nonspecific bowel gas pattern treatment

This concretion forms around a nidus such as a piece of vegetable matter. If the ileocecal valve is incompetent, refluxed gas in the small bowel may erroneously suggest a small bowel obstruction. Repeat abdominal series once again showed a nonspecific bowel gas pattern, though a CT scan of the abdomen showed free air in the abdomen. Bowel gas patterns may point to an underlying cause bowel gas patterns include: Normal Nonspecific Adynamic ileus Mild localized ileus or "sentinel loop" Severe "colonic pseudo-obstruction" Small bowel obstruction; central, valvulae conniventes, pliable ("bent finger") Large bowel obstruction - peripheral, haustra, contains feces Causes Major signs of free air on supine abdominal radiographs include the following: Gas normally outlines only the luminal surface of the bowel. About 25% of patients with appendicitis have an abnormal bowel gas pattern, usually an adynamic ileus, but occasionally a partial or even complete small bowel obstruction may be present (see Fig. Bone calcification in RLQ -Osteophytes 5. border: none; Abdominal CT may be performed to confirm the presence of obstruction and determine its underlying cause ( Fig. Other signs of pneumoperitoneum on supine abdominal radiographs. After 24 hours of intensive treatment, the patient expired. Compression of the duodenojejunal junction at the root of the mesentery may cause severe vomiting. I'm seeing the GI tomorrow afternoon but now they've got me all worried I have some sort of obstruction :(. 12-13 ). Not much gas now but I'm afraid to eat and create more! Closed-loop patterns and a whirl sign were seen only in patients with adhesive bands, and the beak sign and fat notch sign were present more often in patients with adhesive bands. A soft tissue mass can be found in up to one third of patients with perforation. One of the most common causes is a surgically created biliary enteric fistula such as a choledochojejunostomy or cholecystojejunostomy (see Fig. In fact, 70% of patients with toxic megacolon develop this complication during their first episode of colitis. MeSH terms Diagnosis, Differential Flatulence / diagnostic imaging Gases* Humans The normal bowel gas pattern is readily visible on supine abdominal radiographs ( Fig. We all have gas in our bowels and a "non obstructive bowel gas pattern" means it looks like it should look. A cross-table lateral view of the abdomen with the patient in a supine position may demonstrate free air in those who are physically unable to roll onto their sides. Now, getting to the non specific bowel gas pattern. Labs showed hemoglobin of 8.0 g/dL. Abdominal radiographs are often performed as an initial imaging test in patients with abdominal pain and distension. Only $35.99/year. } Study with Quizlet and memorize flashcards containing terms like *"Nonspecific bowel gas pattern"* Not specific for any particular finding: -No free air -No dilated bowel -No displaced bowel gas, *Osteoporosis* w/ loss of disc space between L3-4 and L4-5. 12-5B ). Difficulties with oxygenation ensued, with a progressively widening arterial-alveolar gradient. Most patients with SBO are treated successfully with nasogastric tube decompression. A Surprising Abdominal Mass. . The characteristic findings of cecal volvulus, which are present on abdominal radiographs in about 75% of patients, consist of a markedly dilated, gas-filled cecum containing a single air-fluid level in an ectopic location ( Fig. Duodenal ulcers, iatrogenic duodenal injuries, and blunt abdominal trauma are all possible causes of perforation of the extraperitoneal portion of the duodenum. The medially placed ileocecal valve may produce a soft tissue indentation, so the gas-filled cecum has the appearance of a coffee bean or kidney. 12-14 ). As with sigmoid volvulus, elongation of the transverse mesocolon and close approximation of the hepatic and splenic flexures may allow the transverse colon to twist on its mesenteric attachment. Inspissated feces and calcium salts may adhere to the nidus, so it eventually reaches a size that occludes the appendiceal lumen. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education. Chest radiographs obtained with the patient in an upright position are ideal for demonstrating free air because the x-ray beam strikes the diaphragms tangentially at their highest point. 1 doctor answer 1 doctor weighed in Dr. Edward Hirsch answered Infectious Disease 34 years experience Normal: That is radiologist jargon for having a normal appearing bowel on the x-ray. Occasionally, periportal fat or fat around the ligamentum teres hepatis may be manifested by a faint lucency over the liver, but its appearance is different from that of pneumobilia. The most superior collection of intestinal gas is contained in the stomach (. Conclusion: The term "nonspecific abdominal gas pattern" should be abandoned because it may signify a normal condition or a pathologic state. acidosis, Resp. 1. The abdominal x-rays obtained during admission and 1 hour before her upper esophagogastroduodenoscopy (EGD) revealed a nonspecific bowel gas pattern (Figure 1A and B). 12-3 ), so the absence of colonic distention in no way excludes this condition. Air-fluid levels in the jejunum have also been described in up to 50% of cases. Unless the gas has been introduced iatrogenically by vascular catheterization, endoscopic manipulation, or other iatrogenic causes, the source of the gas is almost invariably the intestine. Answer: B, If the visualized bowel gas in your imaging study was unremarkable,Pneumatosis intestinalis (PI), 2013), 22% meaning, 22% meaning, defined as gas within the bowel wall, Radiograph shows a nonspecific bowel gas pattern with no signs of bowel obstruction, treatment with intravenous fluids, An ultrasound study is ordered to confirm the . Chest X-Ray showed evidence of acute pulmonary injury and edema. Linear collections of gas may also be seen in the subhepatic space, although the latter finding must be differentiated from subhepatic fat. He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. Vascular compromise may lead to edema and thickening or effacement of the folds within this loop. The linear pattern of pneumatosis identified on CT is more likely to be associated with transmural bowel infarction than the bubbly pattern. Larger amounts of free air may occasionally outline the falciform ligament ( Fig. Colonic obstruction is typically manifested on abdominal radiographs by dilated, gas-filled loops of colon proximal to the site of obstruction and a paucity or absence of gas in the distal colon and rectum ( Fig. Colonic volvulus may involve different segments of the colon, as discussed in the following sections. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes. Because the bowels do not move, fluids and gas accumulate, which stretch the bowel wall, causing vomiting, decreased bowel sounds, and constipation. Preference cookies are used to store user preferences to provide content that is customized and convenient for the users, like the language of the website or the location of the visitor. There are two kinds of mechanical obstruction. Obstipation and vomiting are also common findings. Such adhesions may occur as early as 1 week after surgery, but more typically there is a remote history of surgery. However, subsequent investigators have found that differential air-fluid levels may be present in any tubular viscus containing air and fluid. Left psoas shadow -overlying bowel gas, fluid, inflammation . Gas in the wall of the small bowel, which is termed pneumatosis intestinalis, is characterized by two radiographic patternsa bubbly appearance or thin, linear streaks of gas. Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. His one great achievement is being the father of three amazing children. This website uses cookies to improve your experience while you navigate through the website. Upgrade to remove ads. Cecal volvulus should be differentiated from a prolonged colonic ileus in bedridden patients with a persistent mesentery on the ascending colon because the anteriorly located cecum in these patients may become disproportionately dilated, mimicking the appearance of a cecal volvulus. #mergeRow-gdpr fieldset label { The classic radiographic appearance consists of a massively dilated loop of sigmoid colon that has an inverted U configuration and absent haustral folds and extends superiorly above the transverse colon into the left upper quadrant beneath the left hemidiaphragm (even elevating the diaphragm), with air-fluid levels in both the ascending and descending limbs of this loop. post-sexual activity, spa bath, water ski-ing), Hepatodiaphragmantic interposition of the colon, Secondary to colonic distention (obstruction or ileus), Gallstone ileus (biliary-enteric fistula) [, Hepatic portal venous gas (bowel infarction), Hydrogen peroxide ingestion (or other gas forming substance). Gas may also be seen in the transverse colon immediately inferior to the stomach. However, the dilated bowel can be in the midline or can even extend into the right upper quadrant ( Fig. Initially radiographs are nonspecific and may only show bowel dilatation. Gas that enters the retroperitoneal spaces (also known as pneumoretroperitoneum) can usually be distinguished from intraperitoneal gas. Fatty liver disease is characterized by the accumulation of fat within liver . To investigate its mechanisms, we here performed 5-RACE and identified -cell-specific transcription initiation sites for Tph1 . 12-5A ). A long narrowed segment of air-filled stomach may indicate an infiltrating process such as linitis plastica. Very early small bowel obstruction was a possibility, given the history, and continued surveillance was recommended. Patients who have persistent sigmoid dilation despite rectal tube placement and those who develop recurrent sigmoid volvulus may require surgical resection of the sigmoid colon for definitive treatment of this condition. Pass it rectally, which is increased with movements such as walking or lifting 2. This type of scan is also sometimes called a KUB (kidney, ureter, and bladder study). Colonic obstruction resulting from colonic carcinoma. An incompetent sphincter of Oddi, recent sphincterotomy or sphincteroplasty, anomalous insertions of the biliary tree, recent passage of a common duct stone, and infestation of the biliary tract by Ascaris are other causes of pneumobilia. Bowel gas patterns may point to an underlying cause bowel gas patterns include: Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision, Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement, Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction, Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage. An echogenic liver is also commonly identified with diffuse hepatic steatosis during a liver ultrasound examination. Prediction of impending perforation of the cecum, as judged by cecal diameter, is fraught with difficulty because the risk of cecal perforation depends not only the degree of distention, but also on the durationthat is, the risk is considerably less in patients with long-standing cecal distention than in those with an acute increase in cecal caliber. Inflammation and edema may alter the water content of surrounding fat and obscure the normal fat planes of the psoas muscle, obturator muscle, or properitoneal flank stripe. In advanced cases, air can be seen outlining the more centrally located main portal vein, but this finding is less common. A contrast enema may occasionally be required in patients with suspected sigmoid volvulus. The diagnosis of toxic megacolon usually is made based on a combination of the clinical and plain film findings, so a contrast enema does not need to be performed in these patients. An increased amount of gas in the small bowel in patients with severe colitis has also been associated with an increased likelihood of developing this condition. This central location is explained by the flow of bile from the periphery of the liver toward the porta hepatis. CBD And Pain Management: Is This Supplement Right For You. Toxic megacolon develops in 5% to 10% of patients with ulcerative colitis, but in only 2% to 4% of patients with granulomatous colitis. Abdominal radiographs may reveal a dilated, featureless, air-filled loop of bowel in the left upper quadrant that is separate from the stomach, with air-fluid levels in the transverse colon and cecum. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. . Treatment If your gas pains are caused by another health problem, treating the underlying condition may offer relief. Upright and decubitus abdominal radiographs typically reveal multiple air-fluid levels in the dilated small bowel because of accumulation of gas and fluid proximal to the obstruction ( Fig. Unlike patients with true cecal volvulus, however, cecal pseudovolvulus is associated with diffuse colonic distention, so it is usually possible to differentiate these conditions on the basis of the radiographic findings. Nevertheless, a definitive diagnosis can be made only at surgery. Key Words Abdominal diseases diagnostic radiology observer performance radiology reporting systems Air fluid levels are evident, and the diagnosis of SBO is considered unequivocal. There may be a few loops of bowel which are abnormal but not conclusive for a bowel blockage. In some patients with small bowel obstruction who swallow relatively little air, supine abdominal radiographs may be unrevealing, whereas upright or decubitus abdominal radiographs (i.e., horizontal beam views) will show multiple air-fluid levels within small bowel loops proximal to the site of obstruction. Obtaining an accurate diagnosis opens up potential treatment options, including the use of prescription medication to reduce your gas. Cystic fibrosis (a disorder of your genes that causes severe damage to the lungs and other organs) Ileus Symptoms You'll feel symptoms in your stomach area for 24 to 72 hours. may be indistinguishable, such as different infectious pneumonias. The obstruction usually occurs in the sigmoid colon, where the bowel tends to have a narrower caliber and the stool is more solid. A left lateral decubitus radiograph of the abdomen may facilitate visualization of portal venous gas. A small amount of air is almost always present within the stomach, however, so an upright radiograph of the chest or abdomen should demonstrate an air-fluid level within the gastric lumen. Gas in the hepatic artery has been reported anecdotally in a patient in whom the hepatic artery was ligated for the treatment of an unresectable hepatic adenoma. Sign up. If, however, horizontal beam views cannot be obtained in patients who are too sick or debilitated to stand or lie on their side, the radiologist must be able to recognize indirect signs of free intraperitoneal air on supine abdominal radiographs. These cookies will be stored in your browser only with your consent. Normal bowel gas pattern B. Most appendicoliths range from 1 to 2cm in size, but some may be as large as 4cm. 12-2A ). Finally, when patients swallow little or no air, abdominal radiographs may reveal multiple tubular, sausage-shaped soft tissue densities representing fluid-filled loops of small bowel without any intraluminal gas in the small bowel or colon, producing a so-called gasless abdomen. This has been described as cecal pseudovolvulus. The most common causes of obstruction include acute edema and spasm from an ulcer in the distal antrum or pyloric channel or chronic antral narrowing secondary to scarring from a previous ulcer. A complete blood count, chemistry panel, and serum pregnancy testing were normal. In the United States, sigmoid volvulus tends to occur in older men and residents of nursing homes and mental hospitals, in whom chronic constipation and obtundation from medication are predisposing factors for gaseous distention of the sigmoid colon and stretching of the sigmoid mesocolon. The intestinal tract in adults usually contains less than 200mL of gas. Acute appendicitis with partial small bowel obstruction. Probably gastroentrities (unlikely as I don't have any of those symptoms) or ileus'. Gastrointestinal symptoms are a well known consequence of disordered eating seen in acute treatment settings, but . 12-1 ). False-positive and false-negative rates of 20% have been reported in the diagnosis of small bowel obstruction based solely on the radiographic findings. Otherwise, bothersome gas is generally treated with dietary measures, lifestyle modifications or over-the-counter medications. The presence of intramural gas in the region of the dilated cecum should strongly suggest infarction and impending perforation. Paralytic ileus happens if the nerves in the . This will fall in between the normal bowel and grossly abnormal blocked bowel. There are several ways to deal with uncomfortable intestinal gas: 1. He coordinates the Alfred ICUs education and simulation programmes and runs the units educationwebsite,INTENSIVE. In adults with ischemic bowel disease, death often occurs shortly after portal venous gas has been observed. It basically means that the appearance of bowel is unclear on the X-ray and can be normal or abnormal. Symptoms that may warrant the need for an abdominal X-ray include: Abdominal pain Constipation Nausea Vomiting Pain Lack of bowel movements Usually, little gas is seen distally in the colon. oh yeah! Upright or left lateral decubitus abdominal radiographs are based on the principle that air rises to the highest point in the peritoneal cavity. 1 A). It is used synonymously with the terms paralytic ileus and nonobstructive ileus. Patients with sigmoid volvulus sometimes can be successfully treated by placement of a rectal tube for decompression of the dilated sigmoid loop. Abdominal CT or a single-contrast barium enema should therefore be considered in any patient with apparent obstruction of the distal small bowel on abdominal radiographs (especially an older patient who has no prior history of abdominal surgery) to rule out an underlying colonic or cecal carcinoma as the cause of obstruction. An incompetent ileocecal valve allows gas to reflux into the small bowel, decompressing the colon, so the radiographic findings can mimic those of small bowel obstruction. This finding is nonspecific and is usually associated with other signs of appendicitis on abdominal radiographs. A ruptured appendix rarely may lead to the development of a small amount of free intraperitoneal air. 12-5C ). Although some authors have indicated that a cecal diameter of 9 to 12cm suggests impending perforation, cecal diameters of 15 to 20cm are commonly observed in patients who recover spontaneously from Ogilvies syndrome. #mc_embed_signup { The EGD further revealed 1 nonbleeding duodenal ulcer covering half of the duodenal bulb circumference with a cratered area representing a fistula tract, also known as Ulcre . Originally described by Miller in infants, this sign is caused by a large amount of free air filling the oval-shaped peritoneal cavity, resembling an American football. Thus, air-fluid levels should be recognized as a nonspecific finding that can be seen with a mechanical obstruction or adynamic ileus. Gas from a rectal perforation may be confined to the perirectal space or may extend into the anterior and posterior retroperitoneal spaces and even superiorly into the mediastinum. Portal venous gas has even been described as a transient finding on Doppler ultrasound during the early postoperative period after liver transplantation. This doesn't help the ordering physician much, except to tell him to use his clinical suspicion to guide further workup. margin-top: 20px; Apart from recent abdominal surgery, an adynamic ileus may result from a wide variety of causes, including electrolyte imbalances, sepsis, generalized peritonitis, blunt abdominal trauma, and infiltration of the mesentery by tumor. Overall, sigmoid volvulus accounts for 1% to 2% of all intestinal obstructions in the United States. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. What Does A Nonspecific Bowel Gas Pattern Mean? We found the definition to be dichotomous and asynchronous between radiologists and their referring physicians. Her physician suggests a low-fat, mechanical soft diet, and initiated therapy with prochlorperazine 5 mg 4 times daily. The development of acute appendicitis requires obliteration of the appendiceal lumen, usually by a concretion that may be visible on abdominal radiographs. Non specific bowel gas pattern is sometimes used when describing findings on an X-ray of the abdomen by the radiologist. Ileus seems to be a fancy word for 'bowel obstruction'? The amount of gastric distention depends not only on the degree of obstruction, but also on the duration of obstruction, position of the patient, and frequency of emesis. Splenic flexure volvulus is the least common type of colonic volvulus. Sometimes, however, an adynamic ileus is confined to the small bowel, mimicking the findings of small bowel obstruction ( Fig. With mechanical obstruction, a physical, organic, obstructing lesion prevents the passage of intestinal content past the point of either the small or large bowel blockage. Learn how your comment data is processed. Prolonged cecal distention beyond 2 to 3 days should prompt colonoscopic or surgical decompression. Probably gastroentrities (unlikely as I don't have any of those symptoms) or ileus'. Radiologists use the term nonspecific gas pattern to denote a gas pattern that is not quite normal but that does not fulfill the criteria of a more specific diagnosis such as small bowel obstruction. In various series, colonic perforation has been reported in as many as 7% of all large bowel obstructions and 2% of obstructing colonic carcinomas. Subjects. You can also place a warm, wet washcloth. Plain abdominal radiographs revealed a non-specific bowel gas pattern (Fig. These patients have a persistent mesentery on the ascending colon and, because of its greater mobility, the ascending colon can twist on its mesentery, producing a volvulus. Older person 3. They emphasized that the duration of cecal distention was more important than cecal diameter in predicting impending perforation. CT. Bowel dilatation is much more clearly demonstrated on CT. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Morisons pouch is an intraperitoneal recess bounded anteriorly by the liver and posteriorly by the right kidney. The presence of free intraperitoneal air (also known as pneumoperitoneum) is an important radiographic observation that usually indicates bowel perforation in patients with an acute abdomen. The finding of portal venous gas should therefore lead to a careful search for gas in the wall of the bowel caused by intestinal infarction (see later, Intramural Gas ). The presence of pneumoperitoneum does not always indicate an acute abdominal condition. In the supine position, fluid may gravitate to this space. The stomach may also be dilated because of gastroparesis or gastric atony from diabetes (gastroparesis diabeticorum), which is almost always associated with a peripheral neuropathy. . Based on a work athttps://litfl.com. The concept of a cecal bascule was challenged by Johnson and colleagues, who believed that these patients have a focal adynamic ileus of the cecum. font-weight: normal; A nodular mucosa may be visible in the dilated transverse colon as a result of inflammatory pseudopolyps in patients with ulcerative colitis (see Fig. Nevertheless, such radiographs are frequently obtained as the first imaging study in patients presenting to the emergency room with right lower quadrant pain. 12-9 ). The term adynamic ileus refers to dilated bowel in the absence of mechanical obstruction. Location of gas on the abdominal x-ray may suggest the the underlying cause. But opting out of some of these cookies may have an effect on your browsing experience. After treatment, all findings were shown to have resolved on 2-week follow-up CT. Repeat of the laboratory examination revealed a bicarb of 20, normal LFTs and amylase, WBC of 8,000/ml, with a differential of 50 segmented neutrophils and 50 bands. However, the mortality of SBO ranges from 2% to 8% and may increase to as high as 25% if bowel ischemia is present and there is a delay in surgical management ( 2 - 5 ). Second row: Two transverse images from an abdominal ultrasound performed after the patient ingested water shows the anechoic water outlining a . Study with Quizlet and memorize flashcards containing terms like Small and Large Bowel General Complaints, General Diagnostics for Abd Complaints, Bowel Obstruction Complaints and more. The K10 is a non-specific psychological distress scale consisting of 10 questions designed to measure levels of negative emotional states experienced by people in the four weeks prior to interview. 5-Step Plan To Eliminate Heartburn, Acid Reflux and Related GI Disorders! (Courtesy Laura R. Carucci, MD, Richmond, VA.), Air is seen collecting centrally in the biliary tree (, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Perfusion Computed Tomography and Magnetic Resonance Imaging in the Abdomen and Pelvis. The 2008 NATSISS included questions from the K5 to provide a broad measure of people's social and emotional wellbeing. While there appears to be a modest early peak of non-specific inflammation, we were surprised to identify such efficient discrimination . The term "nonspecific gas pattern" is used by radiologists to describe a gas pattern seen in the bowel on an X-ray of the abdomen that may or may not be normal; however, it doesn't meet the criteria for a more precise diagnosis, such as a small bowel obstruction. HIGH:Bilirubin and Jaundice, Hyperammonaemia,Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia. Air-fluid levels on upright view, in colon. Failure of normal fixation of the mesentery may lead to increased mobility of the ascending colon and hepatic flexure, predisposing these patients to volvulus of the transverse colon. Toxic megacolon is traditionally associated with ulcerative colitis, but it can also occur in patients with granulomatous colitis, amebiasis, cholera, pseudomembranous colitis, cytomegalovirus colitis, and ischemic colitis. 12-8 ). ischemic gut, necrotizing enterocolitis), Extension from the chest (e.g. Increased expression of tryptophan hydroxylase 1 (Tph1), a rate-limiting enzyme for serotonin synthesis by lactogenic hormones, is involved in this phenomenon. Nevertheless, it should be recognized that the vast majority of patients with this embryologic variant never develop cecal volvulus. An adynamic ileus occurs as a response to focal inflammation and may be localized to the right lower quadrant (also known as a sentinel ileus). Pneumobilia almost always results from some type of communication between the bile ducts and intestine. Analytical cookies are used to understand how visitors interact with the website. Radiographic evaluation of intestinal gas should include the following: (1) identification of the bowel segments containing gas; (2) assessment of the caliber of these segments; (3) assessment of the most distal point of passage of gas; and (4) evaluation of the bowel contour outlined by gas. C-reactive protein (CRP) was elevated to 6.2. Mechanical obstruction may occur if the terminal ileum is compressed by the appendix or narrowed by adhesive bands. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australias Northern Territory, Perth and Melbourne. First row: Supine and upright abdominal radiographs show a nonobstructive bowel gas pattern with relative paucity of bowel loops over the central upper abdomen (red arrows). An upper endoscopy was also normal. They are usually in the right lower quadrant but can also be located in the pelvis or even in the right or left upper quadrant.