Clip 1: Akinetic, dilated loops of bowel with intraperitoneal free fluid raising the concern for an early strangulated SBO.
Clip 2: Akinetic, dilated loops of bowel with intraperitoneal free fluid raising the concern for an early strangulated SBO.
A 60 something year old male presented with abdominal distention, pain, and emesis. A small bowel obstruction (SBO) was diagnosed at 6:54 PM at the first physician evaluation, after the physical exam but prior to any other diagnostic workup. POCUS abdomen (images above) showed akinetic dilated loops of bowel > 2.5 cm as well as intraperitoneal free fluid. The patient was uncomfortable, had been vomiting so a nasogastric tube was placed. Surgery was consulted a few mins later and came to see the patient. At 9:56 PM a CT looking for a transition point resulted with a high grade SBO and the patient was taken to the OR for exploratory laparotomy. In the OR, a small segment of bowel was found to be incarcerated in the internal inguinal ring but pink and viable, not [yet?] strangulated.
POCUS Pearl: Regarding simple SBO versus strangulation. “Intraperitoneal free fluid is sensitive, but not specific for strangulation. Akinetic loops is an ‘ominous’ sign, as compared to the ‘to-and-fro’ peristalsis of simple SBO. Criteria for early strangulation; 1) The presence of an akinetic dilated loop, 2) Rapid accumulation of free intraperitoneal fluid after the onset of obstruction, and 3) The presence of peristaltic activity in dilated small bowel proximal to the akinetic loop.” [Ma, O. John, James R. Mateer, and Robert F. Reardon. Ma and Mateers Emergency Ultrasound. McGraw Hill Professional, 2020.]