Image 1: Dilated loops of bowel with ‘too and fro’ movement of GI content as well as ‘Tanga’ sign (hyperechoic triangle shape in center of screen) signifying extraluminal free fluid.
Image 2: Bowel diameter measuring more than 2.5 cm (Blue line / Orange box with bowel diameter = 3.29cm). “Keyboard sign” representing well-defined plicae circulares (red arrows).
by Dr. Mario Alberto Lorenzana de Witt
History of Presenting Illness
40s year old male with a PMH of myasthenia gravis c/b multiple prior exacerbations requiring intubation, thymoma s/p thymectomy c/b L phrenic nerve injury and hemidiaphragm paralysis, severe COVID-19 pneumonia requiring intubation c/b PEA arrest, refractory respiratory failure (on home O2 2L) presents to the ED with abdominal pain and distension. 1 day ago patient was eating a sandwich and shortly afterwards developed generalized abdominal pain. His abdomen became distended and his pain slowly worsened. Since then, he has not been able to pass any bowel movements or flatus.
Physical Exam
Abdomen is distended and tense, with generalized tenderness
POCUS PEARLS:
Point-of-care ultrasound (POCUS) offers a rapid & effective method for evaluation of potential small bowel obstruction (SBO) in patients with concerning clinical histories. While POCUS is not the definitive diagnostic imaging for SBO, its utility lies in expediting its treatment. The examination involves systematically scanning the abdomen in the transverse plane across all four quadrants, utilizing a curvilinear transducer. This technique allows for a swift assessment, potentially leading to earlier intervention and improved patient outcomes.
Signs of SBO on POCUS include:
Back and forth peristalsis (Image 1).
Bowel diameter measuring more than 2.5 cm (Image 2).
“Keyboard sign” representing well-defined plicae circulares (Image 2’s arrows).
“Tanga sign” or Free fluid that appears like a triangle between bowel loops (Image 1).
Disposition
The patient's case demonstrates a rapid progression from initial examination to surgical intervention. The findings from POCUS during the initial exam prompted immediate surgical consultation. A decision for admission and treatment was established preemptively, preceding confirmatory CT imaging. Exploratory laparoscopy revealed an adhesive band causing proximal bowel dilation, necessitating distal bowel decompression. This case highlights the importance of how prompt clinical evaluation by POCUS can lead to decisive intervention in managing acute abdominal pathology.