0:01

Okay. So here we have another contrast-enhanced

0:03

CT scan in somebody who's having nausea and

0:05

vomiting, and we're going to rule out obstruction.

0:08

Notice on the first images we already see trauma.

0:11

Look at all that ascites around the liver.

0:13

Look at all the ascites around the spleen.

0:15

This is going to be interesting, right?

0:17

We already know that. We have

0:18

distended loops of small bowel.

0:20

They're contrast-filled, so that's not terrible.

0:21

Again, more ascites coming down the

0:23

paracolic gutters, and then you see

0:26

loops of small bowel here in the left lower abdomen.

0:29

They are very dilated in nature.

0:31

And notice that the walls are,

0:32

you know, they're enhancing but not avidly.

0:34

And there's a lot of fluid in the mesentery and a lot

0:37

of engorgement of those mesenteric vessels as well.

0:40

So this is a small bowel obstruction, but not

0:43

a normal small bowel obstruction, not your

0:45

everyday generic small bowel obstruction.

0:47

When we go on coronals, we're struck by how

0:50

these loops kind of swirl together and that

0:53

there's a single location of decompression.

0:56

So this is, um, the appearance of a closed

0:59

loop small bowel obstruction where you have

1:01

just loops of small bowel that are torsed and/or

1:05

tethered and/or adhered and result in what's

1:08

called a closed loop, meaning that this loop

1:11

can't, um, be drained retrograde, but the contents

1:14

can't go prograde, so they're just on their own here.

1:16

This is a very tense-looking bowel,

1:18

and this is a surgical emergency.

1:20

Look at all that free fluid in the mesentery.

1:23

Now, it's hard, right?

1:24

Because your surgeons are gonna come.

1:25

And they're gonna say, oh, it's a closed loop.

1:27

Are you sure it's a closed loop?

1:28

And you're going to have to do what you got to do

1:30

cause that's a rule of medicine, which is you're

1:32

going to have to break bad news to surgeons and

1:34

you're going to have to say, you know, I suggest

1:36

using the sympathy-validation-sympathy sandwich

1:40

here, where you have to say, I'm really sorry

1:42

this patient has a closed loop obstruction.

1:44

Um, there's really not much I can do about that.

1:46

I'm only imaging them.

1:47

And then you have to validate them.

1:49

You know, you're a good surgeon.

1:50

I think you can do this.

1:52

I think this patient needs you.

1:53

And then maybe a little bit more sympathy.

1:54

Again, I'm really sorry that you're

1:55

going to have to be at the hospital later.

1:57

Choices were made for you.

1:59

I didn't make those choices.

2:01

It's really about telling your surgeon

2:02

that this is a surgical emergency, that

2:04

nothing else is really going to come of it.

2:07

And this is a high-grade closed loop small bowel

2:10

obstruction with torsion of these small bowel loops.