Picture quiz: Cochlear bowel

Case history
A 72 year old man presented at the accident and emergency department with a one day history of diffuse colicky abdominal pain associated with abdominal distension and constipation. There was no associated vomiting. Abdominal examination revealed generalised distension without peritonism and increased bowel sounds. There was an operative scar in the right groin from a previous inguinal herniorraphy. The figure shows the abdominal x ray film.

Questions
(1) What is your diagnosis ?
(2) How would you manage this condition?

Answers
(1) The history and examination suggest bowel obstruction. The presence of an old operative scar makes intestinal obstruction due to adhesions the most likely cause. Other common causes that need to be considered include incarcerated hernia and bowel tumours. The abdominal x ray examination taken with the patient in the supine position shows unusually large concentric loops of jejunum. These loops are dilated and have a rare spiral appearance that is described as "cochlear." There is no evidence of large bowel obstruction. Cochlear bowel is an uncommon radiological finding in bowel obstruction affecting an unusually long jejunum.

(2) The management of the patient presenting with bowel obstruction includes taking a thorough history and careful examination to identify the likely cause. Early investigations should include an erect abdominal film. In obstruction this often reveals multiple air fluid levels.

Discussion
Radiologically, small bowel obstruction can be differentiated from large bowel obstruction. Dilated small bowel loops tend to be central and have a smaller lumen diameter than large bowel. Small bowel is recognised by the presence of complete concentric rings of mucosal folds called valvulae conniventes. The colon is recognised by its larger lumen and assymetrical mucosal folds called haustrations. Blood samples should be sent for full blood count and biochemistry.

"Drip and suck." These patients should be kept fasted. They are often dehydrated as they have lost fluid into the obstructed loops of bowel. Therefore, intravenous fluids are indicated. Careful correction of electrolyte abnormalities is important to prevent arrhythmias. Nasogastric decompression reduces gastric distension and releases splinting of the diaphragm, easing breathing. These patients can often be managed conservatively, as the obstruction may settle. In the event of a failure to improve, or if the patient's condition worsens, then laparotomy is indicated. At operation, the adhesions are identified and divided.

Vibhore Gupta, D Sunderamoorthy, Birmingham Heartlands Hospital, Birmingham B9 5SS
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studentBMJ 2002;10:1-44 February ISSN 0966-6494