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.

Abdominal X Ray: Intussusception

6 months old baby girl with no known medical illness and post weaning one week was brought to hospital by her mother after developing diarrhea, vomiting and fever for one day. The mother describes the diarrhea as a watery stool associated with mucous and blood streak.

This is the picture of her abdominal X ray which shows small bowel dilatation (as evidence of central position and valvulae) and thickening of the bowel wall at right lower quadrant. There was no free gas and no paucity of the bowel gas. Ultrasound abdomen shows classical sign of intussusception which is a “Target Lesion” sign. A diagnosis of Subacute Intestinal Obstruction Secondary to Intussusception was made  and patient was then posted for emergency laparotomy for reduction of intussusception, KIV bowel resection and end to end anastomosis. Intra operatively, there was a ileo-colic intussusception with bluish discoloration of bowel. Otherwise the integrity of the bowel still preserve and the color return to pinkish color after warm packing. Post operatively was uneventful.

Notes: Credited to Dr Juhara Haron (Radiologist USM) for guidance in interpreting the X Ray

Important Dd(x) of urolithiasis or renal colic

1) Abdominal aortic aneurysm

- Beware of the patient age > 60 years old presented with first episode of renal colic

- Rule out AAA first before diagnose urolithiasis

- look for pulsatile abdominal mass

- Bedside ultrasound if available

2) Acute appendicitis

- Alvarado score may be helpful to rule out appendicitis

3) Urinary tract infection with urolithiasis

4) Pyonephrosis/ Pyleneprosis

5) Renal artery embolus

6) Testicular torsion

- Particularly in younger age patient especially late teenage age.

7) Others uncommon causes like bowel obstruction, Infective gastroenteritis, Acute urinary retention, obstructed inguinal hernia, orthopedic problem, abdominal abscess, epididymitis, orchiditis, acute pancreatitis.