MD313 - General Medicine and Surgery – Mock Bowel Obstruction Question (20

marks)

A 65-year old man is referred to the Emergency department with a 4 day history of
constipation and vague central abdominal pain. Over the last 24 hours he has vomited
several times.

His surgical history is significant for an open appendectomy 30 years ago, an open
cholecystectomy 20 years ago and a previous “bowel operation” 10 years ago.

On examination, his abdomen appears distended. He is moderately tender on palpation

throughout his abdomen.

He appears dehydrated, his HR is 110 and is BP is 100/60.

You make a clinical diagnosis of small bowel obstruction

1. List 4 causes of small bowel obstruction (4 marks)

Adhesions**

Hernias** (Adhesion + Hernia – Most common by far!)

Intussusception (more common in paediatrics)

Stricture (eg Crohns)

Tumour

Volvulus

Gallstone ileus (2%)

Adynamic causes – post op ileus/ Ogilvie syndrome/ metabolic disturbance/ burn/

drugs (opioid*)/ ischaemia

2. What is the most likely cause of this man’s obstruction, given his surgical
history? (1 mark)
 Adhesions – history of surgical procedures

You are asked to admit this patient under the surgical team

3. What lab investigations will you order? (4 marks, 4x1)

Full blood count (infection/ anaemia)

Urea and electrolytes (dehydration/ renal injury/ metabolic disturbances)
C reactive protein (CRP) (inflammatory process)
Arterial blood gas (acidosis/ lactate)

4. How will you initially manage this patient? (3 marks, 3x1)

NPO
IV fluids
Analgesia (you must do these 3, common exam question *5MB3)
Urinary catheter (monitor fluid output)
Contact surgical team

You order a plain film abdominal X-ray in ED:

5. Describe the findings on this X-ray (1 mark)

Abdominal x ray showing dilated loops of small bowel

 6. What feature on this X-ray differentiates small bowel from large bowel? (1
mark)

Presence of valvulae conniventes (pliae circularis)

7. What imaging modality will most accurately identify the cause of his
obstruction? (1 mark)

CT abdomen/ pelvis

The patient is admitted to the surgical ward. Over the next few hours he deteriorates
clinically. You are asked to review him. He appears extremely dehydrated despite fluid
resuscitation. His abdomen is exquisitely tender.

You perform a repeat arterial blood gas (ABG):

Normal range
pH 7.255 (7.35-7.45)
pO2 12 kPa (11-13.5)
pCO2 3.7 kPa (4.6-6.0)
HCO3- 12 mmol/L (22-26)
Lactate 7.0 mmol/L (0.5-1.0)
Base excess -5 mmol/L (-2 - +2)

8. Interpret the ABG result (2 marks)

Metabolic acidosis, partial respiratory compromise

High lactate, low base excess
These findings potentially indicate bowel ischaemia.

You inform the consultant and the patient is brought to theatre. Before surgery, you consent
the patient for a laparotomy, plus or minus bowel resection.

9. List 4 potential complications of this surgery? (2 marks, 4x0.5)

General: Bleeding / infection/ anaesthetic complications

Specific:
 Stoma formation (+ stoma complications)
 Anastomotic leak
 Bowel perforation
 Injury to surrounding structures (ureters etc)
 Incisional hernia

You assist as he performs a midline laparotomy. He shows you the small bowel.
10. Do you think this bowel is viable? (1 mark)

No
The bowel appears necrotic. This will not heal and will need resection with either
anastomosis or formation of a stoma.

Adhesional SBO will most likely resolve with conservative treatment, depending on
patient factors. This question gives an example however of a case that necessitates
surgical intervention.
Repeated clinical examination and assessment with lab/radiological investigations are
vital in determining how a bowel obstruction progresses.
MCQs

1. An 85 year old nursing home resident is admitted with crampy abdominal pain,
obstipation and a distended abdomen. He appears dehydrated. He has never had
surgery before, and there are no hernias on examination.
Abdominal X-ray in ED demonstrates a “coffee bean” sign.

What is the most likely diagnosis?

A Small bowel obstruction - Adhesions

B Small bowel obstruction - Hernia

C Large bowel obstruction – Diverticular disease

D Large bowel obstruction – Sigmoid volvulus

E Infected total hip replacement

No surgery [adhesions], no hernias [B]

 2. A 35 year old male is admitted with a small bowel obstruction due to adhesions. He
receives analgesia and IV fluids.
You are called to the ward to review his chest X-ray.

What additional treatment has he received, visible on Chest X-ray?

A IV antibiotics

B NG tube

C Aortic valve repair

You will be asked as a junior doctor to interpret if an NG tube has been inserted correctly.
Beware tubes inserted into the larynx/trachea! You can also aspirate NG and test the pH of
the aspirate to assess if it contains gastric contents.

This is an example of an incorrect NG tube placement!

 3. A 75 year old farmer presents to the ED with a 2 month history of altered bowel
habit. He complains of tenesmus and worsening constipation over the past week.
He also has crampy abdominal pain, distension and nausea over the past week. He
has not passed a bowel motion in one week.
On exam is abdomen is distended and tender. On digital rectal examination, there is
a hard craggy mass palpable.

What is the most likely cause?

A Small bowel obstruction - Adhesions

B Inflammatory bowel disease

C Large bowel obstruction – Diverticular disease

D Large bowel obstruction – Rectal cancer

E Pancreatitis

Always suspect cancer in older patients presenting with bowel obstruction.

4. A 25 year old male attends your outpatient clinic with a mass in his left groin that
has been present for a year.
He is otherwise and healthy and plays football. He says the mass is affecting his
lifestyle.
On examination, the lump is in the inguinal region. It is reducible, non-tender, and
cough impulse is present.
You make a diagnosis of an inguinal hernia.

What is the most appropriate management?

A Analgesia

B Antibiotics

C Emergency surgery

D Book for elective hernia repair

Symptomatic hernia affecting quality of life- book for repair on elective list
 5. You are assisting an inguinal hernia repair. After getting through skin and fascia,
your consultant asks you what is the first layer of muscle encountered?

A Scarpas fascia

B Internal oblique

C Transversus abdominus

D External oblique

E Peritoneum

Important to remember the layers of the abdominal wall.

6. You are consenting a 30 year old male for inguinal hernia repair. You inform him of
potential injury to the spermatic cord.

Which of the following structures is NOT contained within the spermatic cord?

A Cremasteric artery

B Vas deferens

C Femoral artery

D Pampiniform plexus

E Gential branch of genitofemoral nerve

Contents of cord:
 Pampiniform plexus/ vas deferens/ cremasteric artery/ testicular artery/ artery
of vas/ genital branch of genitofemoral nerve/ sympathetic nerve fibres/
lymphatics
7. An 80 year old woman presents to the ED with a 1 day history of vomiting,
abdominal pain, constipation and distension.
You palpate a non-reducible lump below and lateral to the pubic tubercle.
 What is the most likely cause of her presentation?

A Femoral hernia

B Inguinal hernia

C Hiatus hernia

D Sports hernia

E Gastritis

Femoral hernias are more common in Females, however females are still more likely
to have inguinal hernias than femoral hernias.

8. A 35 year old female is admitted with small bowel obstruction.

You take an ECG – it shows ST depression, flattened T waves and U waves.

What is the most likely cause for her ECG findings?

A Hyponatraemia

B Hypophosphataemia

C Hyperkalaemia

D Hypokalaemia

E Myocardial infarction

9. A 40 year old male is admitted with a small bowel obstruction.

He has a history of biliary colic, no previous surgery, no hernias on exam.
CT AP demonstrates Rigler’s triad:
 Small bowel obstruction (white arrow)
 Gallstone outside gallbladder (Dotted black arrow)
 Pneumobilia (air in biliary system) (Black arrow)
 What is the most likely cause of his obstruction?
A Adhesions

B Hernia

C Tumour

D Gallstone ileus

E Ogilvie syndrome

Gallstone ileus – accounts for ~1% of bowel obstruction, but a much higher
percentage of medical school exam questions on obstruction

10. An 85 year old male is transferred by helicopter. He has a 2 week history of

obstipation, and a 1 day history of severe abdominal pain and vomiting. This is on
a background of 6 months altered bowel habit. He has never had a colonoscopy.
 On exam, his abdomen is rigid and he is exquisitely tender. He is guarding.
ABG shows a lactate of 8.5.
You perform a portable chest X-ray in ED resus:

What is the most likely cause for this man’s presentation, given the radiological
findings and history?

A Myocardial infarction

B Pneumothorax

C Oesophageal cancer

D Ruptured viscus

E Rib fracture

Pneumperitoneum bilaterally! (air under diaphragm) – this man likely has an

intra-abdominal perforation - potentially a perforated colorectal tumour based on
his history. This is a surgical emergency.