Working Diagnosis:
Acute small bowel obstruction of unknown etiology.

Treatment:
Treatment with intravenous fluids, analgesics, anti-emetics, cefazolin, and a nasogastric tube were initiated as management of acute small bowel obstruction in a stable patient. The patient was kept on dietary restrictions of nothing per mouth and vital signs were closely monitored. Further laboratory tests were conducted which revealed C-reactive protein and erythrocyte sedimentation rate within normal limits. Ten hours after admission, an upper gastrointestinal series with small bowel follow through was performed which revealed resolution of the small bowel obstruction. Case Photo #2 Transabdominal ultrasound was performed and showed trace free fluid with no ovarian, tubal, or uterine abnormalities. Case Photo #3 Case Photo #4 Case Photo #5 Case Photo #6 After these imaging tests were performed in conjunction with gradual reduction of pain, her diet progressed gradually until she was tolerating regular diet and stooling upon discharge.

Outcome:
The athlete returned to full athletic participation nine days post presentation without recurrence of symptoms. Further workup was performed on an outpatient basis by gastroenterology, and magnetic resonance imaging of the abdomen and pelvis with and without contrast showed no evidence of inflammation or bowel wall thickening which would suggest inflammatory bowel disease. Case Photo #7 Case Photo #8 Case Photo #9 Case Photo #10

Author's Comments:
Based on the history and exam, we still included less likely diagnoses on our differential which merit explanation for their inclusion. Although the patient stated that there was a low likelihood of pregnancy, in a female of reproductive age with abdominal pain, regardless of the date of her last menstrual period, ectopic pregnancy with or without rupture must be considered. Mesenteric ischemia was included because her race increased her likelihood of being a carrier of the sickle cell trait, or other hemoglobinopathies, which could predispose to mesenteric ischemia.
This case is unique for an otherwise healthy female to have a small bowel obstruction in the absence of prior abdominal surgery and with no personal or family history of inflammatory bowel disease; thus, we searched the literature for alternative explanations regarding the etiology. Casey et al. (2005) suggests that an inverse relationship exists between exercise and gastrointestinal disease; however, van Nieuwenhoven et al. (2004) speculates that running decreases small bowel transit time, perhaps increasing this athlete's risk of small bowel obstruction. Of course there are many caveats: one the temporal relationship between exercise and bowel obstruction in this patient is not known, most studies which look at gastrointestinal distress in athletes have studied endurance sports so it is not known if these findings would be generalizable to a basketball player. This case illustrates that providers must have a high suspicion for acute small bowel obstruction even when there is no apparent change in bowel patterns nor abnormal bowel sounds. To decrease morbidity from an exploratory laparotomy, conservative treatment with decompression and hydration was undertaken first, given the patient's stability and her profession which requires extensive physical activity. Had these efforts not been successful, the athlete would have progressed to surgical management.

Editor's Comments:
Acute abdominal pain is a very common complaint in the emergency setting. The differential for acute abdominal pain in a female of reproductive age is vast. It is important in the acute setting to rule out the conditions that could cause significant morbidity and mortality. These include many of those listed above including ectopic pregnancy, appendicitis, bowel obstruction, pelvic inflammatory disease, and abscess. While quite uncommon in this age group epigastric pain, nausea, vomiting can also be the only presenting symptoms of cardiac disorders including myocardial infarction. Women and young patients have also been demonstrated to have a delay in diagnosis as they sometimes present with atypical symptoms. For a variety of reasons including possible delay in diagnosis and less inclusion in clinical trials, women have increased mortality compared to men for acute myocardial infarction.
Other considerations that are not life threatening that should be considered include gastritis, peptic ulcer disease, diverticulitis, hernia, endometriosis, and uterine fibroids.
In this case the temporal relationship to exercise is not discussed, however, there has been some studies as to exercise induced gastrointestinal disturbance. Gastrointestinal distress is a relatively frequent complaint of endurance athletes but has been less described in sports such as basketball. There is no known relationship between exercise or being an athlete and small bowel obstruction at this time.
Small bowel obstructions are blockages of the small bowel that block the flow of contents. Most small bowel obstructions occur in the setting of past surgery as the scar tissue can cause the obstruction. Other causes include hernias, inflammatory bowel disease, intussusception, volvulus, superior mesenteric artery syndrome, gallstones, and tumors. A small bowel pseudo-obstruction is a condition that mimics a small bowel obstruction but there is no mechanical obstruction. Some causes of this in adults include medications, cancers, smooth muscle disorders, nerve disorders,and autoimmune disorders such as lupus or scleroderma. She will likely need further work up for her pseudo-obstruction as an outpatient especially if this persists.

References:
Cartwright, Sarah L., and Mark P. Knudson. “Evaluation of Acute Abdominal Pain in Adults.” American Family Physician 77, no. 7 (April 1, 2008): 971–78.
Casey, Ellen, Dilaawar J. Mistry, and John M. MacKnight. “Training Room Management of Medical Conditions: Sports Gastroenterology.” Clinics in Sports Medicine 24, no. 3 (July 2005): 525–40. https://doi.org/10.1016/j.csm.2005.05.002.

Kruszka, Paul S., and Stephen J. Kruszka. “Evaluation of Acute Pelvic Pain in Women.” American Family Physician 82, no. 2 (July 15, 2010): 141–47.

Mehta, Laxmi S., Theresa M. Beckie, Holli A. DeVon, Cindy L. Grines, Harlan M. Krumholz, Michelle N. Johnson, Kathryn J. Lindley, et al. “Acute Myocardial Infarction in Women: A
Nieuwenhoven, Michiel A. van, Fred Brouns, and Robert-Jan M. Brummer. “Gastrointestinal Profile of Symptomatic Athletes at Rest and during Physical Exercise.” European Journal of Applied Physiology 91, no. 4 (April 2004): 429–34. https://doi.org/10.1007/s00421-003-1007-z.


Vaghef-Davari, Farzad, Hadi Ahmadi-Amoli, Amirsina Sharifi, Farzad Teymouri, and Nobar Paprouschi. “Approach to Acute Abdominal Pain: Practical Algorithms.” Advanced Journal of Emergency Medicine 4, no. 2 (2020): e29. https://doi.org/10.22114/ajem.v0i0.272.

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