Mechanical bowel obstruction is differentiated from paralytic ileus in X rays by
Correct Answer: Absence of rectal gas shadow
Description: Answer: a) Absence of rectal gas shadow (BAILEY 26th ED, P-1189)INTESTINAL OBSTRUCTIONProximal small bowelDistal small bowelLarge bowel* Vomiting early and profuse* Minimal distension* Colicky pain* Peristalsis not seen* Little evidence of air fluid levels in X-ray* Pain - intermittent, colicky* Central distension* Vomiting delayed (bilious)* Step ladder peristalsis* Multiple air fluid levels* Pronounced early distension* Pain is mild* Vomiting (faeculent) and dehydration are late* Right to left peristalsis may be seen* Proximal colon and caecum are distended on X-rayJejunum - Concertina or ladder effect due to valvulae conniventes (Herring bone pattern)Fluid levels appear later than gas shadowThree inconstant fluid levels in adults (considered normal)Fundus of stomachDuodenal capTerminal ileumFew fluid levels in the small intestine may be physiological in infants less than 1 yearFluid levels in non obstructive conditions (Inflammatory bowel disease, Acute pancreatitis, Intraabdominal sepsis)PARALYTIC ILEUSFailure of transmission of peristaltic waves secondary to neuromuscular failureIntestinal obstruction/slowing/absence of passage of luminal contents without a demonstrable mechanical obstructionEtiologyPost operativeA degree of ileus usually occurs after any abdominal procedureSelf-limiting (24-72 hours)May be prolonged in Hypoproteinemia or metabolic abnormalityIntra-abdominal inflammation(peritonitis, abscess, retroperitoneal hemorrhage)Reflex ileus: following fractures of spine/ribs, retroperitoneal hemorrhage or application of a plaster jacketMetabolic & electrolyte derangements (uremia, hypokalemia, hyponatremia, hypo and hypomagnesemia, diabetic coma, hypoparathyroidism, hypothyroidism)Drugs (opiates, psychotropic agents, anticholinergic agents, calcium channel blockers)Intestinal ischemia; Myocardial infarction; Ureteric colicClinical featuresAbdominal distension usually without colicky abdominal painNausea, vomiting, absent bowel sounds and absolute constipationNo passage of flatusIn the absence of gastric aspiration, effortless vomiting may occur X-Ray: gas filled small and large bowel loops with multiple air fluid levelsTreatmentNasogastric decompression, IV fluids, electrolyte managementTreat the underlying causeCatchpole regime: adrenergic blocking agent + cholinergic stimulant (neostigmine) used in resistant casesParalytic ileusMechanical Obstruction* Generalized, uniform, gaseous distension of the large and small bowel* Diffuse air fluid levels* Involvement of large bowel and lack of a transition point* Quiet abdomen* Dilated loops of small bowel proximal to the obstruction; no air in colon* Step ladder air/fluid levels* Transition point seen* Valvulae conniventes are visible in jejunum (concertina or ladder effect)* Featureless ileum* Initially active peristalsis; later quite
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