Emerg Med J doi:10.1136/emermed-2012-202075
  • Images in emergency medicine

Distal intestinal obstruction syndrome: a mimic of acute appendicitis

  1. Sree Harsha Tirumani2
  1. 1SVS Medical College, Mahabubnagar, India
  2. 2Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Sree Harsha Tirumani, Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Ave, Boston, MA 02215, USA; tirumani.sreeharsha{at}
  • Received 15 October 2012
  • Revised 9 December 2012
  • Accepted 24 December 2012
  • Published Online First 23 January 2013

A 23-year-old female with a history of cystic fibrosis (CF) presented to the emergency room with abdominal pain (7/10), vomiting and constipation for 3 days. Clinical examination revealed severe dehydration and distended tympanitic abdomen with palpable tender right lower quadrant lump. Laboratory examination revealed leukocytosis, anaemia and metabolic acidosis. Plain abdominal radiograph revealed small bowel obstruction and right lower quadrant mottled lucencies. CT of the abdomen revealed partial small bowel obstruction (arrowhead) with faecal matter impacted in the distal small bowel loops (asterisk), and dilated mucous-impacted appendix mimicking acute appendicitis (arrow) (figure 1). A diagnosis of distal intestinal obstruction syndrome (DIOS) was made based on the history of CF and faecal impaction in the distal small bowel loops. DIOS or meconium ileus equivalent occurs in 10–22% of CF patients, predominantly in the young age group due to poor motility and thick intestinal secretions. Precipitating factors include dehydration, uncontrolled diabetes and drugs like anticholinergics and opiates.1 DIOS can mimic clinically appendicitis, appendicular mass, intussusception or adhesions related to prior surgeries.1 CT is required to exclude potential surgical conditions because the standard treatment for DIOS, like rehydration and laxatives, may be hazardous in these conditions. Our patient was managed conservatively with rehydration and laxatives.

Figure 1

CT of the abdomen reveals dilated small bowel loops (arrowhead), solid muco-feculent material impacted in the distal ileal loops (asterisk), and a thickened appendix (arrow).


  • Contributors SHT: design and data acquisition. HT: draft of manuscript.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Institutional review board approval is not required for single case reports.

  • Provenance and review Not commissioned; internally peer reviewed.


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