Bowel Obstruction With Intra-Intestinal Sand
Radiology Cases in Pediatric Emergency Medicine
Volume 5, Case 19
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 16-month old male who presents to the
emergency department with a two day history of
fussiness, abdominal pain, and vomiting. His mother
attempted to cure his condition by administering herbal
teas and herbal enemas. He became poorly responsive
which promoted his mother to bring him to the E.D. He
has felt warm, but his temperature was not measured at
Exam: T 37.4 (rectal), P195, R40, BP 99/54,
Oxygen saturation 98% in room air. He is drowsy but
arousable. Eyes somewhat sunken. TM's normal.
Oral mucosa sticky. Lips dry. Neck supple. Heart
regular, tachycardic, without murmurs. Lungs clear.
Abdomen shows moderate distention with intermittent
hypoactive bowel sounds. There is diffuse tenderness.
No masses are appreciated. No hernias. Testes are
IV fluid hydration is started. Blood studies are
drawn. A nasogastric tube is inserted. Greenish fluid
returns. Abdominal radiographs are obtained.
View abdominal radiographs.
The decubitus view is a left lateral decubitus film
(left side down). The flat view is taken in the supine
position. There is a nasogastric tube with its tip in the
stomach. There is no evidence of free air.
Review Case 18 in Volume 3 (Test Your Skill In
Distinguishing Bowel Obstruction From Ileus) to review
the radiographic findings consistent with a bowel
obstruction. Assessing these criteria in this set of
a) Gas distribution: Gas is distributed throughout
the abdomen except for the right lower quadrant on the
b) Bowel distention: This is best assessed by the
smoothness of the bowel walls rather than measuring
the diameter of the bowel lumen. In a bowel
obstruction, the bowel acquires a smooth appearance
resembling large hoses or sausages. As the bowel
distends, it loses its normal plicated/haustrated
appearance and the bowel walls become smooth. In
this case, the bowel is distended (smooth and
c) Air/Fluid levels: There are several large air fluid
levels seen on the lateral decubitus view. While small
air/fluid levels are most often indicative of an ileus, large
air fluid levels with J-shaped (candy cane or hairpin
turns) loops are more suggestive of a bowel
d) Orderliness: This is best appreciated on the flat
(supine) view. In this case, the gas pattern is orderly
rather than disorderly. In other words, it resembles a
bag of sausages more so than a bag of popcorn. The
orderly (bag of sausages) appearance is more
indicative of a bowel obstruction.
Both the flat and left lateral decubitus films show
considerable bowel dilatation. There are large air/fluid
levels on the decubitus view. This is consistent with a
distal mechanical bowel obstruction. In addition to the
findings of a bowel obstruction, there is granular
radioopaque material in the bowel (mostly colon).
Upon obtaining further history inquiring about his
diet, he has a history of eating sand, dirt, and glass. It
is likely that the granular material in the bowel is
probably a mixture of sand and other debris. How does
this affect our treatment approach ?
While barium studies may be useful to further image
his bowel, at this point, he is felt to have an acute bowel
obstruction. Clinically, his degree of abdominal
distention and tenderness is felt to necessitate a
laparotomy. What about the possibility of the sand and
other debris obstructing the bowel ?
At this point, the differential should include,
intussusception, appendicitis, and midgut volvulus. In
general, causes of bowel obstruction include conditions
that start with AIM:
Inguinal hernia (incarcerated)
At laparotomy, he is found to have a midgut volvulus
with necrotic bowel caused by a tight band around a
Meckel's diverticulum. The necrotic bowel is resected
and viable bowel is reanastomosed. There is no
evidence of bowel perforation. The radioopaque sand
and other debris seen on the abdominal radiographs
were "red herrings". A further imaging work-up would
have only delayed surgical intervention.
Two percent of the population are born with a
Meckel's diverticulum (one in fifty !!). It is located 50 to
75 cm proximal to the terminal ileum. Meckel's
diverticulum is most often asymptomatic as only 2% of
those with Meckel's diverticulum manifest clinical
The Meckel's rule of 2's:
a) 2% of the population are born with a Meckel's.
b) Only 2% of those with a Meckel's manifest clinical
c) Usually located 2 feet proximal to the terminal
ileum and the diverticulum is usually 2 inches long.
d) Symptoms commonly manifest at age 2 years.
The most common presentation of a Meckel's
diverticulum is painless intestinal bleeding. The
Meckel's diverticulum contains ectopic acid-secreting
gastric mucosa. The epithelium in the Meckel's
diverticulum may ulcerate and bleed. Slow bleeding
may present with signs of iron deficiency anemia and
occult stool blood loss or melena. More rapid bleeding
may present with hematochezia. An ulcerating
Meckel's may also perforate leading to peritonitis and
an acute abdomen.
Less commonly, a Meckel's diverticulum may
present as a bowel obstruction or with abdominal pain.
The base of the Meckel's diverticulum may form a
leading edge for an ileal intussusception. If the
Meckel's diverticulum is still attached to the anterior
abdominal wall, this may predispose one to a volvulus.
Both of these presentations will present with signs and
symptoms of a bowel obstruction.
A Meckel's diverticulum may become inflamed. This
results in abdominal pain with a clinical picture similar to
that of appendicitis (see Case 9 of Volume 4,
Periumbilical Abdominal Pain). If a Meckel's
diverticulitis perforates, it will lead to peritonitis. One
mechanism of Meckel's diverticulitis is a volvulus of the
diverticulum itself leading to ischemic necrosis.
Meckel's diverticulum can be diagnosed on
scintigraphy. The so-called Meckel's scan is based on
an isotope labeled compound that localizes in gastric
mucosa. This isotope normally accumulates in the
stomach and bladder. Additionally, upper GI peristalsis
carries the isotope into the duodenum and proximal
jejunum. A positive study will demonstrate a hot spot in
the lower abdomen, usually on the right. The
pre-treatment administration of pentagastrin and
cimetadine may improve the accuracy of the scan.
Barium studies will sometimes identify a Meckel's
diverticulum. However, upper GI series and barium
enemas cannot be used to reliably rule out a Meckel's
Meckel's diverticulum is often diagnosed at
laparotomy when surgical intervention is indicated, such
as in a bowel obstruction refractory to conservative
measures, a refractory intussusception, a suspected
volvulus, a rule-out appendicitis or an acute abdomen.
Goglia RP. Meckel's Diverticulum. In: Ashcraft
KW, Holder TM (eds). Pediatric Surgery, second
edition. W.B. Saunders, Philadelphia, 1993, pp.
Return to Radiology Cases In Ped Emerg Med Case Selection Page
Return to Univ. Hawaii Dept. Pediatrics Home Page
Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine