Diagnose It Answer — April 22, 2026

63-year-old female presents with a 2-day history of crampy, intermittent abdominal pain that has become constant and severe over the past 12 hours. She has not had a stool in 3 days and has been unable to pass gas since yesterday. She has vomited four times today — the vomit smells 'like feces,' she says. Her abdomen is visibly distended.

History of right hemicolectomy for colon cancer 4 years ago (currently in remission) and a prior open appendectomy at age 22. She has no history of prior bowel obstructions. Medications include lisinopril and vitamin D. She has not eaten since yesterday. She denies any hernia history. No recent change in bowel habits before this episode.

BP 114/72 mmHg, HR 106 bpm, RR 20 breaths/min, Temp 37.4°C, SpO2 97% on room air. Patient is in visible discomfort, changing positions frequently to try to relieve cramping. Abdomen appears markedly distended and tympanitic. She has not passed flatus in over 24 hours.

Abdomen: diffuse distension, high-pitched 'tinkling' bowel sounds on auscultation, tympanitic to percussion. Mild tenderness to palpation throughout — no rebound, no rigidity (no signs of perforation at this time). Rectal exam: no masses, no stool in vault. NGT placed to low wall suction — 600mL of dark bilious fluid drains immediately. IV fluids initiated. Surgery consulted. Serial abdominal exams ordered q2h to monitor for signs of strangulation or perforation.

WBC 13,200/µL. BMP: Na 131 mEq/L, K 3.0 mEq/L, Cl 88 mEq/L, CO2 32 mEq/L — hypochloremic metabolic alkalosis from vomiting. Lactate 2.4 mmol/L (mildly elevated — monitor for ischemia). Abdominal X-ray series: multiple dilated loops of small bowel with air-fluid levels and a 'step-ladder' pattern on upright view; paucity of colonic gas. CT abdomen/pelvis with contrast: multiple dilated small bowel loops with transition point in the right lower quadrant; no free air; presumed adhesive obstruction consistent with prior abdominal surgery.