Generalized Abdominal Pain, Nausea, and Vomiting

Figure 1: Chest X-ray demonstrating no acute abnormalities.An 85-year-old woman presents to the emergency department with concern of severe, sudden-onset abdominal pain, nausea, and vomiting. She woke up suddenly from sleep around 3:30 am with severe abdominal pain. She had several episodes of nonbloody and nonbilious emesis and denies diarrhea, frank blood in her stools, or melena. Her last bowel movement was that day, prior to her presentation to the emergency department (ED). She has no chest pain or shortness of breath. The day before, prior to going to sleep, she was feeling well, without any recent sick symptoms including fever, cough, congestion, or GI upset. At that time, she also was eating and drinking normally. She has a past medical history of coronary artery disease, hypertension, stage 3 chronic kidney disease, gastro-esophageal reflux disorder, and bilateral renal carcinoma status post bilateral cryoablation. Past surgical history includes appendectomy and hysterectomy. Upon arrival to the emergency department, the patient is afebrile with a pulse rate of 65 and blood pressure of 178/86 mmHg. She is not tachypneic and oxygen saturation is 98% on room air. She appears in no acute distress, and her abdomen is soft and nondistended, but diffusely tender with guarding. There is no rebound tenderness, and Murphy's sign is negative. Radial and dorsalis pedis pulses are 2+ and equal bilaterally. Labs obtained in the emergency department were not revealing leukocytosis, anemia, or thrombocytopenia. Lipase was within normal limits, and lactic acid was 1.2. Initial high-sensitivity troponin and 1-hour repeat were both less than 9. Her metabolic panel revealed no clinically significant electrolyte derangements, and a creatinine of 1.39, consistent with patient's chronic kidney disease. Upright chest X-ray was obtained to evaluate for free air under the diaphragm and was normal (Figure 1). CT abdomen and pelvis was subsequently obtained. What is the patient's diagnosis? Diagnosis: Closed-Loop Small Bowel Obstruction Small bowel obstruction (SBO) accounts for approximately 2%-4% of all ED visits for abdominal pain. Elderly populations are disproportionately affected, with up to 12%-25% of abdominal pain complaints ultimately being diagnosed as a bowel obstruction. Even more deadly are the morbidity and mortality rates in this population, which can range between 7% and 14% compared to the general population rates of