Instructions
You are a medical student on placement in the emergency department. Emmanuel Dela Cruz, 84, has come by ambulance from his aged-care home with a tight, swollen belly.
Interpret the abdominal X-ray provided
Outline to the examiner:
- Your most likely diagnosis and differentials
- Next steps in management, including relevant investigations
- You do not need to take a history or examine the patient
Transfer note: this episode
Belly swelling and getting tighter over 2 days. No bowel action or wind for 2 days. Vomited green fluid twice this morning. Crampy pains; eating very little.
Transfer note: background
Parkinson disease for 12 years. Long-standing constipation; bowels usually open every 2 to 3 days. A similar but milder swelling 14 months ago settled on its own within a day. Mild memory problems; walks with a frame. No weight loss or blood in the stools noted.
Transfer note: medicines
Levodopa 100 mg with carbidopa 25 mg at 7 am, 11 am, 3 pm and 7 pm; last dose 7 am today. Macrogol 1 sachet each morning; senna 2 tablets at night; paracetamol 1 g as needed. No known drug allergies.
Transfer note: contacts
Daughter, Marisol Dela Cruz, is his enduring guardian and is on her way. No advance health directive on file.
Supine abdominal X-ray (today, 11.40 am)
| Item | Value | Reference range |
|---|---|---|
| Patient and film | Emmanuel Dela Cruz, today 11.40 am. Supine AP abdomen; both hemidiaphragms to the pubic symphysis included; adequately exposed | - |
| Large loop | One very large gas-filled loop of bowel, about 13 cm across, rises out of the left side of the pelvis as an upside-down U and reaches up under the right hemidiaphragm, above the level of the transverse colon. Its wall is smooth, with no folds crossing it | Colon under 6 cm across |
| Centre of the loop | Where the two limbs of the loop lie side by side, their walls make a thick white line that runs down to a point in the left pelvis, where the limbs meet | - |
| Rest of the colon | Ascending, transverse and descending colon gas-filled and mildly widened, with folds that partly cross the bowel; caecum 7 cm across. The large loop overlaps the lower edge of the liver and the descending colon | Colon under 6 cm; caecum under 9 cm |
| Small bowel | A few loops in the centre of the abdomen, none more than 3 cm across | Under 3 cm across |
| Rectum | No gas seen in the rectum | - |
| Faeces | A little mottled faeces in the ascending colon; no large faecal mass in the rectum or pelvis | - |
| Gas outside the bowel | Gas lies only inside the bowel: the outer surface of the bowel wall is not outlined, and there is no gas over the liver, in the bowel wall or in the liver | - |
| Solid organs, bones and calcification | Psoas and liver outlines partly hidden by the large loop. Degenerative change in the lumbar spine; calcification in the aorta and iliac arteries; no stones seen | - |