Radiology of small bowel obstruction:

contemporary approach and controversies

D. D. T. Maglinte,
1
F. M. Kelvin,
2
K. Sandrasegaran,
1
A. Nakeeb,
3
S. Romano,
4
J. C. Lappas,
1
T. J. Howard
5
1
Department of Radiology, Indiana University Medical Center, 550 North University Boulevard, Room UH 0279, Indianapolis,
IN 46202, USA
2
Methodist Hospital of Indiana, Indianapolis, IN 46202, USA
3
Division of General Surgery, Indiana University Medical Center, Indianapolis, IN 46202, USA
4
Department of Radiology, A. Cardarelli Hospital, 80131 Naples, Italy
5
Division of General Surgery, Indiana University Medical Center, Indianapolis, IN 46202, USA
Abstract
The radiologic workup of patients with known or sus-
pected small bowel obstruction and the timing of surgical
intervention in this complex situation have undergone
considerable changes over the past two decades. The
diagnosis and treatment of small bowel obstruction, a
common clinical condition often associated with signs
and symptoms similar to those seen in other acute ab-
dominal disorders, continue to evolve. This article ex-
amines the changes related to the use of imaging in the
diagnosis and management of patients with this poten-
tially dangerous problem and revisits pertinent contro-
versies.
Key words: Small bowel obstructionLong-tube de-
compressionComputed tomographic enterocly-
sisAbdominal radiographyAbdominal computed
tomographyNasogastric intubation
The dictum, never let the sun rise or set on small bowel
obstruction, was once popular among general surgeons
because of the feared complication of strangulation and
the difculty associated with its preoperative recognition
[1]. Advances in imaging techniques and the introduction
of more versatile nasointestinal tubes continue to change
the workup and treatment of patients with suspected
small bowel obstruction (SBO) [2].
Intestinal obstruction remains a difcult entity to
diagnose accurately and treat [13]. Many controversies
remain in the diagnosis and management of SBO, an
entity that clinically mimics many other acute abdominal
disorders [415]. Radiology has a critical role in the
clinical decision making of patients with suspected or
known SBO because it can answer specific questions that
have a major impact on clinical management [2]. These
questions include: Is the small bowel definitely ob-
structed? What are the level, cause, and severity of ob-
struction? Is strangulation likely to be present? Should
treatment be operative or nonoperative [16]?
In this article, the role and controversies of conven-
tional and newer radiologic methods of examination in
the diagnosis and treatment of SBO are reviewed.
Overview of clinical controversies
The major causes of SBO have changed during the past
ve decades [1517]. Currently, the three most common
causes of SBO in Western society are adhesions, Crohn
disease, and neoplasia [17]. Hernias still represent the
predominant cause of SBO in many developing coun-
tries. Crohn disease has only recently been acknowledged
in the surgical literature as a leading cause of SBO, a fact
that has long been suspected by many radiologists [17,
18]. With regard to treatment, controversies still exist
concerning patients with adhesive SBO. If the obstruc-
tion is partial and occurs early in the postoperative pe-
riod, many surgeons prefer a trial of conservative
treatment with intestinal decompression in the belief
that, with close patient monitoring, surgery frequently
can be avoided [1821]. Simple mechanical obstruction Correspondence to: D. D. T. Maglinte; email: [email protected]
Springer Science+Business Media, Inc. 2005
Published online: 1 February 2005
Abdominal
Imaging
Abdom Imaging (2005) 30:160178
DOI: 10.1007/s00261-004-0211-6
cannot be reliably differentiated clinically from strangu-
lated obstruction on the basis of the clinical, laboratory,
or abdominal plain film findings [5, 18, 2326]. Historical
data in patients with surgically proved strangulation
have shown that the preoperative diagnosis is unreliable
in 50% to 85% of cases [3, 18, 2731]. Based on these
data, a minority of surgeons have been vocal advocates
of early surgical management of all patients, particularly
those with complete intestinal obstruction, based on the
high complication rate associated with delayed operative
intervention [5, 22, 23] Despite this concern, the current
mortality rate of patients with adhesive intestinal ob-
struction is only 1% to 2% [3234]. This suggests that the
vast majority of patients do not have strangulated ob-
struction and the risks associated with nonoperative
management may be acceptable as long as immediate
surgery is performed if the patient does not improve or
develops signs and symptoms of incarceration or stran-
gulation. Recent clinical series have shown that even
high-grade mechanical SBO often resolves spontaneously
with conservative nasointestinal decompression, further
supporting an even-handed approach to this complex
problem [6, 20, 32, 33].
In recent years, there has been increasing interest in
the use of minimally invasive techniques (laparoscopy)
for the management of patients requiring operative in-
tervention for SBO. Several investigators have shown
that adhesiolysis leads to relief of intestinal obstruction
in 40% to 70% of patients who undergo exploration [35
38]. Laparoscopic management is associated with de-
creased formation of postoperative intra-abdominal ad-
hesions, results in earlier postoperative recovery of
intestinal motility, and decreases postoperative length of
hospital stay. Achieving safe access to the peritoneal
cavity can be a major challenge to surgeons considering
laparoscopic adhesiolysis. Computed tomographic (CT)
enteroclysis with multiplanar reformatting to map the
areas of adhesions and the locations of parietal and
visceral peritoneal adhesions can be helpful in identifying
an appropriate region of the abdomen for gaining safe
initial access to the peritoneal cavity [39]. CT enteroclysis
may also be extremely helpful in selecting which patients
may be candidates for a laparoscopic approach (ob-
struction caused by a single adhesive band versus dense
entero-enteric adhesions or malignancy; evidence of
bowel ischemia or necrosis; the presence of massively
dilated bowel). Distended small bowel loops can be de-
compressed before laparoscopic intervention by long-
tube decompression in conjunction with CT enteroclysis
[39].
The diagnosis of early postoperative SBO has often
been difcult because the clinical presentation of this
condition may be clouded by incisional pain, narcotics,
abdominal distention, and the presence of adynamic ileus
after celiotomy [13, 14]. Another controversy relates to
the diagnosis and treatment of patients with SBO who
have a history of prior surgery for intra-abdominal ma-
lignancy. The rationale that tempers early operative
treatment is that an obstruction due to recurrent cancer
is unlikely to be relieved surgically [5, 4043]. One series
reported that, in 26% of patients with malignancies and
SBO, the obstructions were caused by benign adhesions
rather than tumor [44]. In this series, surgically treated
patients were more effectively palliated and survived for
longer periods. It has been stated that operative treat-
ment of these patients should be vigorously pursued
because nonoperative treatment often does not relieve
the obstruction. The need for accurate diagnosis in this
group of patients and in patients with early postoperative
SBO, Crohn disease, and a history of prior radiation
cannot be overemphasized. Because of this need for ac-
curacy, the radiologic investigation assumes a vital role
in clinical decision making in these situations [45]. A
prompt and precise imaging diagnosis allows triage of
these patients into a surgical or nonsurgical management
category and decreases the length of the hospital stay,
morbidity rate, and the cost of patient care.
Plain abdominal radiography: why
bother?
Despite its limitations, abdominal radiography often re-
mains the initial imaging study in patients with suspected
SBO. Plain lms are least helpful with vague abdominal
pain and nonspecic physical ndings. In the setting of
SBO, abdominal radiographs are diagnostic in 50% to
60% of cases [2326, 46, 47]. A recent critical analysis of
plain film findings found a sensitivity of only 66% of
proved cases of SBO [47]; 21% of patients reported as
normal in this analysis had obstruction. Of patients
thought to have abnormal but nonspecific plain film
findings, 13% had low-grade and 9% had high-grade
obstruction. Abdominal radiography has shown a low
specificity for SBO because mechanical and functional
large bowel obstructions can mimic the radiographic
findings observed in SBO [47, 48]. Although in many
instances abdominal radiographs obtained early in the
clinical evaluation are nondiagnostic, the findings can be
valuable in guiding subsequent imaging or following
disease progression. Despite frequent use of CT in the
emergent setting in most patients with acute abdominal
pain, a cost-effective approach using plain films in ad-
dition to careful clinical examination to triage diagnostic
workup can be done [49]. This radiologic approach relies
on direct communication between the radiologist and the
surgeon to prevent unnecessary delays in diagnosis. The
clinical background of each patient and findings on ab-
dominal radiographs help to determine the most appro-
priate subsequent imaging method. Prior controversy
surrounding the meaning of commonly used terms used
to describe intestinal gas patterns has been recently
clarified [50]. The normal small bowel gas pattern is
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 161
defined as the absence of small bowel gas or presence of
small amounts of gas within up to four nondistended
(<2.5 cm in diameter) loops of small bowel (Fig. 1).
These radiographs show a normal distribution of gas and
stool within a nondistended colon. The abnormal but
nonspecific gas pattern describes a pattern of at least one
loop of borderline or mildly distended small bowel (2.5
3 cm in diameter), with three or more airfluid levels on
upright or lateral decubitus radiographs. The colonic and
fecal distributions are normal or display a similar degree
of borderline distention. This equivocal pattern, correctly
labeled mild small bowel stasis, is seen in many conditions
including low-grade obstruction, reactive or reflex ileus,
and medication-induced hypoperistalsis. In these two
plain film patterns, enteral volume-challenged examina-
tions (enteroclysis and its current modifications) are the
most informative imaging methods of choice for further
investigation [45, 5052] (Fig. 2). This technique is dis-
cussed further below; interested readers are referred to a
recent treatise on this technique [45]. An important
benefit of enteroclysis and its modifications in the
workup of these two categories of plain film patterns is
the ability to exclude lower grades of partial mechanical
SBO, which is not possible with noninfusion methods of
small bowel examination [2, 46].
The probable SBO plain film pattern is defined as an
abnormal gas distribution consisting of multiple gas- or
fluid-filled loops of dilated small bowel with a relatively
small or moderate amount of colonic gas. This pattern
can be seen in several acute intra-abdominal inflamma-
tory conditions that involve the small bowel, such as
appendicitis, diverticulitis, or mesenteric ischemia. Ad-
ditional radiologic investigation depends on clinical cir-
cumstances (Fig. 3). Immediate abdominal CT with
intravenous contrast is the procedure of choice if the
patient has fever, tachycardia, localized abdominal pain,
or leucocytosis because these features suggest the pres-
ence of an abscess, ischemia, or strangulation. However,
if the clinical history suggests simple mechanical ob-
struction, elective barium enteroclysis or CT enteroclysis
is appropriate. Both forms of enteroclysis are highly
accurate in confirming or excluding the diagnosis of
SBO, assessing its severity, and defining its etiology. An
unequivocal SBO pattern is defined as dilated gas- or
fluid-filled small loops of small bowel in the setting of a
gasless colon. This combination of findings is pathog-
nomonic of SBO [45]. Multiple factors influence the se-
lection of further imaging procedures with this pattern. If
high-grade or complete SBO is suspected on abdominal
radiography, immediate surgical evaluation of the pa-
tient is essential. The need for urgent operation (clinical
findings of strangulation) will contraindicate further di-
agnostic imaging. However, a recent report has suggested
that, in patients with this plain film pattern who have a
history of prior abdominal surgery, a nonoperative ap-
proach with nasointestinal suction and fluid replacement
may be useful for up to 5 days because this may avoid the
need for surgical intervention [20, 21]. During this period
of nonoperative treatment, abdominal CT can be of
value to determine the etiology and to look for signs of
strangulation. Demonstration of a specific etiology by
CT will often change management [34]. If CT findings
suggest adhesive obstruction without evidence of stran-
gulation, serial abdominal radiography may be per-
formed to follow the course of the obstruction. In
patients with an unequivocal SBO pattern and a history
of malignancy, Crohn disease, or prior external radia-
tion, barium or CT enteroclysis and conventional ab-
dominal CT are complementary. CT enteroclysis, in
particular, combines the advantages of both methods
and is the optimum method of further investigation when
expertise is available [39, 52, 53]. Volume-challenged
enteral examination (enteroclysis) is approximately 85%
accurate in distinguishing adhesions from metastases,
tumor recurrence, and radiation damage [45, 5456].
When plain film suggests SBO in elderly or infirm pa-
tients, CT appears to be the more appropriate and better
tolerated method of further investigation. Further, this
Fig. 1. Normal intestinal gas distribution. A small amount of
gas is present in the duodenal bulb (straight arrow) and
nondistended distal ileum (curved arrow). Otherwise, there
should be no gas in the small intestine. A moderate amount of
gas in a nondistended stomach and intraperitoneal segments
of the colon is usually seen.
162 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
obstructive pattern may well be caused by colonic ob-
struction, mesenteric ischemia, or appendicitis. Patients
without a history of prior abdominal surgery who have
unequivocal SBO pattern but no clinical signs requiring
urgent surgery may need further investigation before
exploratory surgery, particularly if a laparoscopic ap-
proach is used (Fig. 4).
When plain lm radiography shows colonic disten-
tion and diffuse gaseous dilatation of the small intestine,
adynamic ileus may be difcult to distinguish from an
evolving high-grade SBO or colonic obstruction. The
approach to additional imaging is modied by several
factors: (a) if a nonobstructive colonic ileus or distal
colonic obstruction with an incompetent ileocecal valve
is suspected, a barium enema is an inexpensive and fast
method to rule out colonic obstruction and conrm the
diagnosis of colonic ileus; in the elderly or inrm patient,
Fig. 2. Abnormal but nonspecific intestinal gas pattern in a
patient with low grade obstruction from sclerosing peritoneal
encapsulation of small bowel. A Gas-filled. mildly distended
loops of small bowel in the mid and right lower abdomen and
a long, moderately distended gas-filled loop in the upper ab-
domen (curved arrow) are seen. A normal gas distribution is
seen in the stomach and colon. B Axial CT enteroclysis image
of the lower abdomen shows a faintly calcified peritoneal sac
(open arrows) encasing fixed, distorted loops of nondistended
small bowel (enteroenteric adhesions). Diffuse anterior en-
teroparietal peritoneal adhesions (solid arrows) are also seen,
as indicated by the loss of the fat plane between anterior
small bowel walls and the adjacent peritoneal lining. A small
amount of contrast is seen in the cecum. C Coronal CT ent-
eroclysis reformatted image shows the dilated small bowel
loops proximal to the obstructing peritoneal encapsulation a-
nd adhesions. The patient (with chronic renal problems sec-
ondary to Alport syndrome) presented with recurrent episodes
of unexplained severe lower abdominal pain.
Fig. 3. (See page 164.) Probable SBO plain film pattern. A
Multiple, mildly to moderately distended gas-filled loops of
small bowel are seen in the left upper abdomen. There is
normal colonic gas without evidence of distention. B, C Axial
images at the level of the lower abdomen of the most recent of
three abdominal CT images done in 2 years with oral and in-
travenous contrast enhancement for recurrent abdominal pain
show no evidence of significant intestinal distention. Contrast
is seen in the colon. C cecum. D, E Axial CT enteroclysis
images at the same levels as conventional CT (B, C) show a
clear transition point (arrow) indicating obstruction secondary
to anterior right paramedian enteroparietal peritoneal adhe-
sion. F Coronal CT enteroclysis reformat shows level of ob-
struction. Note collapsed loops distal to the obstruction.
Precise characterization of the site and cause of obstruction
facilitated a laparoscopic approach to adhesiolysis.
c
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 163
Fig. 3. See figure legend on page 163.
164 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
Fig. 4. See figure legend on page 166.
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 165
CT is preferred (Fig. 5); (b) in patients with fever or
leucocytosis and localized abdominal pain or in the im-
mediate postoperative period, CT is the suggested
imaging method of choice because of its ability to dem-
onstrate mural or extraintestinal changes [34, 5759].
In clinical practice, the suspicion of mechanical SBO
unfortunately may not be corroborated by plain ab-
dominal radiographs. In some instances, the abnormality
seen on plain lms may be accompanied by minimal
clinical ndings. Because of the consequences of undi-
agnosed strangulation, additional imaging studies are
frequently needed; in the United States, abdominal CT
with intravenous contrast is frequently performed [60
68].
Does abdominal ultrasound
have a role in the assessment
of SBO?
Ultrasound is frequently used in many countries for the
workup of SBO [6973]; recent articles have confirmed
the value of this widely available technique [74, 75].
However, because it is operator dependent (available
personnel may not be immediately available in the
emergency department) and has inherent limitations in
the evaluation of gas-containing structures, abdominal
sonography is not commonly performed in the United
States for the diagnosis of SBO. Because sonography is
commonly used in the initial evaluation of patients,
particularly female patients with pelvic complaints, it
may be the first study to detect fluid-filled, dilated, small
Fig. 5. Distal colonic obstruction versus adynamic ileus gas
pattern. A Distended small bowel loops and fluid-filled cecum
and ascending and transverse colon (arrow) are seen. The
presence of a distended colon with fluid rather than gas
should favor a diagnosis of mechanical obstruction. B Axial
CT image with oral and intravenous contrast enhancement
shows a short-segment carcinoma (arrow) in splenic flexure.
Note fluid in the distended colon proximal to the annular
stricture. (Maglinte DDT, Herlinger H, Turner WW, et al.
Emerg Radiol 1994;1:138149; reproduced with permission.)
Fig. 4. (See page 165.) SBO intestinal gas pattern. A, B
Supine and upright abdominal radiographs obtained in an
elderly patient with multiple episodes of abdominal pain with
no history of prior abdominal surgery (outside institution). Air
fluid levels in the distended small bowel are present. A normal
gas distribution in the stomach and colon is seen. C, D Axial
images of abdominal CT done with oral but without intrave-
nous contrast (hypertensive patient with elevated creatinine)
show a distended small bowel with particulate material (dirty
feces sign) in the right lower abdomen (arrow) with a col-
lapsed distal ileum consistent with SBO. Feces are seen in
a normal-caliber cecum. Exploratory laparoscopic surgery
(done at an outside institution) did not show a point of small
bowel obstruction. Colonoscopy done before laparoscopic
surgery was reportedly unremarkable. E CT enteroclysis done
after referral to our institution (coronal image at the level of the
right colon) shows an annular mass in the proximal ascending
colon (arrow). No SBO was seen. Repeat colonoscopy con-
firmed the presence of a mass. Biopsy and culture showed
Mycobacterium tuberculosis.
b
166 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
Fig. 6. Superiority of
intubation infusion examination
over oral barium examination.
A Abdominal radiograph in an
elderly patient with recurrent
abdominal pain and diarrhea.
No significant intestinal
distention is seen. Residual
contrast is seen in the appendix
and sigmoid from a prior barium
enema. B, C Overhead
radiographs of conventional
small bowel followthrough done
(A) 20 and (B) 40 min after
upper gastrointestinal
examination and (D) spot
compression radiograph of
terminal ileum were reportedly
unremarkable. Dilated loops in
the left hemiabdomen were not
appreciated at the time of
examination. E Barium
enteroclysis done subsequently
shows diluted barium mixture in
a fluid-filled, distended, distal,
small bowel. Inset represents a
delayed compression
radiograph of a malignant
stricture causing high-grade
partial SBO. Surgery revealed
metastases from lung
carcinoma. (Herlinger H,
Maglinte DDT. In: Clinical
radiology of the small intestine.
Philadelphia: WB Saunders,
1989:479507; reproduced with
permission.)
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 167
bowel secondary to obstruction. It is therefore important
to recognize the features of SBO on sonography. Similar
to other examinations that do not test the distensibility
and fixation of a segment of bowel, sonography may not
be sensitive enough to diagnose lower grades of ob-
struction and may not allow reliable exclusion of low-
grade SBO [2]. Although hindered by excessive bowel
gas, meticulous sonographic examination through the
flanks by an expert sonologist may show the presence,
level, and cause of obstruction. In cases of proximal SBO
in which plain films may be normal secondary to vom-
iting, sonography has been shown to be accurate in de-
termining the level and cause of obstruction [71, 74].
Peristaltic movement is readily observed and, with ex-
perience, the differentiation of mechanical obstruction
from paralytic ileus is relatively easily made. The level of
SBO may be determined by sonographic assessment of
the valvulae conniventes of the dilated bowel and the
transition point between the dilated and the collapsed
bowel. Adhesions or an internal hernia may be suggested
as the cause of obstruction when there is no apparent
cause of obstruction, such as a mass or inflammation.
The presence of free fluid between dilated small bowel
loops on sonography suggests worsening mechanical
obstruction and suggests the need for surgical manage-
ment rather than medical therapy [74]. It has also been
suggested that abdominal sonography may aid in the
selection of patients to undergo emergent CT or elective
CT enteroclysis [74]. Where there is immediate availa-
bility of an expert sonologist, abdominal sonography has
a role in the workup of SBO.
Barium and water-soluble contrast
oral small bowel radiography
Radiography using water-soluble agents was once used
by some institutions to triage patients with suspected
SBO into surgical and nonsurgical management [7681].
The widespread use of abdominal CT has largely sup-
planted this practice in the United States [2]. Despite the
strong opinion of a few remaining advocates, the use of
water-soluble contrast agents has been shown to have no
therapeutic effect in patients with postoperative SBO [79,
82]. Disadvantages of oral small bowel radiography in-
clude:
1. Inability of patients with suspected SBO to ingest
large amounts of unpalatable contrast.
2. Difficulty in assessing distensibility and fixation of the
small bowel.
3. Flocculation and dilution of barium in high-grade
obstruction leading to incomplete bowel opacification
or poor mucosal detail.
4. Length of time, sometimes several hours or longer,
before passively ingested contrast reaches the ob-
struction point.
Enteroclysis examinations
The intubation infusion method of small bowel exami-
nation overcomes the limitation of the nonintubation
techniques by challenging the distensibility of the bowel
wall and exaggerating the effects of mild or subclinical
mechanical obstruction [2, 83] (Fig. 6). Intubating the
small bowel bypasses the stomach and allows delivery of
a nondiluted barium or iodinated contrast bolus (in CT
enteroclysis) directly into the jejunum. The advantages of
intubation infusion of contrast include:
1. Controlled infusion of contrast promotes its ante-
grade flow toward the site of obstruction despite the
presence of diminished bowel peristalsis.
2. The resultant luminal distention facilitates detection
of fixed and nondistensible bowel segments.
3. High sensitivity (100%) and specificity (88%) for SBO
and high accuracy in determining the cause of ob-
struction (86%) [45].
4. Ability to detect multiple levels of obstruction; this
diagnosis is usually not possible with other modalities.
5. High reliability in diagnosing partial low-grade ob-
struction or excluding this diagnosis compared with
conventional CTor oral small bowel studies (Figs. 3, 6).
SBO is excluded by enteroclysis when unimpeded ow
of contrast is observed through normal-caliber small
bowel loops from the duodenum to the right colon. The
diagnosis of mechanical obstruction is conrmed by the
demonstration of a transition zone, dened as a change
in the caliber of the lumen from a distended segment
proximal to the site of obstruction to a segment that is
collapsed or decreased in caliber distal to the site of
obstruction [2, 811, 47, 5759]. Enteroclysis has also
been reported to objectively gauge the severity of intes-
tinal obstruction, an important advantage over other
imaging modalities [46, 47, 83, 84]. In low-grade partial
SBO, there is no delay in the arrival of contrast to the
point of obstruction, and there is sufficient flow of
contrast to the point of obstruction such that the fold
pattern of the postobstructive loops is readily defined.
High-grade partial SBO is diagnosed when the presence
of retained fluid dilutes the barium and results in inad-
equate contrast density above the site of obstruction,
allowing only small amounts of contrast material to pass
through the obstruction into the collapsed distal loops.
Complete obstruction is arbitrarily diagnosed when there
is no passage of contrast material beyond the point of
obstruction as shown on delayed radiographs obtained
up to 24 h after the start of the examination [47].
A disadvantage of volume-challenged enteral exami-
nation is the need for nearly constant radiologist in-
volvement. This can be impractical in a busy outpatient
clinic or emergency room. In addition, many institutions
lack individuals with the necessary expertise to perform
this study. Many patients also nd nasointestinal intu-
168 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
bation an unpleasant procedure. Importantly, the newer
multipurpose nasointestinal catheters used for enteroc-
lysis are better tolerated than the conventional nasogas-
tric tube [85, 86]. The elective use of conscious sedation
also has made enteroclysis a better tolerated procedure in
our practice [87].
CT and CT enteroclysis: does the
addition of enteral volume challenge
to CT give added value?
Initial studies of conventional CT in SBO reported sen-
sitivities of 90% to 96%, a specicity of 96%, and an ac-
curacy of 95% [5759]. However, these studies were
mostly in patients with high-grade obstruction. In a
critical analysis of the reliability of CT, in which an equal
number of patients with high- and low-grade SBO were
assessed, less favorable results were found [10]. Overall,
sensitivity was 63%, specificity was 78%, and accuracy
was 66% (Fig. 3). In addition to identifying the severity
and probable location of SBO, CT is useful for
determining presence of closed-loop obstruction and
strangulation [34, 6068]. Recognition of these two
complications is of great concern to surgeons, particularly
those who believe that a trial of conservative nonopera-
tive management is warranted in simple mechanical SBO
[21, 45]. Although the specificity of contrast-enhanced
mono-slice CT for intestinal ischemia has been reported
to be as low as 44%, its high sensitivity (90%) and negative
predictive value (89%) are quite helpful in making deci-
sions concerning continued nonoperative versus surgical
management [61, 88].
Most cases of strangulation occur as complications of
intussusception, volvulus, internal hernia, or other types
of closed-looped obstruction in which there is an im-
paired arterial supply or venous drainage of a segment of
small bowel [6067, 89]. Simple obstruction rarely causes
strangulation unless the luminal pressure exceeds venous
hydrostatic pressure. Axial CT signs of closed-loop ob-
struction depend on the orientation of the obstructed
Fig. 7. Closed-loop obstruction with strangulation. A Axial
CT image performed with water as an oral contrast agent with
intravenous contrast enhancement acquired during the late
arterial/early portal venous phase shows a markedly dis-
tended stomach and biliopancreatic limb. The patient had a
history of a prior Whipple procedure and presented with se-
vere abdominal pain. Fatty replacement of segment 6 of the
liver is seen. B, C Axial CT images of the lower abdomen
show distended hyperemic loops (arrow) of small bowel in the
left hemiabdomen. The presence of two horizontal loops (B)
and twisted mesenteric vessels (C, curved arrow) raised the
possibility of strangulated closed-loop obstruction. Surgery
confirmed obstruction distal to gastrojejunostomy from volv-
ulus of an internal hernia with mucosal ischemia. There was
no evidence of metastasis.
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 169
loop. If the loop is predominantly horizontal, a dis-
tended, often edematous, C- or U-shape loop is seen
(Fig. 7). The two ends of the loop should be close to each
other. In more obliquely orientated or vertical loops,
radiating obstructed loops are seen on consecutive slices.
Multiplanar reconstructions sometimes facilitate identi-
fication of the two ends of the closed loop and the
swirling of mesenteric vessels. The obstructed ends often
have a triangular or beaked appearance. Attention to the
course of vascular arcades in the bowel on CT with the
use of coronal mesenteric vascular mapping may help
identify cases of closed-loop obstruction before they
progress to strangulation [63, 6568].
Signs of strangulation are better detected with faster
multichannel CT technology because it is possible to
acquire images accurately during peak arterial and ve-
nous bowel wall enhancement. Thinner overlapping
slices also allow for better multiplanar reformatting.
The early signs of strangulation described during the
era of mono-slice CT were nonspecic and included
localized ascites at the site of the obstructed loop, bowel
wall thickening, mesenteric vessel blurring or engorge-
ment, and the halo sign due to the presence of sub-
mucosal edema. Later signs suggesting impending
perforation include hemorrhagic ascites (Fig. 8), pneu-
matosis, and mesenteric or portal venous air. Multi-
channel CT allows for dual phase acquisition of the
abdomen and pelvis to assess the arterial supply and
venous drainage of the intestines. A sign we have found
to be highly specific for bowel ischemia is decreased
enhancement of a focal segment of the bowel wall in the
arterial phase and increased enhancement in the venous
phase [64, 89]. If CT is used appropriately, its higher
initial cost may result in an overall cost savings by
expediting or avoiding surgery in appropriate patients,
thereby decreasing comorbidity and hospital length of
stay [2]. CT is also useful in distinguishing SBO from
ileus, bowel inflammation such as appendicitis, and
other causes of small bowel dilatation such as a blind
pouch syndrome [88]. In cases of high-grade obstruc-
tion, CT has a reported sensitivity of 100% for distin-
guishing obstruction from other causes of small bowel
dilatation, as compared with 46% for that of plain ab-
dominal radiographs. By differentiating paralytic ileus
from obstruction, CT findings have been shown to
modify management in 21% of patients by changing
conservative management to a surgical one (18%) or
vice versa [11, 34, 88]. CT is particularly helpful in
patients in whom obstructive symptoms are associated
with specific medical conditions such as a history of
prior malignant abdominal tumor, known inflammatory
bowel disease, a palpable abdominal mass, or abscesses
[45].
Controversy exists as to which oral contrast is prac-
tical to use when abdominal CT is performed for acute
abdominal pain [2]. In the era of mono-slice CT, using
positive oral contrast for all examinations was conven-
tional. The use of water as an oral contrast agent is
currently gaining popularity with the widespread avail-
ability of multichannel CT technology. Advantages of
water as an oral contrast agent include:
Fig. 8. Strangulated small bowel intussusception. Axial CT
image of the lower abdomen using intravenous contrast en-
hancement shows findings consistent with ileo-ileal intus-
susception. Mucosal hyperemia of the walls of the
intussuscipiens (curved arrow) is seen; lack of mucosal en-
hancement, suggesting absent perfusion of segments of the
interseptum (solid arrow), is visible. The latter finding sug-
gests infarction, which was confirmed at surgery. Also
note hyperdense ascites (open arrow), indicating hemo-
peritoneum.
Fig. 9. CT enteroclysis of peritoneal carcinomatoses.
Demonstration of site and cause of obstruction. A Abdominal
radiograph of an elderly patient with a history of prior partial
gastrectomy for malignancy presenting with recurrent ab-
dominal pain shows a gas pattern suggesting SBO. Prior
examination done in outside institution did not show ob-
struction. B Fluoroscopic radiograph of a CT enteroclysis
shows the enteroclysis catheter balloon in a small gastric
remnant occluding the gastroesophageal junction. The cath-
eter tip is in the efferent limb of jejunum. Note a nodular defect
(arrow) at the anastomotic site. C Axial CT enteroclysis image
at the level of the upper abdomen shows anterior peritoneal
(straight arrow) and mesenteric (curved arrow) implant. D
Axial image at the level of the lower abdomen shows a tran-
sition point (arrow) at the entry of the small bowel (anterior
aspect of the neck) into a right lateral flank incisional hernia. E
Coronal CT enteroclysis image at same level as shown in D
shows retained particulate matter in a dilated small bowel
proximal to the point of obstruction. A small soft tissue density
(straight arrow) is seen at the transition point, suggesting
metastatic obstruction. Also note nodular defects (curved ar-
row) at the gastrojejunal anastomosis. The site of obstruction
was confirmed at surgery. Recurrence at the gastrojejunal
anastomosis and peritoneal carcinomatosis were also seen.
c
170 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 171
1. Better differentiation of the lumen and bowel wall,
allowing for accurate estimation of bowel wall thick-
ness, mucosal hyperemia, and bowel wall edema.
2. Decreased likelihood of admixture defects that can
result in pseudo-masses or pseudo-fold thickening of
the small bowel.
3. Improved tolerability of water compared with con-
trast material.
4. Clearer multiplanar reformatted images for the as-
sessment of mesenteric vessels without artifact from
dense luminal contrast.
5. Subsequent studies are not degraded by the presence
of dense enteral and colonic contrast.
Disadvantages of using water as an oral contrast
agent include possible reduced distention of the bowel
lumen and potential difculty in separating the bowel
from peritoneal uid collections. This is obviated by
giving a large volume of oral water (1.82.5 L) in small
aliquots in addition to intravenous contrast enhance-
ment. Other enteral contrast agents are currently under
investigation. In the absence of clinical ndings suspi-
cious for strangulation and when abdominal CT results
are equivocal or uninformative, CT enteroclysis can of-
ten help establish the diagnosis by providing volume-
challenged distention of bowel loops [45, 56]. CT ente-
roclysis is emerging as the optimal method for investi-
gating the small bowel for obstruction [39, 56]. In this
technique, water-soluble contrast is infused through an
enteroclysis catheter into the duodenum or proximal
small bowel, followed immediately by CT acquisition
during continued infusion to maintain distention of the
small bowel loops. Important functional information is
obtained during the fluoroscopic part of the procedure,
when an appropriate concentration (1015%) of water-
soluble contrast agent is used [87]. Postprocessing of
fluoroscopically obtained images adds confidence to the
CT diagnostic findings. Multiplanar reformats are ob-
tained routinely to precisely define the site and cause of
obstruction. Our early experience suggested that precise
localization of sites of adhesive obstruction and decom-
pression of distended small bowel facilitates a laparo-
scopic approach to management (Fig. 3) [39, 41, 45]. The
volume challenge provided by infusion overcomes the
unreliability of CT for diagnosing lower grades of ob-
struction. Initial reports indicated that the reliability of
this method is equivalent to that of barium enteroclysis
(88% sensitivity and 82% specificity) in patients with
suspected low-grade partial SBO [52, 53]. Other reports
showed greater sensitivity and specificity (89% and
100%, respectively) with CT enteroclysis than with CT
alone (50% and 94%, respectively) in patients with sus-
pected partial SBO, a difference that is even greater when
there is a history of abdominal malignancy [54]. Precise
demonstration and characterization of the transition
point by CT enteroclysis adds confidence in differenti-
ating malignant from benign causes of SBO [45]. The
presence of peritoneal nodules, asymmetric thickening,
enhancement of the transition site, and mesenteric
whirling has been shown to be useful features in facili-
tating this differentiation (Fig. 9) [55]. The use of CT
enteroclysis using water or methylcellulose with intrave-
nous contrast enhancement can also diagnose mechani-
cal obstruction but currently is used more for evaluation
of unexplained anemia or gastrointestinal bleeding [90]
(Fig. 10). We are using this technique more in patients
with symptoms of obstruction with normal plain films or
with the mild stasis pattern.
Additional imaging may be contraindicated in pa-
tients with high-grade or complete SBO [8]. Unless clini-
cal signs of strangulation are present, recent experience
has shown that in patients who develop high-grade SBO
in the immediate postoperative period and in patients
with a history of prior surgery for abdominal malignancy,
known Crohn disease, or prior radiation treatment, CT
enteroclysis after an initial nasointestinal decompression
is of value in formulating a definitive surgical manage-
ment plan. [39, 45]. Preliminary decompression of
markedly distended small bowel loops is necessary to
prevent the potential complication of small bowel perfo-
ration. Adjustment of infusion rates (i.e., decrease) under
fluoroscopic guidance should also be done.
Magnetic resonance imaging and
enteroclysis: what are their roles?
Magnetic resonance (MR) imaging to date has played
only a limited role in the clinical evaluation of me-
chanical SBO. With increasingly fast sequences (many
now completed within a single breath-hold), it is now
possible to image the entire abdomen and pelvis within
10 min [90]. A recent study based on a small number of
patients reported that half-Fourier acquisition imaging
in three planes is superior to helical CT in diagnosing
SBO [91]. However, in this report, there was no men-
tion of the severity of obstruction. MR enteroclysis has
the potential to change the assessment of the small
bowel through its direct multiplanar imaging capabili-
ties, its lack of ionizing radiation, and the functional
information and soft tissue contrast that it can provide
[92]. Compared with CT enteroclysis, MR enteroclysis
provides distinct advantages of direct imaging in the
coronal plane and real-time acquisition of functional
information. In addition, the accuracy of the MR
imaging technique does not rely as heavily on the ex-
perience of the fluoroscopist as do barium enteroclysis
techniques [89]. Currently, MR methods of examination
are not part of the routine evaluation of SBO. Further
research and experience may help clarify whether MR
imaging and enteroclysis will become integral parts in
the investigation of SBO or will be used solely as a
problem-solving examination.
172 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
Nasogastric versus nasointestinal
(long-tube) decompression in the
nonsurgical management of small
bowel obstruction
With better understanding of the pathophysiology of the
many types of bowel obstruction, there has been an in-
creasing willingness of surgeons to use nonoperative
treatment for most patients with SBO.
The gastrointestinal tract normally secretes 8.5 L of
uid daily, most of which is reabsorbed in the small in-
testine [93]. In cases of SBO, there is an impaired ability
of the small intestine to reabsorb secreted fluid above an
obstruction, which, over time, results in a net flux of fluid
out of the bowel and into the lumen [94, 95]. The func-
tional and physiologic derangements of intestinal ob-
struction are borne predominantly by the bowel
immediately proximal to the point of occlusion [96]. As
progressive distention occurs, these segments become at
risk for the development of ischemia, gangrene, and
perforation.
With an intact pylorus, nasogastric tubes cannot de-
compress the small bowel until the pressure of backed-up
intestinal uid and gas is strong enough to overcome the
strength of the pyloric sphincter. The results of several
studies have shown that the efcacy of decompression is
inversely proportional to the distance between the de-
compressing tube tip and the site of the blockage. Con-
sequently, advancement of the decompression tube
beyond the pylorus into the small bowel signicantly
improves decompressive efcacy over standard nasogas-
tric tube positioning [94]. This pathophysiologic principle
explains why nasointestinal rather than nasogastric in-
tubation is considered the optimal method for decom-
pressing the distended small bowel (Fig. 11). An added
advantage to using a long tube is that, as soon as the tube
passes the pylorus and begins to decompress the small
bowel, the colicky pain of obstruction is largely relieved
[97, 98]. Because nasogastric tube decompression is lim-
ited to the stomach, a patients abdominal pain persists
until the obstruction is relieved or effective decompres-
sion is achieved, whether spontaneously or surgically.
There is controversy regarding the use of nasogastric
tubes versus the long nasointestinal tubes (e.g., Miller
Abbott, Cantor, Maglinte, etc.) in the nonsurgical man-
agement of small bowel obstruction. In one series, 40%of
patients treated with a long nasointestinal tube did not
require surgery, whereas 81% of patients treated with
nasogastric tube did not require surgery [14]. Analysis,
however, shows that this was likely because the patients
treated with long tubes were those who had more severe
obstruction. Some researchers have emphasized that the
need for surgery is not related to whether or not the long
tubes pass beyond the pylorus [19, 20]. In reality, much of
the controversy relates to the difficulty in passing the long
intestinal tube beyond the pylorus. It is because of the
latter difficulty that many surgeons have accepted the
superiority of nasogastric intubation as opposed to long-
tube intubation [99]. In institutions where immediate
placement of a long intestinal tube is possible, the use of
long tubes has been advocated [39, 98].
Because the Salem sump nasogastric tube (Sherwood
Medical, St. Louis, MO, USA), currently the most com-
monly used nasogastric decompression tube, is too short
to be advanced into the small bowel, a multipurpose
catheter (diagnostic and therapeutic) was introduced
Fig. 10. Added value of enteral volume challenge during CT
in the demonstration of partial SBO. A Axial CT image of the
lower abdomen done with oral and intravenous contrast in an
elderly patient with severe abdominal pain shows no evidence
of mechanical SBO. A partially calcified mesenteric mass with
spiculated margins radiating toward adjacent small bowel
loops is seen (arrow). B Axial CT enteroclysis image at same
level as shown in A using a neutral enteral contrast agent
(water) with intravenous contrast enhancement done after CT
of the lower abdomen to exclude mechanical SBO shows a
dilated small bowel proximal to the mesenteric mass, with
collapsed small bowel loops distal to the mass. The transition
point (arrow) is well defined because of the effect of continued
infusion (volume challenge) during CT acquisition. Open-
wedge biopsy showed sclerosing mesenteritis.
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 173
(MDEC-1400, Cook, Inc., Bloomington, IN, USA) in
1992 [100]. This catheter is better tolerated by patients
because of its smaller caliber. Early experience with this
multipurpose catheter showed that it was well tolerated in
a study of 150 patients [86]. This catheter has allowed
optimization of the radiologic investigation and nonsur-
gical management of patients with suspected SBO [39].
This multipurpose (nasogastric, nasoenteric decom-
pression, and enteroclysis) tube is a modication of the
standard balloon enteroclysis catheter [100]. It is a 14-F,
155-cm long, triple-lumen disposable catheter made of
radiopaque polyvinyl chloride and has been adapted for
use with wall mechanical suction devices currently used
in hospitals. The smaller tube and the ease with which it
can be advanced under fluoroscopy into the small bowel
have made it a practical alternative to the currently used
nasointestinal tubes for decompression and subsequent
diagnostic studies [39]. The important addition of sump
ports to the multipurpose tube prevents intestinal debris
and collapsed bowel from occluding the decompression
side ports and thereby permits effective decompression
compared with other long tubes. The side ports com-
municating with the sump and suction lumina allow
flushing from a proximal attachment to clear any
blockage of the ports by debris or thick secretions
during suction. The construction of the tube makes it an
efficient decompression catheter. The small size and
tapered end result in less mucosal irritation of the nose
during intubation. All the functions of a nasogastric
tube can be carried out with this multipurpose catheter,
in addition to its capability of nasoenteric decompres-
sion and diagnostic studies. The complications reported
with other nasointestinal tubes, such as perforation,
have not been reported in the literature with this tube
since its introduction [101]. The availability of this
multipurpose catheter (Maglinte decompression ente-
Fig. 11. Nasogastric versus long-tube nasointestinal
decompression. A Supine abdominal radiograph obtained 2
days after laparotomy and lysis of adhesions in an elderly
patient shows abnormal distribution of intestinal gas,
consistent with postoperative ileus. B Supine abdominal
radiograph obtained 24 h after insertion of a Salem sump
nasogastric tube (arrow). The small bowel loops remain
distended. C Anteroposterior abdominal radiograph obtained
48 h after insertion of a long tube and intermittent mechanical
suction shows interval decompression of most of the
distended small bowel loops. The patient had an uneventful
postoperative course after long-tube decompression.
(Maglinte DDT, Kelvin FM, Rowe MG, et al. Radiology
2001;218:3946; reproduced with permission.)
174 D. D. T. Maglinte et al.: Radiology of small bowel obstruction
roclysis catheter, Cook, Inc.) has provided the surgeon
with the option to use long-tube decompression of the
obstructed small bowel and perform immediate CT
enteroclysis or barium enteroclysis, if indicated [39].
Objections to the discomfort of intubation in more re-
cent studies are diminished with the use of this tube
[101103]. Conscious sedation should be offered, how-
ever, to patients who complain of discomfort during
intubation [103].
Discussion
The dilemma that radiologists face is not the use of one
technique over another but the decision of which exam-
ination to use rst in the context of the clinical presen-
tation and abdominal plain lm ndings [2, 45].
SBO pattern on a plain lm radiograph conrms the
clinical diagnosis and opens the door for a decision as to
whether to use a trial of conservative nonoperative man-
agement or to perform surgery [84]. Factors that favor
early surgical exploration include no prior history of ab-
dominal surgery, clinical suspicion of bowel compromise,
incarcerated hernia, or the presence of complete SBO. The
indication to undergo immediate exploration with plain
film patterns of SBO in patients who have no history of
prior abdominal surgery and no clinical signs of strangu-
lationappears tobe overstatedandpredates the current era
of high-quality radiologic imaging and endoscopic tech-
niques. This indication was adopted because of the diffi-
culty in examining the bowel lumen for masses and the
difficulty in the diagnosis of internal hernias and strangu-
lation in the past. This indication needs reassessment.
Factors that favor initial conservative management in-
clude the presence of a partial SBO, history of a resected
abdominal tumor, prior radiation therapy, history of in-
flammatory bowel disease, and early (<6 weeks) post-
operative obstruction [45]. When initial conservative
management is entertained, emergent CT is helpful in ex-
cluding aclosed-loopor strangulatedobstruction. Surgical
patients presenting early after surgery with abdominal
distentionandnosigns of bowel compromise (tachycardia,
leukocytosis, localized tenderness, or fever) are treated
conservatively for several days. CTis recommendedonly if
the clinical findings or small bowel distention on abdomi-
nal plain films do not improve, or if signs of intra-ab-
dominal abscess or bowel compromise develop. CT
enteroclysis with positive enteral contrast is an excellent
problem-solving tool and is easier to performthan barium
enteroclysis in the postoperative patient or one who is
critically ill [56]. If the abdominal plain film shows colonic
distentioninadditiontosmall bowel dilatation, abdominal
CT or a contrast enema is preferred to exclude colonic
obstruction. In this clinical setting, CT is preferred in eld-
erly or infirm patients, patients with a clinical suspicion of
abscess or diverticulitis, and patients with a history of
previously resected colon carcinoma. CT is also preferred
in the acute setting in patients with poor sphincter tone
[104]. WhenCTis not readily available, the contrast enema
is the method of choice. In countries where sonographic
expertise is available, sonographic evaluation may follow
plain film examination for small bowel obstruction [74].
Discordance between the clinical presentation and
plain lm or sonographic ndings often requires addi-
tional radiologic imaging. In patients with acute abdomi-
nal symptoms and an abnormal but nonspecic bowel gas
pattern on plain lms, CT using water as an oral contrast
agent with intravenous contrast enhancement is recom-
mendedinthe emergent situation. CTnot only is reliable in
showing many of the acute abdominal conditions that can
mimic SBObut also has a high sensitivity for high-grade or
complete obstruction and can reveal closed-loop and
strangulating obstruction. When the CT examination is
not diagnostic and all management-relevant questions are
unanswered, elective CTenteroclysis, bariumenteroclysis,
or even MR enteroclysis can be performed. CT enteroc-
lysis is the best initial imaging technique in patients with a
history of laparotomy or complaints of mild intermittent
abdominal pain who have few physical ndings and nor-
mal or abnormal but nonspecic ndings on abdominal
plain lm. Low-grade intermittent obstructions and in-
traluminal tumors can be detected and evaluated better
with this technique. Barium enteroclysis can be performed
in institutions where expertise in CT enteroclysis is not
available. MR enteroclysis also can provide additional
information, particularly in patients with inammatory
bowel disease or in pregnant patients with suspected ob-
struction.
Patients with high-grade SBO and other causes of the
acute abdomen are currently afforded accurate diagnosis
by conventional abdominal CT with intravenous contrast
in the emergency setting. The possibility of low-grade
mechanical SBO should be considered in any case of un-
diagnosed acute abdominal pain. The long tube, whose
temporary demise has been lamented by experienced sur-
geons, has reemerged as a smaller multipurpose diagnostic
and decompression catheter. The initial use of the multi-
purpose tube instead of the Salem sump nasogastric tube
prevents the trauma of reintubation without compromis-
ing nasogastric decompression if a diagnostic radiologic
procedure or a trial of long-tube decompression is re-
quired. The smaller tube and its softer material decrease
the discomfort associated with the use of conventional
nasogastric tubes. The ease with which it can be advanced
beyond the pylorus uoroscopically after nasogastric de-
compression negates the objection to previously designed
long intestinal tubes. These advantages offset the lowprice
of the conventional Salem sump nasogastric tubes com-
pared with the multipurpose catheter.
Unfortunately, the all too frequent and erroneous
application of conventional examination methods with
low sensitivity is frequent in clinical practice because of
the mistaken notion of cost containment. This delays the
D. D. T. Maglinte et al.: Radiology of small bowel obstruction 175
diagnosis of SBO, results in misdiagnosis, and prolongs
hospital stay, leading to increased cost and morbidity
rate. Recent improvements in CT and enteroclysis tech-
nology have changed the approach to the evaluation of
patients with suspected SBO [105]. The continued use of
conventional methods of investigation with poor specif-
icity without exploring newer methods of investigation
will result in the continued use of an ineffective routine to
the detriment of patient care (Fig. 3). Active collabora-
tion among surgeons, emergency physicians, and radiol-
ogists is necessary to optimize the diagnostic evaluation
and management of SBO, which remains a common and
potentially dangerous problem [39].
Conclusion
The modern era of radiologic management of SBO in the
United States relies on judicious selection of CT, CT
enteroclysis, and nasoenteric decompression (Fig. 12).
These techniques have replaced the traditional radiologic
approach that depended on plain films and oral barium
examination, which greatly limited the information
available to clinicians and prolonged diagnostic workup.
The informed radiologist is now a key member of the
team managing SBO.
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