Adhesion Colic: Don’t Forget the Erect CXR

This patient is a 45 years old lady with history of hysterectomy five years ago due to uterine fibroid and two history of admission due to sub acute IO secondary to adhesion colic which relief by conservative treatment. She presented to health care provider for three times within 24 hours due to severe abdominal pain.

The pain being described as colicky, starting at the upper abdomen and radiate to the whole abdomen, initially relieve temporarily with IV analgesia given by the healthcare provider. The pain score is 7-8/10, and associated with nausea and vomiting, anorexia and feeling un well.

The abdominal radiograph shows dilated small bowel and the CXR erect shows air under the right diaphragm.

Discussion

Two modalities of radiological investigation in emergency department for evaluating acute abdomen are plain radiograph and CT scan.

Selection of modality depends on your working diagnosis. The current practice to use plain radiograph as screening modality should be discouraged except under certain circumstances.

Abdominal and CXR Erect is particularly helpful in evaluating acute abdomen due to free air secondary to small bowel obstruction, perforated peptic ulcer disease and foreign body. In my practice, I still prefer to take AXR as an evidence of diagnosing constipation.

Meanwhile, CT abdomen has higher sensitivity for bowel obstruction, urolithiasis, appendicitis, pancreatitis, pyelonephritis and diverticulitis (James H Street & Xzabia Caliste)

Adhesion colic can present with varying degree of severity. Most often, it is the movement of bowel together with the joined bowel by adhesion that causing pain. However, the presence of vomiting, constipation warrants and AXR to look for mechanical bowel obstruction. If Patient presented with a very tender abdomen and patient look un well, you should take the erect CXR as well since minority of them may actually develop perforated viscous or leakage of air.