Small Bowel Obstruction

Oleh :
Robin Permadi
1210070100176
Radiologic imaging has assumed a paramount role in
directing the management of small bowel obstruction,
promoted by the widespread availability of MDCT. The
key question for a clinician managing a case of
suspected small bowel obstruction is how to optimally
treat the patient.
 Imaging Modalities

1. Radiography

Radiographs have accuracy of 67–83% in the diagnosis of

small bowel obstruction, with reported sensitivity of 64–
82% and specificity of 79–83%

Associated findings in a patient with small bowel

obstruction include dilatation of the stomach, absence of
colonic dilatation (normal caliber or collapsed colon), and
the presence of multiple gas-fluid levels on upright or
decubitus abdominal radiographs
( 1). The presence of air-fluid levels greater
than 2.5 cm in width and air-fluid levels
differing more than 5 mm from each other
within the same loop of small bowel are
additional findings indicative of small bowel
obstruction on erect radiographs

[2]. Free intraperitoneal gas may be

visualized on radiographs in complicated
small bowel obstruction
Fig. 1—Small bowel obstruction
A. Supine abdominal
radiograph shows dilated
loops of small bowel.
B. Erect abdominal radiograph shows
small bowel dilatation with multiple air-
fluid levels. Air-fluid level wider than 2.5
cm (horizontal line) and differential air-
fluid levels within same small bowel loop
(vertical line) are identified.
The severity of small bowel obstruction may be underestimated on

abdominal radiography if the dilated bowel loops are predominantly

fluid-filled (Fig. 2).

The presence of a gasless abdomen on radiography in a patient with

suggestive clinical features should raise the possibility of small

bowel obstruction.
 2. MDCT ( Multiple Detector Computed Tomography )

MDCT has been established as the modality of choice for imaging suspected
acute small bowel obstruction and is widely available.

The reported accuracy of CT for high-grade small bowel obstruction is

95%, with sensitivity of 90–94% and specificity of 96%

The diagnosis of small bowel obstruction requires the presence of small bowel
dilatation (transverse diameter > 2.5 cm) and the presence of a discrete
transition zone between dilated proximal and nondilated distal bowel
 Fig. 2—Small bowel obstruction
(B) abdominal
radiographs show loop of
dilated small bowel in left
lower quadrant, with paucity of
bowel gas elsewhere
in abdomen.
C. Coronal CT image shows multiple
loops of dilated small bowel filled with
intraluminal fluid, which are not visible
on radiographs. This 35-year-old patient
had small bowel obstruction due to
adhesions from prior laparotomy
 3. Ultrasound

Ultrasound has a limited role in the assessment of small bowel

obstruction because of poor visualization of gas filled structures.

4. Enteroclysis

This technique requires the placement of a

nasojejunal tube for instillation of a large amount of
oral contrast material. The transition zone at the site
of obstruction can be missed using enterography or
CT without volume challenge but is readily identified
after enteroclysis.
 5. MR Enterography

MR enterography is an
increasingly attractive option
for the assessment of small
bowel obstruction.
Therefore, it is most useful in
the setting of chronic small
bowel abnormality and
lowgrade obstruction. This is
particularly true in Crohn
disease, where reducing the
accumulated dose of ionizing
radiation in young patients is
desired.
 Adhesions

Adhesions are not visible on

radiologic imaging. Therefore, this
is a diagnosis of exclusion if no
ther cause can be identified at the
site of abrupt transition between
dilated proximal small bowel and
nondilated distal loops.

Fig. 5—Adhesion causing small-bowel obstruction in 50-year-old woman

with prior surgery for Crohn disease. Axial CT image shows sharp transition point
(arrows) at site of band adhesion, which required surgical repair. “Small bowel
feces” sign, presence of particulate material visible in proximal dilated segment of
intestine, is useful in identifying site of obstruction because particulate matter
tends to be most prominent just proximal to transition zone.
 Crohn Disease

Small bowel obstruction may

occur in Crohn disease by the
direct effect of strictured and
inflamed segments of bowel or
by adhesions caused by prior
surgical procedures

Fig. 9—MR enterography in Crohn disease in 31-yearold woman.

Images show discrete mid ileal segment with circumferential mural
thickening and enhancement (arrows), consistent with active Crohn disease.
There is transition point between inflamed segment of ileum and dilated
proximal bowel.
 Abdominal Hernias

Fig. 10—Femoral hernia in elderly woman with acute abdominal pain.

abdominal CT images show loop of small bowel (white arrow) protruding into
right groin. There is dilatation of proximal small bowel. Orifice of hernia arises
inferior in relation to inguinal ligament and lateral to pubic tubercle (black
arrow, A), consistent with femoral hernia.
CT images show small defect in
musculature of right anterior
abdominal wall that developed
spontaneously.
 Neoplastic Disease
Metastatic disease is the most frequent neoplastic cause of small bowel obstruction,
Obstruction occurs by extrinsic compression of the small bowel lumen

Fig. 12—58-year-old woman with

ovarian carcinoma.
A. Sagittal IV contrast-enhanced CT
image shows transition point (arrows)
between markedly dilated small bowel and
distal bowel, without luminal dilatation.
Widespread peritoneal metastases are
present in abdomen and pelvis
Intussusception

Fig. 13—Intussusception in 35-

year old man with melanoma.
Axial CT image shows mass in right
lower quadrant of abdomen with
target-like appearance due to
multiple adjacent bowel wall layers
(arrows). Findings were due to
ileocolic intussusception, with small
bowel metastasis acting as lead point.
Gallstone ileus

Fig. 14—Gallstone ileus in elderly woman with small bowel obstruction due
to gallstone ileus.
A. Axial CT image of pelvis shows large laminated calculus within dilated
loop of distal ileum in midline (arrow).
B. Axial CT image through liver shows pneumobilia (arrows), consistent with
biliary-enteric fistula.
Intraluminal Obstruction

Small bowel obstruction is rarely caused by intraluminal material. The site of

obstruction is usually at the ileocecal valve, where the lumen of the bowel is
smallest

Axial CT image shows vascular

engorgement
(white arrows) and edema in
mesentery of left flank
(black arrow), with ascites
identified in right flank.
Coronal CT image shows
luminal narrowing at site of
internal hernia in anterior
aspect of left lower abdomen
(arrow) and presence of ascites
Sagittal CT image through left side
of abdomen shows
hypoenhancement and mural
thickening of loop of small bowel
(black arrows) consistent with
ischemia. There is edema of adjacent
mesenteric fat and engorgement of
mesenteric veins (white arrows).
At surgery, transomental internal
hernia was reduced, and resection
of long segment of infracted small
bowel was performed.
 Management Strategies

The ultimate role of radiologic imaging in small bowel

obstruction is to determine whether the patient can be managed
with conservative measures or surgery is required. Indications for
emergency surgery include evidence of complete obstruction with
absence of gas or fluid in the distal gastrointestinal tract and signs
of strangulation or bowel perforation. A closed-loop obstruction
occurs when a segment of small bowel becomes obstructed at two
adjacent points
 Conclusion

Small bowel obstruction remains an important cause of acute abdominal pain in

patients presenting to the emergency department. MDCT is the modality of
choice for identifying the cause of small bowel obstruction and determining
whether emergent surgery is required. Adhesions are by far the most common
cause of small bowel obstruction. Other less frequent causes include Crohn
disease, neoplasms, and abdominal hernias. Identifying the transition point
between dilated and nondilated small bowel, although not required to make the
diagnosis of obstruction, is the key to establishing the site and cause of small
bowel obstruction.