William Herring, M.D.

2002

Recognizing
SBO, LBO and Ileus

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 Abdominal Images
What to Examine

Gas pattern-this lecture

Extraluminal air
Soft tissue masses
Calcifications-other
lectures
 Normal Gas Pattern

Stomach
Always

Small Bowel
Two or three loops of non-distended bowel
Normal diameter = 2.5 cm = 1 US quarter

Large Bowel
In rectum or sigmoid almost always
 Gas in
stomach

Gas in a few
loops of
small bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

Stomach
Always (except supine film)

Small Bowel
Two or three levels possible

Large Bowel
None normally
 Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen
 Large vs. Small Bowel

Large Bowel
Peripheral
Haustral markings don't
extend from wall to wall
Small Bowel
Central
Valvulae
extend across lumen
Maximum diameter of 2"
Complete Abdomen
Obstruction Series

Supine
Prone or lateral rectum
Erect or left decubitus
Chest - erect or supine
 Complete Abdomen
Supine

Looking for
Scout film for gas
pattern
Calcifications
Soft tissue
masses
Substitute none
 Complete Abdomen
Prone

Looking for
Gas in
rectum/sigmoid
Gas in ascending and
descending colon
Substitute lateral
rectum
 Complete Abdomen
Erect

Looking for
Free air
Air-fluid levels

Substitute left
lateral decubitus
 Complete Abdomen
Erect Chest

Looking for
Free air
Pneumonia at bases
Pleural effusions

Substitute supine
chest
Abnormal Gas Patterns

Functional Ileus
Localized (Sentinel Loops)
Generalized adynamic ileus

Mechanical Obstruction
SBO
LBO
 Localized Ileus
Key Features

One or two persistently dilated loops

of large or small bowel
Gas in rectum or sigmoid
Supine Prone

Sentinel Loops
 Sentinel Loops
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis

Ulcer
Ureteral calculus
 Localized Ileus
Pitfalls

May resemble early

mechanical SBO
Clinical course
Get follow-up
 Generalized Ileus
Key Features

Gas in dilated small bowel and

large bowel to rectum
Long air-fluid levels
Only post-op patients have
generalized ileus
 Supine Erect

Generalized Adynamic Ileus

 Is It An Ileus?

Is the patient immediately post-op?

Are the bowel sounds absent or
hypoactive?
If no, then it isnt an ileus

Patientsdont present to the ER with

a generalized adynamic ileus!
 Mechanical SBO
Key Features

Dilated small bowel

Fighting loops
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB
SBO
 Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

*Cause may be visible on plain film

 Mechanical SBO
Pitfalls

Early SBO may

resemble localized
ileus -get F/O
 Mechanical LBO
Key Features

Dilated colon to point of

obstruction
Little or no air in rectum/sigmoid
Little or no gas in small bowel, if
Ileocecal valve remains competent
Supine Prone

LBO
Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception
 Mechanical LBO
Pitfalls

Incompetent ileocecal valve

Large bowel decompresses into small
bowel
May look like SBO
Get BE or follow-up
 Supine Prone

Carcinoma of Sigmoid LBO

Decompressed into SB
Special Cases
 Air in
biliary
SBO tree

Gallstone Gallstone Ileus

Post-op C-section
Adynamic Ileus
Sigmoid Volvulus
Mesenteric Occlusion
Abnormal Gas Patterns
Review

Localized ileus
Generalized ileus
Mechanical SBO
Mechanical LBO
 Abdominal Images
What to Examine

Gas pattern-this lecture

Extraluminal air
Soft tissue masses
Calcifications-other
lectures
 Important Points

Look for air in the rectum/sigmoid first

Identify the most dilated loops-are they large
bowel or small bowel?
Sentinel loops are 1-2 dilated loops of small
bowel
Generalized adynamic ileus almost always occurs
in immediate post-op patients
Always correlate the clinical findings with imaging
findings
 Identify the Types of
Abnormal Gas Patterns

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What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
 Correct

There are multiple air-

containing and dilated loops
of small bowel with little or
no gas in the colon. The
findings are those of a
mechanical small bowel
obstruction. The patient had
undergone prior surgery
and the cause of this
obstruction was adhesions
form the prior surgery.

Go Back Go ahead
 Correct

There is a dilated colon

to the splenic flexure/
Little or no gas is seen
in the rectum or in the
small bowel. The
findings are those of a
mechanical large bowel
obstruction. The cause
was an annular
constricting carcinoma
at the splenic flexure.

Go Back Go ahead
 Correct

There are several air-

containing and slightly
dilated loops of small bowel
in the LLQ. These were
persistent. The findings are
those of a localized ileus
(sentinel loops) and their
location would suggest
diverticulitis. The patient had
appendicitis. The sentinel
loops do not always
correspond to the area of
inflammation.
Go Back Go ahead
 Correct

All of the bowel is dilated.

There is air in the rectum.
The patient was post-op
abdominal surgery and the
bowel sounds were absent.
This is a generalized
adynamic ileus as is seen
sometimes after abdominal
surgery.

Go Back Go ahead
 Wrong
Look Again

Click on the Go Back

button and look again

Go Back
Congratulations, You Graduate

You know
your
bowel gas

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