CASE STUDY

Waad Tageldin Abdalla Alhussein

U16103173
SMALL INTESTINE BOWEL
OBSTRUCTION X-RAY.

1. INTRODUCTION
A 45 years old male-patient came to the hospital on the 2nd of October 2018 with an
abdominal pain that has been going on for 3 days, the patient was referred to the x-ray
department for an abdominal x-ray examination.

2. ANATOMY
The abdomen is the area between the thorax and the pelvis, it starts below the
diaphragm and ends above the hip bone.
The abdomen is divided into nine regions as shown below in fig (1).:
1. Right hypochondriac region.
2. Epigastric region.
3. Left hypochondriac region.
4. Right lumbar region.
5. Umbilical region.
6. Left lumbar region.
7. Right iliac (inguinal) region.
8. Hypo gastric region.
9. Left iliac inguinal region.

1
 Fig(1). Regions of the abdominopelvic cavity. © 2018 Quizlet Inc.

It’s also surrounded by a lining called the peritoneum. The abdomen includes the
following organs:

 Stomach
 Intestines
 Liver
 Kidney
 Spleen
 Pancreas
 Gallbladder
 Abdominal aorta
 Inferior vena cava

The small intestine:

The intestines is divided into two parts, the small intestine, and the large intestine. The
small intestine itself is also sub divided into 3 parts, duodenum, jejunum, and ileum.
1. Duodenum: as shown in fig(2). it’s the first part of the small intestine
which is connected directly to the stomach at an end and to the jejunum
at an end, its also the shortest and the widest part of the small intestine
(25cm). its C-shaped and located at the umbilical region and the right
hypochondriac region.
2. Jejunum: as shown in fig(2). it’s the second or the middle part of the
small intestine, it connects to dedendum at an end and to ileum at an
end, its located at the umbilical region, its more thicker and vascular
than the ileum.

2
 3. Ileum: as shown in fig(2). it’s the last and the longest part of the small
intestine , its about (3.5 meter) long and its less muscular and less
vascular than the jejunum, it connects to the jejunum at an end and to
the large intestine at an end,its located at the umbilical region.

dedendum

jejunum

ileum

fig(2). Illustration of Parts of the small intestine.Copyright © All About Diagram 2016.

3. PHYSIOLOGY
The main function of the small intestine is digestion and absorption of nutrients and
minerals from food.

Digestion involves two distinct parts. The first is mechanical digestion by chewing,
grinding, churning and mixing that takes place in the mouth and the stomach. The second
part of digestion is the chemical digestion that uses enzymes, bile acids etc. in order to
break down food material into a form that can then be absorbed, then assimilated into the
tissues of the body. Chemical digestion occurs in the small intestine (and, to a lesser
extent, also in some other part of the gastrointestinal tract.

Once broken down the nutrients are absorbed by the inner walls of the small intestine
into the blood stream.

The small intestine is good for absorption since it has a large inner surface area. This is
formed due to the plicae circulars which project many tiny finger-like structures of tissue
called villi. [Rice University,14th -october-2018].

3
4. RADIOGRAPHIC ANATOMY
Abdomen, AP projection (Upright)

spleen

Transverse colon

descending colon

Psoas muscle

ascending colon

kidney

Iliac crest

rectum

4
5. PATHOLOGY
Small bowel obstruction refers to a partial or complete blockage of the small intestine.
If the small bowel is functioning normally, digested products will continue to flow
onward to the large intestine. An obstruction in the small bowel can partly or
completely block contents from passing through. This causes waste matter and gases
to build up in the portion above the blockage. It could also disrupt absorption of
nutrients and fluids.

causes
There are many causes of small bowel obstruction. It may occur in people of all ages.
Some of the common causes and risk factors include
 Adhesions:These are bands of scar tissue that may form after abdominal or pelvic
surgery. Prior abdominal surgery is the leading risk factor for small bowel
obstruction in the United States.
 Hernias: Segments of the intestine may break through a weakened section of the
abdominal wall. This creates a bulge where the bowel can become obstructed
if it is trapped or tightly pinched in the place where it pokes through the
abdominal wall. Hernias are the second most common cause of small-bowel
obstruction in the United States.
 Inflammatory disease: Inflammatory bowel disorders such as Crohn’s
disease or diverticulitis can damage parts of the small intestine. Complications
may include narrowing of the bowel (strictures) or abnormal tunnel-like
openings (fistulas).
 Malignant tumors: Cancer accounts for a small percentage of all small-bowel
obstructions. In most cases, the tumor does not begin in the small intestine,
but it spreads to the small bowel from the colon, female reproductive organs,
breasts, lungs, or skin.

symptoms
Symptoms may include
 Abdominal (stomach) cramps and pain.
 Bloating.
 Vomiting.
 Nausea.
 Dehydration.
 Malaise.
 Lack of appetite.
 Severe constipation – In cases of complete obstruction, a person will not be
able to pass stool (feces) or gas.

diagnosis

5
  Medical history:The doctor will ask the patient about any previous abdominal
or pelvic surgeries or relevant procedures that have been done.
 Physical examination: The doctor will examine the abdominal area for signs of
swelling, pain, masses, bulges or hernias, surgical scars, or tenderness.
 Blood tests: A complete blood count and electrolyte analysis will be done.

treatment
 Hospitalization: Patients with an intestinal obstruction are hospitalized.
Treatment includes giving intravenous (in the vein) fluids, bowel rest with
nothing to eat (NPO), and sometimes the need for bowel decompression
through a nasogastric tube.
 Anti-emetics: Medications may be required to relieve nausea and vomiting.
 Surgery: If the small intestine is completely blocked or strangulated, surgery
may be needed. Surgery’s goals are to identify and treat the causes of bowel
obstruction. At times, segments of the bowel may need surgery. The diseased
segment may need to be re-sectioned and removed. [©Cleveland Clinic, 14th -
october-2018]


6. PATIENT HISTORY
a 45 years old patient came to the hospital referred from a private clinic
experiencing acute lower abdominal pain for 3 days with distention in addition
to vomiting and diarrhea, the pain started at the left iliac fossa and now its in the
epigastrium, the patient has been feeling nausea and dull aching for the past 2
months, the patient showed at the hospital and has been given medication.

7. CLINICAL ASSESMENT AND DIAGNOSIS

clinical assesment
Abdomen is rigid, tender in the epigastric area, no bowl sounds heard.
diagnosis
Evidence of multiple air fluid levels with distended, no air under the diaphragm small
bowl loops. Small intestine bowl obstruction with no definite mechanical cause of
obstruction

6
8. INVESTIGATIONS REQUESTED
A Complete Blood Count test and an Electrolyte blood tests were requested to check the
electrolytes balance in the blood, the electrolytes blood test shows low levels of
N+,K+CL-,CO2 which indicates that the patient has lost nutrients and the electrolytes
isn’t balanced, in addition to an abdominal X-ray that shows the bowl obstruction and
the level of fluid and air.

9. MEDICAL DIAGNOSTIC IMAGING

The radiographer called the patient by the first 3 names and double checking by the
patient ID, the radiographer explained the procedure to the patient, asked him to
change his clothe and wear the hospital gown and then started positioning the patient.
Abdomen (AP) upright:
Using the DR system, the patient was in standing AP upright position with back in close
contact with the IR. The vertical grid was parallel with the midsagittal plane, central ray
was directed 2 inches (5cm) above the iliac crest, collimation field included the shadow
of the abdomen crosswise and included the diaphragm lengthwise, the technical factors
used were 65 KVp, 40 mAs, and SID of 100cm.

7
 Small intestine

Level of bowel obstruction

FIG(5). PATIENTS RADIOGRAPH,(ABDOMEN, AP PROJECTION IN UPRIGHT POSITION}, TAKEN

AT THE 2 N D OF OCTOBER-2018.

10. RESULTS OF MEDICAL DIAGNOSTIC IMAGING

Radiologist opinion:
Evidence of multiple air fluid levels with distended small bowel loops. No air under
diaphragm.

11. PATIENTS PROGNOSIS

Prognosis:
No surgery needed. The patient had some prescribed oral medications for 5 days that
will result in full recovery:
1.cefuroxime: an antibiotic to stop the growth of bacteria and skin/tissue inflammation.
2.metronidazole: antibiotic used for intestinal and stomach inflammation and ulcers
caused by a bacteria. [© 2005 - 2018 WebMD LLC, 14th -october-2018].

8
 Effectiveness of the MDI investigation:
X-ray investigation of the abdomen enabled the doctor to see the location, shape, and
size of the bowl obstruction clearly, this helped in setting the treatment plan for the
patient.

12. CONCLUSION
a 45 years old patient came to the hospital referred from a private clinic
experiencing acute lower abdominal pain for 3 days addition to vomiting and
diarrhea, the patient was referred to the X-ray department for an abdominal X-
ray which showed that he has a small intestine bowl obstruction, he was given
medication that will result in full recovery.

13. REFERENCES

 23.5 The Small and Large Intestines – Anatomy and Physiology. (2018).
Retrieved from https://opentextbc.ca/anatomyandphysiology/chapter/23-5-the-
small-and-large-intestines/
 9 Regions of the Abdominal Cavity Flashcards | Quizlet. (2018). Retrieved from
https://quizlet.com/12216753/9-regions-of-the-abdominal-cavity-flash-cards/

 Air American Samoa | All About Diagram. (2018). Retrieved from

https://airamericansamoa.com/

 (2018). Retrieved from https://memorize.com/anatomy-of-the-intestines/mwhyett

 Cefuroxime: MedlinePlus Drug Information. (2018). Retrieved from

https://medlineplus.gov/druginfo/meds/a601206.html

 Cold, F., Health, E., Disease, H., Disease, L., Management, P., & Conditions, S.
et al. (2018). Drugs & Medications. Retrieved from
https://www.webmd.com/drugs/2/drug-6426/metronidazole-oral/details

9
  LONG, B. (2018). MERRILL'S ATLAS OF RADIOGRAPHIC POSITIONING AND
PROCEDURES (13th ed., pp. 83-94). [S.l.]: ELSEVIER MOSBY.

 Morgan, M. (2018). Abdomen (PA erect view) | Radiology Reference Article |

Radiopaedia.org. Retrieved from https://radiopaedia.org/articles/abdomen-pa-
erect-view-1

 Redirect Notice. (2018). Retrieved from

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rj
a&uact=8&ved=2ahUKEwie5IbtlLveAhVByxoKHZvrCCEQjRx6BAgBEAU&url=htt
ps%3A%2F%2Fquizlet.com%2F12216753%2F9-regions-of-the-abdominal-
cavity-flash-
cards%2F&psig=AOvVaw0as4BVcCIf0gWg566q7QbM&ust=1541435497387450

 Schmidler, C. (2018). Jejunum's Function in the Small Intestine and Digestive

System:. Retrieved from https://www.healthpages.org/anatomy-
function/anatomy-function-digestive-system/

 Small Bowel Obstruction Management and Treatment | Cleveland Clinic. (2018).

Retrieved from https://my.clevelandclinic.org/health/diseases/15850-small-bowel-
obstruction/management-and-treatment

10