EM Forum Case #96 "Sickly Obstruction"
by Charlene Babcock Irvin, MD, FACEP  

A 68 y/o female presents with vomiting and abdominal pain for 1 day. She is on the cot with the head of the bed elevated, laying on her side, with an emesis basin next to her mouth, already 1/4 full. History is limited because she is retching and vomiting during your interview. She simply states: “I can’t breath, and I can’t stop throwing up!” She shakes her head for quick ROS questions: No chest pain, no vomiting up blood, no blood or black stools. She did have a BM today, “Hard, as usual.” She is short of breath and has abdominal pain and vomiting.

When I asked her where it hurt, she gestured with her free arm all over the abdomen. Because of the active vomiting, I limited my history and went on to physical exam.

VS: HR=110, RR=28, BP=160/110, Temp = 98, Sat (RA) = 90% at triage, now on 2L with sat 95%.

HEENT: Clear to green tinged vomit. MM dry, neck supple, no JVD.

HEART: RRR with Gallop, no murmurs.

Lungs: Rales 1/3 up bilaterally. Decreased breath sounds on right base.

Chest wall: S/P mastectomy bilaterally. Old Incisions were healed and clean.

Abdomen: Distended, only minimally tender, Bowel sounds difficult as she is retching. No rebound. Cholecystectomy scar and lower abdominal incision (? C-section vs. Total Abd Hyst).

Rectal: Guiac negative, hard stool in vault.

Ext: Unremarkable.

Neurologic: Grossly normal (detailed exam not done due to her intermittent vomiting), but she could move all extremities.

Just as I finish the exam, her daughter comes in, “Mom, oh no. I came as soon as I heard. I hope it’s not that bowel obstruction like you had last time!” She looks at me and fills in more history, “My mom has metastatic breast cancer with mets in her liver, back and a small spot on the lungs. She is getting chemotherapy weekly. This same thing happened last month. She gets a bowel obstruction because she is so sick.”

I ask if she has any other medical problems besides the breast cancer. “Oh yea, a bunch. She has CHF; she had a heart attack a few years ago. Oh, and she has high blood pressure.”

Questions:

1. What type of bowel obstruction can you get ‘because you are so sick’? How is it treated?

2. What is the threshold of colonic distention that should make you worry about perforation?

3. In a cancer patient, what electrolyte disturbance can cause ‘abdominal groans’? How often will cancer patients develop this electrolyte disturbance? Could it explain this patient’s complaints?

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