ACUTE ABDOMENSurgical Emergencies 2614 The pain becomes more continuous and generalized if strangulation occurs
(most common with a femoral hernia), associated with tachycardia and signs
of shock.
5 Always examine the hernial orifices and perform a rectal examination.
6 Gain i.v. access and send blood for FBC, U&Es, lipase/amylase and blood
sugar.
7 Request erect and supine abdominal X-rays and look for the following features:
(i) Small bowel obstruction:
(a) X-rays show dilated loops of small bowel and a colon devoid
of air
(b) small bowel is usually central in distribution with regular
transverse bands (valvulae conniventes) extending across the
entire diameter of the bowel
(c) fluid levels, with over five considered significant. Note fluid
levels also occur in gastroenteritis.
(ii) Large bowel obstruction:
(a) X-rays show dilated large bowel, with a peripheral
distribution, irregular haustral folds and faecal mass content.
MANAGEMENT1 Commence an infusion of normal saline to correct dehydration from vomit-
ing and f luid loss into the bowel.
2 Pass a nasogastric tube, administer analgesia, and refer the patient to the
surgical team.
Intussusception
DIAGNOSIS
1 This is caused by telescoping or prolapse of one portion of bowel into an
immediately adjacent segment. It usually occurs in children aged 3–18
months and is characterized by intermittent abdominal pain with sudden
screaming and pallor, followed by vomiting.
2 Abdominal distension and a mass may be felt, with blood-stained mucus
(‘redcurrant jelly’) found on rectal examination in 50%.
3 Send blood for FBC, U&Es and blood sugar.
4 Request erect and supine AXRs, which may be normal in the early stages, or
reveal signs of intestinal obstruction.
(i) Look for evidence of a soft-tissue mass surrounded by a crescent
of air (‘doughnut sign’) or free air from perforation of a viscus.
5 Arrange an abdominal ultrasound, or a contrast or air enema.
(i) Both have high degrees of sensitivity, with an enema resulting in
therapeutic reduction in 75% of cases.