MEHU107 - U2 - T29 - CK - Diamond M Small Bowel Obstruction 2019

Small Bowel Obstruction
and Ischemia
Matthew Diamond, MD, John Lee, MD, Christina A. LeBedis, MD*
KEYWORDS
Small bowel obstruction Bowel ischemia Bowel strangulation
Computed tomography of bowel obstruction Closed-loop obstruction
KEY POINTS
Suspected bowel obstruction is best evaluated using CT of the abdomen and pelvis with IV contrast
only.
Identifying and evaluating the transition point is the key to diagnosing and determining the cause of
the obstruction.
When evaluating the obstruction, it is best to determine if the cause is intrinsic, extrinsic, or intra-
luminal, keeping in mind that the most common cause of SBO is intra-abdominal adhesions.
The presence or absence of a closed-loop obstruction, which increases the likelihood of ischemia
and failed nonoperative management, should be mentioned when reading MDCT.
Reduced bowel wall enhancement and mesenteric edema are the most specific and sensitive,
respectively, signs of bowel ischemia, a surgical emergency. Mimics of other signs of ischemia limit
their usefulness when identified individually.
INTRODUCTION Radiologists play a significant role not only in the

diagnosis of SBO but also in the guidance of its
Small bowel obstruction (SBO) is a common sur- management. Increasingly, conservative manage-
gical emergency accounting for 20% of emer- ment has been the dominant method of treatment,
gency surgical procedures of patients with only 18% of patients with SBO requiring sur-
presenting with abdominal pain and approxi- gical treatment.6 Nonoperative management is the
mately 300,000 hospitalizations in the United treatment of choice in the absence of signs of
States annually.1,2 SBO causes high morbidity strangulation, ischemia, and peritonitis and is
with an average hospital stay of 8 days and in- effective in 70% to 90% of patients.3 Although
hospital mortality rate of 3% per episode.3 there is a slightly decreased risk of recurrence in
Following abdominal surgery, the incidence of patients treated operatively, with a 5-year rate of
SBO is up to 9%.3 It is also a significant cause recurrence of 16% versus 20%, there is a high
of hospital readmission following abdominal sur- risk of morbidity for surgical interventions
gery, with 5.7% of all readmissions following including bowel injury.3,7 It is the radiologist’s job
open abdominal and pelvic surgery being to determine the presence not only of SBO but
directly related to SBO.4 Although the incidence also signs that require immediate surgical explora-
of SBO has been reduced to 1.4% following tion and the possible cause of obstruction.
laparoscopic abdominal surgery compared with A feared complication of SBO is a strangulated
3.8% following open abdominal surgery, SBO obstruction, which is SBO with ischemia.8 Stran-
continues to be a significant cause of hospitali- gulation occurs in approximately 10% of cases
zation and surgical consultation.5
radiologic.theclinics.com
Disclosure Statement: Nothing to disclose.

Department of Radiology, Boston Medical Center, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA
02118, USA
* Corresponding author.
E-mail address: [email protected]
Radiol Clin N Am 57 (2019) 689–703

https://doi.org/10.1016/j.rcl.2019.02.002
0033-8389/19/Ó 2019 Elsevier Inc. All rights reserved.
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690 Diamond et al
of SBO and has a greatly increased mortality risk or valvulae conniventes. The large bowel contains
of 20% to 40%.9,10 Before the advent of multide- thick haustral folds known as plicae semilunares,
tector computed tomography (MDCT), there was which do not extend around the whole circumfer-
great difficulty in determining strangulation based ence of the bowel. Small bowel also tends to be
on clinical values and abdominal radiographs more centrally located.
alone.10 Recognizing the presence or absence of The intestinal tract secretes up to 8.5 L of fluid a
strangulated bowel is crucial for determining day, most of which is reabsorbed within the intes-
which patients are likely to fail conservative tines.12 Luminal narrowing and obstruction pre-
management. vents or reduces the passage of material,
The typical clinical presentation of SBO includes causing distention of the proximal loops of bowel.
abdominal pain, vomiting, obstipation, and Distention of loops of bowel can result in the
abdominal distention. Indications of possible compromise of circulation beginning with venous
strangulation include elevated white blood cell return that increases the risk of gangrene and
count (>10,000/mm3), elevated lactate, elevated bowel necrosis.13 The region of bowel most sus-
C-reactive protein (>75 mg/L), and peritoneal ceptible to vascular compromise and ischemia is
signs including rebound tenderness and guard- just proximal to the site of the obstruction and
ing.3,10,11 The failure of nonoperative treatment is the transition point.13 The transition point is the
defined by persistent obstruction for longer than site of obstruction when the bowel goes from dis-
72 hours, drainage volume from nasogastric suc- tended to collapsed. Identifying the transition point
tion of greater than 500 mL on the third day, or on imaging greatly aids in the diagnosis of SBO,
the presence of peritonitis or ischemia.10 The identifying the cause and determining the
water-soluble oral contrast challenge is a new severity.1,8,11,13
technique used in patients with presumed adhe-
sions producing SBO who fail nasogastric tube ABDOMINAL RADIOGRAPHY
decompression after 48 hours. Patients who
pass the water-soluble oral contrast challenge Although abdominal radiographs are often used
have been shown to have lower surgical explora- for screening of SBO, MDCT has become the
tion rates and bowel resection, shorter lengths of main imaging modality for SBO. Abdominal radi-
stay in hospital, and complication rates similar to ography has limited value in initial diagnosis and
those in patients who fail.12 evaluation of SBO because of its low sensitivity
for partial low-grade obstruction, with a false-
negative rate of up to 20%, a false-positive rate
DEFINITIONS of 42%, and a diagnostic accuracy rate of 50%
Complete or high-grade obstruction: total to 60% for high-grade SBO.14 Radiography also
luminal occlusion without passage of gas or offers limited evaluation for strangulation and the
intestinal contents cause of the obstruction.14,15
Incomplete, partial, or low-grade obstruction: Abdominal radiographs can be performed in su-
luminal narrowing allowing passage of some pine, upright, or decubitus positions. The radio-
gas or intestinal contents graphic signs of SBO are presented in Box 1.
Simple obstruction: obstruction with an intact
blood supply (no signs of ischemia) Box 1
Strangulating obstruction: obstruction with a Radiographic signs of SBO
compromised blood supply resulting in
ischemia Gas-filled or fluid-filled small bowel loops
greater than 3 cm
Closed-loop obstruction: a segment of bowel
occluded at 2 adjacent points that isolate the Distended stomach
lumen of that segment from the remaining Stretch sign
bowel Gasless abdomen
Greater than 2 air-fluid levels (upright or
NORMAL ANATOMY AND IMAGING decubitus)
TECHNIQUE
Differing heights of air-fluid levels in the same
One of the main anatomic considerations when loop of bowel (upright or decubitus)
determining the presence of SBO is differentiating Air-fluid levels longer than 2.5 cm (upright or
small bowel loops from colon. The small bowel decubitus)
contains mucosal folds extending circumferen- String-of-beads sign (upright or decubitus)
tially around the bowel known as plicae circulares
Small Bowel Obstruction and Ischemia 691
Fig. 1. Supine abdominal radiograph demonstrating a Fig. 2. Upright abdominal radiograph demonstrating
stretch sign (arrow). air-fluid levels of different heights with a width great
than 2.5 cm (arrow).
The signs with the highest sensitivity include more
than 2 air-fluid levels, air-fluid levels wider than
drawbacks to using oral contrast with question-
2.5 cm, and air-fluid levels of differing heights in
able benefits. The current American College of
the same loop of bowel.11,14,16,17 Less sensitive
Radiology Appropriateness Criteria recommend
signs include a distended stomach, a gasless
evaluating possible high-grade obstruction with
abdomen, and the stretch and string-of-beads
an MDCT using intravenous (IV) contrast only un-
signs. The stretch sign is defined as small bowel
less contraindicated.15 The use of oral contrast de-
gas arrayed as stripes perpendicular to the long
lays care for up to 3 hours, delaying diagnosis and
axis of the bowel outlining the valvulae conni-
care and decreasing emergency department
ventes as seen in Fig. 1.11,17 The string-of-beads
throughput.15,18–20 Patients with suspected SBO
sign is defined as a series of air-fluid levels
often have a difficult time ingesting oral contrast
measuring less than 1 cm.17
because of nausea and vomiting, creating the po-
Determining severity on radiographs can be
tential for aspiration of contrast.18 Oral contrast
difficult. The 2 signs most associated with com-
also increases the radiation dose to the patient
plete or high-grade obstruction are air-fluid levels
when using modern MDCT scanners with auto-
of differential heights in the same loop of bowel
mated exposure control.19–21
and air-fluid levels with a width greater than
Diagnostic drawbacks of positive oral contrast
2.5 cm on upright radiographs, as seen in Fig. 2.
include obscuring intraluminal causes of bowel
The presence of both signs showed a positive pre-
obstruction and several signs of bowel ischemia,
dictive value of 86% for the presence of complete
such as decreased wall enhancement and the
obstruction.17
presence of intraluminal hemorrhage.15,22,23
Decreased bowel wall enhancement is the most
COMPUTED TOMOGRAPHY
specific sign of bowel wall ischemia and can be
Technique
difficult to discern with intraluminal positive
Although the use of water-soluble positive oral contrast, as shown in Fig. 3.22–24 During SBO, nor-
contrast is still widely prevalent, there are multiple mally secreted fluid that has not been reabsorbed
Fig. 3. Axial (A) and coronal (B) IV

contrast-enhanced CT images demon-
strating a decreased bowel wall
enhancement (arrows).
692 Diamond et al

strating the use of normally secreted
fluid that has not been reabsorbed by
the bowel as a natural negative
contrast in diagnosing bowel obstruc-
tion (arrows).
by the bowel creates a natural negative contrast in axial slice acquisition approximately 70 seconds
distended loops of bowel that can aid in the diag- following the power injection of 100 mL of typically
nosis of intraluminal causes of obstruction, nonionic IV contrast at 3 to 5 mL/s in portal venous
decreased bowel wall enhancement, and intralu- phase. The timing of the contrast bolus can be
minal hemorrhage (Fig. 4) instead of obscuring it adjusted so that maximum attenuation of the liver
as does positive oral contrast. is achieved. Additional thick-slice 3.75 mm axial
The benefits of using positive oral contrast along with 3 to 5 mm coronal and sagittal refor-
include the exclusion of high-grade obstruction mats are created to increase the ability to localize
with the passage of contrast and being able to the transition point and assess the cause of the
evaluate for possible resolution of the obstruc- obstruction.18
tion using a plain abdominal radiograph.3,18 On
follow-up abdominal radiographs, if contrast ma- Role of Multidetector Computed Tomography
terial is seen within the colon, either the obstruc-
MDCT plays a critical role in the diagnosis and
tion has resolved or it is low grade.3 However, in
guidance of treatment of SBO with a reported
a large retrospective study involving 1992 pa-
sensitivity of 90% to 96%, a specificity of 96%,
tients evaluated with MDCT with IV contrast
and an accuracy of 95%.25 When evaluating a sus-
only for acute abdominal pain, Uyeda and col-
pected obstruction using MDCT several questions
leagues20 showed that only 4 patients (0.2%)
need to be answered (Box 2).
required repeat CT imaging because of lack of
oral contrast.
A typical protocol, summarized in Table 1, IMAGING FINDINGS
for MDCT of the abdomen and pelvis for evaluation Diagnostic Criteria
of suspected acute SBO consists of thin 1.25-mm Diagnosing SBO first requires the identification of
dilated loops of small bowel, typically 3 cm or
greater, with a normal-sized colon less than 6 cm
Table 1 in diameter or 9 cm for the cecum.11,23,25 Some cli-
Typical MDCT protocol for evaluating SBO nicians use a diameter of 2.5 cm or greater as a
cutoff for small bowel dilation, which yields higher
Area of acquisition Abdomen and pelvis; sensitivity.8,11,26,27 A transition point, the point at
lung bases to the
proximal thighs
IV contrast 100 mL of nonionized Box 2
iodinated contrast Questions to answer for suspected SBO
Injection speed 3–5 mL/s
Oral contrast None Is SBO present?
Phase of Portal venous phase: Where is the transition point?
acquisition 70 s delay before Is there a single transition point or is a closed-
acquisition loop obstruction present?
Reconstructions Thin 1.25-mm and thick What is the cause of the obstruction?
3.75-mm axial slices,
3–5 mm coronal and Are there signs of complications such as
sagittal reformats ischemia, necrosis, or perforation?

strating the transition point (arrows).
which the bowel transitions from dilated to nondi- sign is low, ranging from 6% to 37%.26,28 The
lated loops of bowel, should be identi- main utility of the sign is that it most often
fied8,11,23,25,26 as seen in Fig. 5. The presence of occurs just proximal to the transition point.28
dilated loops of small bowel and a transition point Finding the small bowel feces sign can help
within the small bowel are major imaging findings localize the transition point, which is crucial
necessary for the diagnosis of SBO. Additional for diagnosing and assessing the cause of the
signs of SBO not required for, but can aid in the SBO.
diagnosis of, SBO include air-fluid levels,
collapsed colon, and the small bowel feces Differential Diagnosis
sign.8,11,25,26 SBO diagnostic criteria are summa-
The list of differential diagnoses is short, consist-
rized in Table 2.
ing of paralytic ileus and large bowel obstruction.
Air-fluid levels, collapsed colon, and the small
Finding the transition point is the key to diag-
bowel feces sign are unreliable signs of obstruc-
nosing SBO. If a transition point can be located,
tion that may or may not be present.8,11,28 Air-
paralytic ileus is effectively ruled out. If the
fluid levels are not specific for obstruction and
transition point is within loops of small bowel
were seen in 69% of cases of unobstructed
as opposed to the colon, SBO can be diagnosed
cases.27 Although the colon is more likely to be
and large bowel obstruction excluded.27 Table 3
collapsed, with a greater than 50% difference in
lists the differential diagnosis and key
the diameter of the proximal dilated small bowel
distinguishing diagnostic features between
and the colon, in high-grade obstruction it can
them and SBO.
be of normal size depending on the timing of
obstruction.26
Severity of the Obstruction
The small bowel feces sign is the fecalization
of material within the small bowel resulting in Determining the severity of an obstruction can be
formation of particulate, partially aerated mate- difficult on MDCT. Although the passage of
rial as seen in Fig. 6. The prevalence of this positive oral contrast past the point of obstruc-
tion effectively rules out high-grade obstruction,
oral contrast is not frequently used for reasons
Table 2 previously stated. The presence or absence of
Diagnostic criteria for SBO multiple signs have been suggested to determine
the grade of the obstruction, although having
Major criteria Dilated loops of small a high-grade obstruction does not always
(necessary for bowel 3 cm with indicate that nonoperative management will
diagnosis) normal-sized colon
fail.1,25,29,30 What is crucial for the clinical man-
(<6 cm)
Transition point from agement of the patient is to evaluate the transi-
dilated to tion point for the presence of a closed-loop
nondilated bowel obstruction, cause of the obstruction, and signs
within the small of ischemia.
bowel
Minor criteria (not Air-fluid levels Closed-Loop Obstruction
necessary but useful Collapsed colon
Once the diagnosis of SBO is made, the first step
for diagnosis) Small bowel feces sign
in evaluating the obstruction is to identify whether
694 Diamond et al
Fig. 6. Axial (A) and sagittal (B) IV

strating fecalization of material within
the small bowel, known as a small
bowel feces sign (arrows).
there is a single transition point or a closed-loop closed-loop obstruction can also form a “C” or
obstruction. Closed-loop obstructions occur a “U” configuration based on the orientation of
when a segment of bowel is isolated at 2 or the segment in axial, coronal, and sagittal
more adjacent points, effectively isolating the planes, as seen in Fig. 8. The segment will
segment from the remainder of the converge on the site of the obstruction.11,25
bowel.8,11,18,25 When a closed-loop obstruction The presence of 2 or more beak signs and a
is present, gas and material can no longer pass “C” or “U” configuration of a dilated loop of
through the lumen of bowel, resulting in the bowel is associated with the failure of nonoper-
buildup of secreted fluid causing further dilation ative treatment.1
of bowel and compression of surrounding mesen- A small bowel volvulus with a twisting mesen-
tery, predisposing to the bowel to vascular teric stalk can cause a closed-loop obstruction
compromise and ischemia.18,25 Even without that appears as a radial distribution of fluid-
overt signs of ischemia, closed-loop obstruction filled dilated loops of bowel around a single
is considered a precursor to bowel ischemia point. This configuration is also known as the
and therefore, is often considered a surgical spoke-wheel sign and carries an incidence of
emergency.25 concurrent bowel ischemia in up to 46% of pa-
The CT signs of a closed-loop obstruction tients.31 As seen in Fig. 9, the vessels of radially
depend on the cause and orientation of the distributed loops of bowel converge on a single
loops. The causes of closed-loop obstructions central point.
include adhesions, internal and external hernias,
and a small bowel volvulus.25,31 At the site of a
closed-loop obstruction, the bowel often
gradually tapers to a point causing a beak
sign, as seen in Fig. 7. When a closed-loop
obstruction is caused by a single adhesive
band or single site of a hernia, the 2 adjacent
transition points often form into beak signs.1
The dilated fluid-filled segment of bowel in a
Table 3
Differential diagnosis for SBO
Differential Distinguishing
Diagnosis Features
Paralytic ileus Dilated loops of bowel
without a transition
point
Large bowel Transition point within
Fig. 7. Axial IV contrast-enhanced CT image demon-
obstruction the colon
strating a beak sign (arrow).
Fig. 8. Axial (A) and coronal (B) CT images demonstrating “C” and “U” configurations of closed-loop obstruction.
Axial (C, D) IV contrast-enhanced CT images with iodine overlay demonstrates hypoenhancement of the ob-
structed bowel (arrows).
CAUSES OF SMALL BOWEL OBSTRUCTION bodies.26,32 A summary of causes of

bowel obstruction ids presented in Table 4.
To determine the cause of the obstruction, the Once the cause of obstruction is limited to
best place to look is at the transition point. The a category, the clinical history can be incorpo-
cause of the obstruction is almost always rated with additional diagnostic clues to further
located at or around the transition point. The narrow down the possible causes of the
causes of bowel obstruction are categorized as obstruction.
extrinsic, intrinsic, and intraluminal. Extrinsic
causes of SBO exert external pressure on the
Extrinsic Causes
bowel causing the obstruction. If the underlying
cause of obstruction is due to or arising By far the most common cause of bowel
from the bowel wall itself, it is categorized as obstruction is adhesions, causing 60% to 85%
an intrinsic cause. Intraluminal causes include of cases of SBO.25,32,33 Although most adhe-
blockages from gallstones, bezoars, and foreign sions form following prior abdominal surgery,
696 Diamond et al
Fig. 9. Axial IV contrast-enhanced CT image demon- Fig. 10. Coronal IV contrast-enhanced CT image
strating a spoke-wheel sign from volvulus with radial demonstrating adhesion as a cause of SBO, diagnosed
distribution of fluid-filled dilated loops of bowel by excluding other causes of obstruction (arrow).
around a single point.
dilation. Fig. 11 demonstrates an example of a

approximately 10% to 15% of patients with ad- parastomal hernia. Internal hernias occur when
small bowel protrudes through an opening in
hesive SBO do not have a surgical history, so
the mesentery or peritoneum into another cavity.
these adhesions are most likely due to prior ep-
isodes of peritonitis.32 Since the adhesive bands Identifying internal hernias can be difficult on
MDCT; however, the crowding of small bowel
are not directly visible on MDCT, the diagnosis is
loops, swirling of mesenteric vessel or swirl
made by excluding other causes of obstruction
sign, mushroom-shaped herniation of the
(Fig. 10).
mesenteric root and vessels or “mushroom
Hernias cause an estimated 10% to 20% of all
sign”, and the abnormal location of small bowel
cases of SBO.32,33 External hernias can be easily
can indicate the presence of an internal
identified by locating the transition point at
hernia.32,34,35
the neck of the hernia with proximal bowel
Roux-en-Y gastric bypass
The increase in laparoscopic Roux-en-Y gastric
bypass (LRYGB) surgery has resulted in an
Table 4 increased number of internal hernias causing
Causes of SBO SBO with an incidence rate of 1% to 4%.34,36
Dilauro and colleagues34 found that the swirl sign
Extrinsic Adhesions in LRYGB patients has a higher sensitivity for inter-
Hernias (internal and external) nal hernias than the typical criteria for SBO, 86%
Endometriosis
to 89% versus 22% to 25%. The presence of the
Neoplasms (extraintestinal)
swirl sign in LRYGB patients indicates an internal
Intrinsic Inflammatory/infectious
hernia even without the presence of dilated loops
diseases
of small bowel. A proposed superior mesenteric
Neoplasms of the small bowel
(primary and secondary) vein (SMV) beaking sign, consisting of the tapering
Vascular causes (mesenteric or beaking of the SMV, was also found to have
ischemia) high sensitivity of 80% to 88% for the presence
Intramural hematoma of an internal hernia in LRYGB patients, as seen
Radiation enteritis in Fig. 12.34
Intussusception
Intraluminal Gallstone ileus Intrinsic Causes
Bezoars
Crohn disease is a common cause of
Foreign bodies
SBO with diagnostic characteristics of

strating parastomal hernia (asterisks)
as a cause of SBO (arrows).
narrowing of the bowel lumen, skip into another.38 The presence of an intussuscep-
lesions, and transmural thickening.25 Signs tion in an adult should precipitate a search
of active Crohn disease can mimic the for a lesion. Benign and malignant lesions
target sign, a sign of bowel ischemia, with including adenomatous polyps, adenocarci-
submucosal edema causing stratified mural noma, lymphoma, metastases, and gastrointes-
enhancement.25,37 tinal stromal tumors can cause intussusception
Mesenteric ischemia resulting from occlusion or resulting in SBO or obstruction through the
a critical stenosis of the superior mesenteric ar- narrowing and occlusion of the bowel lumen.38
tery (SMA) can cause SBO from ischemic An example of intrinsic small bowel lesion
changes including lack of peristalsis and wall causing intussusception and obstruction is
thickening, as seen in Fig. 13. Diffuse decreased shown in Fig. 14.
bowel wall enhancement of the small bowel Intramural hematoma is a rare cause of
should prompt an evaluation of the SMA for obstruction that is most often due to anticoagu-
occlusion. lant use. The typical presentation on MDCT is
An estimated 80% to 92% of cases of circumference thickening of the bowel wall with
intussusception in adults is secondary to an SBO on anticoagulation therapy.39 A patient on
organic lesion, causing a lead point to initiate warfarin with a supratherapeutic international
the invagination of a loop of bowel normalized ratio should raise the suspicion of an
intramural hematoma as a possible cause of
obstruction.
Obstruction caused by radiation enteritis can
present anywhere from 2 months to 30 years
following radiation treatment.40 Chronic radiation
enteritis that causes SBO is really an occlusive
vasculitis resulting in submucosal fibrosis with
bowel wall thickening and luminal narrowing, as
seen in Fig. 15.
Intraluminal Causes
Gallstone ileus is a rare cause of SBO whereby a
passed gallstone becomes lodged in the small in-
testine, causing obstruction. Typical imaging fea-
tures include Rigler’s triad of pneumobilia, SBO,
Fig. 12. Coronal IV contrast-enhanced CT
and a gallstone at the transition point, as seen in
image demonstrating a superior mesenteric vein
Fig. 16.32
beaking sign of a patient with a surgically
confirmed internal hernia causing bowel obstruc- Two additional rare intraluminal causes of SBO
tion after gastric bypass surgery (arrow). Also include foreign body ingestion and bezoars. Eval-
seen are ischemic loops of obstructed bowel uating the transition point for the presence of an
with hypoenhancement of the bowel wall intraluminal mass is the key to identifying these
(arrowheads). causes.
698 Diamond et al
Fig. 13. Axial (A) and sagittal (B) IV

strating mesenteric ischemia (arrows)
as evidenced by lack of peristalsis and
wall thickening caused by occlusion or
critical stenosis of the SMA (asterisks).
SIGNS OF ISCHEMIA Mesenteric edema or fluid presents as haziness

in the mesentery adjacent to a loop of obstructed
Identifying the presence of ischemic or strangu- bowel, as seen in Fig. 18; this has a sensitivity of
lated bowel is essential because its presence 84% and specificity of 40% for ischemia.23 Abun-
greatly increases the risk of mortality from 2% dant ascites can confound or mimic mesenteric
to 8% to up to 40% in cases of SBO.9 MDCT edema, which can be problematic in cirrhotic
has a sensitivity of 83% and specificity of 92% patients.
for the diagnosis of bowel ischemia.25 Signs of Less specific and sensitive signs of bowel
ischemia as listed in Table 5 include decreased ischemia including the target sign, pneumatosis,
bowel wall enhancement, mesenteric edema, mesenteric and portal venous gas, engorged
bowel wall thickening greater than 3 mm that mesenteric vessels, and the whirl sign need to be
can present as a target sign, intraluminal hemor- viewed in conjunction with the patient’s overall
rhage, engorged mesenteric vessels, the whirl clinical picture and additional imaging findings on
sign, pneumatosis, and mesenteric or portal the MDCT. Numerous mimics of these signs
venous gas.9,11,25,26,37,41 decrease their value when they are seen in
Decreased bowel wall enhancement is the most isolation.
specific sign of bowel ischemia, with a specificity Circumferential bowel wall thickening >3 mm,
of 94% to 100%.8,9,23–25 The presence of also known as the target sign, is a relatively
decreased bowel wall enhancement increases nonspecific sign with numerous possible causes.
the likelihood of bowel ischemia by 11-fold.9 Active inflammation in Crohn disease can cause
Fig. 17 shows an example of decreased bowel submucosal edema, which can mimic ischemia.
wall enhancement in a patient with ischemic In addition, deposition of fat within the submu-
bowel. The use of dual-energy CT has the potential cosa, which can be due to chronic Crohn disease
to make identifying bowel ischemia easier. Iodine or benign intramural fat deposition, can also cause
overlay maps make the difference in bowel wall bowel wall thickening with a stratification of
enhancement more prominent and easier to enhancing layers mimicking ischemia, as seen in
detect.42 Fig. 19.37

strating intrinsic small bowel lesion, a
jejunal adenocarcinoma, causing intus-
susception and obstruction (arrows).

strating radiation enteritis causing
occlusive vasculitis and submucosal
fibrosis with small bowel wall thick-
ening and luminal narrowing (arrows).
Fig. 16. Axial (A) IV contrast-enhanced CT image demonstrating acute gallstone cholecystitis. Axial (B, C) and cor-
onal (D) IV contrast-enhanced CT images after a few months, demonstrating collapsed gallbladder with foci of
air, pneumobilia, and gallstone ileus (arrows).
700 Diamond et al
Table 5
Signs and mimics of bowel ischemia
Sign of Bowel
Ischemia Mimics of the Sign
Decreased bowel wall None
enhancement
Mesenteric edema Ascites
Occlusion of a None
mesenteric vessel
(typically the SMA)
Intraluminal Retained fecal
hemorrhage material or contrast
Target sign (bowel Crohn disease
Fig. 18. Axial IV contrast-enhanced CT image demon-
wall thickening) Infectious enteritis
strating mesenteric fluid (arrow).
Benign intramural fat
deposition
Whirl sign Internal hernia
without ischemia
Whirl sign without Pneumatosis and mesenteric and portal
ischemia or an venous gas are important late-stage signs of
internal hernia bowel ischemia, indicating transmural bowel
Engorged mesenteric Internal hernia necrosis. As such, additional signs of ischemia
vessels without ischemia should be present to make the diagnosis of
Pneumatosis Pneumatosis strangulated bowel. Portal venous gas is
intestinalis cystoides seen as tubular air-filled structures within the
intestinalis liver. Portal venous gas can be distinguished
Pseudopneumatosis from pneumobilia by the peripheral extent of
Mesenteric or portal Pneumobilia gas within the liver, whereas pneumobilia
venous gas typically remains centrally located within the
large intrahepatic biliary ducts as seen in
Fig. 20.44
Pneumatosis intestinalis caused by ischemia,
The whirl sign, which consists of swirling mesen- which is characterized by air within the
tery, and the engorgement of mesenteric vessels bowel wall, can be confused with pneumatosis
are important signs of volvulus and internal hernia, cystoides intestinalis, a rare benign condition of
especially in LRYGB patients.34,43 Visualization of air-filled cysts within the bowel wall.45,46
either of these signs should prompt a careful Pneumatosis cystoides intestinalis is associated
search for additional signs of ischemia. When with chronic obstructive pulmonary disease,
seen in isolation, they are highly suspicious for prior intestinal surgeries, and connective tissue
an internal hernia or volvulus and should be re- disorders.45 Furthermore, pneumatosis intestina-
ported as such. lis is only associated with life-threatening
Fig. 17. Axial (A) and coronal (B)

IV contrast-enhanced CT images
demonstrating decreased bowel wall
enhancement from bowel ischemia
(arrows).
Fig. 19. Axial IV contrast-enhanced CT image demon- Fig. 20. Axial CT images demonstrating pneumobilia
strating chronic terminal ileitis causing a bowel wall (arrow).
thickening with intramural fat deposition and a strat-
ification of enhancing layers mimicking ischemia
(arrow).
Including pertinent clinical history when
ordering the examination, especially history
bowel ischemia 30% of the time, with the of any prior abdominal surgery (particularly
remaining causes representing benign pro- Roux-en-Y gastric bypass), is essential for
cesses.47 Benign nonischemic pneumatosis is raising the suspicion of an internal hernia
theorized to be caused by increased intraluminal causing obstruction.
pressure, gas diffusion, bacterial invasion of the Most obstructions can be treated conserva-
bowel wall, mucosal injury, and a defective im- tively with nonoperative management. The
mune barrier.47 Pseudopneumatosis is gas role of MDCT is to diagnose, find the cause,
trapped with stool and fluid along the bowel and look for complications of SBO that can
wall that can mimic pneumatosis, but respects lead to the failure of nonoperative treatment.
fluid levels and does not occur in air-filled areas. The presence of a closed-loop obstruction or
Fig. 21 shows examples of pneumatosis and its signs of ischemia, particularly reduced bowel
mimics. wall enhancement, are surgical emergencies
that require immediate evaluation by the sur-
WHAT THE REFERRING PHYSICIAN NEEDS TO gical team.
KNOW
SUMMARY
CT of the abdomen and pelvis with IV contrast
only is the best and most efficient method to SBO is a common condition that often results in
evaluate suspected SBO. ischemia, which carries a high risk of mortality if

contrast-enhanced CT images in lung
window demonstrate 2 examples of
ischemic pneumatosis mimics, with (A)
showing pseudopneumatosis (arrow)
and (B) showing benign pneumatosis
intestinalis (arrows) without bowel
ischemia. Pseudopneumatosis is air
that is trapped with stool and fluid
along the bowel wall, whereas pneu-
matosis would be seen along the bowel
wall that does not abut the intraluminal
contents, including antidependent wall.
702 Diamond et al
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mine which patient is likely to need surgical of abdominal radiography in acute small-bowel
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Am J Roentgenol 2007;188(3):W233–8.
15. Ros PR, Huprich JE. ACR appropriateness criteria
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Small Bowel Obstruction

INTRODUCTION Radiologists play a significant role not only in the

Disclosure Statement: Nothing to disclose.

Radiol Clin N Am 57 (2019) 689–703

Fig. 3. Axial (A) and coronal (B) IV

Fig. 4. Axial (A) and coronal (B) IV

Fig. 5. Axial (A) and coronal (B) IV

Fig. 6. Axial (A) and sagittal (B) IV

CAUSES OF SMALL BOWEL OBSTRUCTION bodies.26,32 A summary of causes of

dilation. Fig. 11 demonstrates an example of a

Fig. 11. Axial (A) and coronal (B) IV

Fig. 13. Axial (A) and sagittal (B) IV

SIGNS OF ISCHEMIA Mesenteric edema or fluid presents as haziness

Fig. 14. Axial (A) and coronal (B) IV

Fig. 15. Axial (A) and coronal (B) IV

Fig. 17. Axial (A) and coronal (B)

Fig. 21. Axial (A) and coronal (B) IV

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