
BIC: 24.1
Tb:0.6
DB:0.1
IDB:0.5
SGPT: 39
GGT: 48

Abdominal X- Ray
Distended loops of small bowel and
air fluid levels

 Patient was kept NPO

NG tube
Maintenance Fluids were started with
Normal Saline
Foleys catheter
IV Analgesia with Morphine
IV Metoclopramide
Patient was admitted under care of
General Surgery Team.

LITERATURE REVIEW

Am Surg. 2013 Apr;79(4):422-8.

Routine nasogastric decompression in

small bowel obstruction: is it really
necessary?
Fonseca AL, Schuster KM, Maung AA, Kaplan LJ, Davis KA

A retrospective chart review was

conducted of adult patients admitted to
Yale New Haven Hospital over five years
with the diagnosis of SBO
290 patients fit the criteria
Sixty-eight patients (23.45%) did not
present with emesis; however, nearly 75
per cent of these patients received NGTs

 Development of pneumonia and

respiratory failure was significantly
associated with NGT placement. Time
to resolution and hospital length of
stay were significantly higher in
patients with NGTs.

References
Am Surg. 2013 Apr;79(4):422-8.
Routine nasogastric decompression in small
bowel obstruction: is it really necessary?
Fonseca AL1, Schuster KM, Maung AA, Kaplan LJ, Davis
KA
Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL,
Ansaloni L, et al. Bologna guidelines for diagnosis
and management of adhesive small bowel
obstruction (ASBO): 2013 update of the
evidence-based guidelines from the world society
of emergency surgery ASBO working group. World
J Emerg Surg. Oct 10 2013;8(1):42. [Medline]

THANK YOU!