Signs

• patient weak and sitting forward in distress

• visible peristalsis, loud borborygmi

• abdomen soft (except with strangulation)

• tender when distended

• increased sharp tinkling bowel sounds

• dehydration rapidly follows, especially in children and elderly

PR: empty rectum, may be tender

Note: check all hernial orifices including umbilicus

X-ray: plain erect film confirms diagnosis 'stepladder' fluid levels in 3-4 hours Gastrografin follow through for precise diagnosis

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