A 46-year-old man is brought to the emergency department after a fall during a downhill bicycle race. The patient lost consciousness for approximately 1 minute and has severe back and abdominal pain. He has no other medical conditions. CT scan of the head reveals no intracranial bleeding; CT scan of the abdomen reveals a small retroperitoneal hemorrhage and splenic laceration. Lumbar film suggests a compression wedge fracture of the L2 vertebral body, and a brace is placed. The patient is conservatively managed with analgesics and supportive measures. On hospital day 3, he has mild, diffuse abdominal pain and nausea. His abdomen is distended, tympanic, and mildly tender without rebound or guarding. Bowel sounds are absent. Upright x-ray of the abdomen is shown in the image below: Which of the following is the most likely diagnosis?

Question

A 46-year-old man is brought to the emergency department after a fall during a downhill bicycle race.  The patient lost consciousness for approximately 1 minute and has severe back and abdominal pain.  He has no other medical conditions.  CT scan of the head reveals no intracranial bleeding; CT scan of the abdomen reveals a small retroperitoneal hemorrhage and splenic laceration.  Lumbar film suggests a compression wedge fracture of the L2 vertebral body, and a brace is placed.  The patient is conservatively managed with analgesics and supportive measures.  On hospital day 3, he has mild, diffuse abdominal pain and nausea.  His abdomen is distended, tympanic, and mildly tender without rebound or guarding.  Bowel sounds are absent.  Upright x-ray of the abdomen is shown in the image below:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d902_f7ae_bc81_8d1753f9a6a3_MD0003_00 This patient developed abdominal pain and absent bowel sounds following a traumatic injury. X-ray demonstrates gastric dilation and gas-filled loops of both the small and the large intestines on abdominal x-ray, suggesting paralytic (adynamic) ileus. Ileus is most commonly a complication of abdominal surgery but can also be seen in other conditions such as retroperitoneal/abdominal hemorrhage, intraabdominal inflammation (eg, pancreatitis), intestinal ischemia, and electrolyte abnormalities. Contributors to the pathophysiology of ileus include irritation and temporary paralysis of the abdominal sympathetic and parasympathetic nervous system, local release of inflammatory mediators, and opioid analgesic use. Signs and symptoms of ileus include nausea, vomiting, abdominal distension, failure to pass flatus or stool (obstipation), and hypoactive or absent bowel sounds. The diagnosis is clinical, but abdominal x-rays (classically revealing uniformly dilated, gas-filled loops of bowel with no transition point) can be helpful in confirmation. Management is conservative and includes bowel rest, supportive care, and treatment of secondary causes. (Choices A and E) The most common sites of volvulus in adults are the cecum/proximal ascending colon and sigmoid colon. Abdominal x-rays frequently reveal a transition point at the cecum or sigmoid colon. Patients are usually much older than this patient and have a more insidious onset of symptoms. Neither cecal nor sigmoid volvulus is a common complication of trauma. sigmoid colon (Choice B) In complete small bowel obstruction, the bowel distal to the obstruction is not distended. In addition, hyperactive "tinkling" bowel sounds are typically present on physical examination. Peristaltic waves on the abdominal wall can also be observed. small bowel obstruction (Choice C) Gastric outlet obstruction demonstrates only a distended stomach on x-ray. A succussion splash may be heard over the stomach; otherwise, bowel sounds may be normal or hyperactive. (Choice F) Perforation of abdominal viscus commonly causes free air under the diaphragm as well as diffuse abdominal tenderness with rebound and guarding (due to peritonitis), neither of which is present in this patient. free air under the diaphragm Educational objective: Ileus is commonly due to abdominal surgery but can also be seen in retroperitoneal/abdominal hemorrhage, intraabdominal inflammation (eg, pancreatitis), intestinal ischemia, and electrolyte abnormalities. Signs and symptoms include nausea, vomiting, abdominal distension, obstipation, and hypoactive or absent bowel sounds. Abdominal radiography classically reveals uniformly distended, gas-filled loops of both the small and the large intestines. References: Paralytic ileus in the orthopaedic patient. (http://www.ncbi.nlm.nih.gov/pubmed/25917235)

A 46-Year-Old Man Is Brought to the Emergency Department After