Small Bowel Obstruction:

What to Look For

Yessa Mandra Y

150070200111024

Hemas Abidah R 105070103121004

Aisyah Nuurietha 105070107111004
Edelen Nauli P

115070107111058

Pembimbing: dr. A. Bayhaqi Nasir Aslam, Sp.Rad

ABSTRACT
Small bowel obstruction (SBO) is a common clinical syndrome for
which effective treatment depends on a rapid and accurate
diagnosis.
SBO is often diagnosed late or misdiagnosed, resulting in
significant morbidity and mortality.
When an SBO is accompanied by signs of strangulation,
emergent surgical treatment is advised.
If a complete or high-grade obstruction is suspected,
crosssectional studies such as ultrasonography or multidetector
CT are used to exclude strangulation. An algorithmic approach to
imaging is proposed for the management of SBO to achieve
accurate diagnosis of the obstruction; determine its severity,
site, and cause; and assess the presence of strangulation.
Radiologists have a pivotal role in clinical decision making in
cases of SBO by providing answers to specific questions that
significantly affect management.

INTRODUCTION
Common condition secondary to
mechanical or functional obstruction of
small bowel
Preventing normal transit of contents

Most of these resolve spontaneously

with nonsugical option (nasointestinal
decompression)
Imaging become primary focus

In Diagnostics
Is the small bowel obstructed?
How severe is the obstruction?
Where is it located?
What is its cause?
Is strangulation present?

Plain Radiography
50-60% accurate
Only sensitive in high obstruction

USG
Rarely used because of air
Adhesion cant be detected with USG
Useful if obstructed segment dilated with
fluid

Contrast Imaging
demonstrate the presence of obstruction in
100% of cases
the level (proximal vs distal) of obstruction in
89% of cases
cause of the obstruction in 86% of surgically
treated patients

CT Scan
Preoperative evaluation of SBO
sensitivity of 90%96%
specificity of 96%
accuracy of 95%.

Standart CT Scan high-grade obstruction

Multidetector CT low grade obstruction +
pathologic tissue damage
To determine treatment for patient
conservative management and close
immediate surgical intervention

CT scan
Condition not urgent
Assess severity & cause of obstruction
Sensitivity of 82%100% for high-grade and
complete SBO
Substitute: sonography

 challenges distensibility of the

small bowel
small bowel follow-through study
enteroclysis
CT enteroclysis

CT criteria for
SBO

Click icon to add picture

Plain Abdominal
Radiography
diagnostic in 50%60% of cases
equivocal in about 20%30%
normal,nonspecific, or misleading in 10%20%
Determine need of immediate surgery

Plain Radiography
Differentiate high and small grade SBO
presence of small bowel distention
maximal dilated loops averaging 36 mm in diameter
exceeding 50% of the caliber of the largest visible colon
loop
2.5 times increase in the number of distended loops in
the abdomen compared with the normal number

presence of more than two air-fluid levels

air-fluid levels wider than 2.5 cm
air-fluid levels differing more than 2 cm in height
from one another within the same small bowel
loop

Click icon to add picture

High grade SBO

Finding at Sonography
Bowel obstruction is present when
Lumen of the fluid filled small bowel loops is
dilated to more than 3 cm
Length of the segment is more than 10 cm
Peristalsis of the dilated segment is increased,
as shown by the to-and-fro or whirling motion
of the bowel contents

High sensitivity in demonstrating the presence

of SBO:
Level
Level of the obstruction is determined by means
of the location of the bowel loops and the pattern
of the valvulae conniventes.
Cause
Cause of the SBO may be deter- mined by
examining the area of transition from the dilated
to normal bowel
Severity of the obstruction
Severity of the obstruction can also be assessed.
The presence of free fluid between dilated small
bowel loops, aperistalsis, and wall thickening (>3
mm) in a fluid-filled distended bowel segment
suggests bowel infarction

Figure 3. Sonogram of the ileum shows a dilated fluid-filled bowel loop

with a caliber of more than 3 cm (dotted line). The absence of valvulae
allows the obstruction to be localized to the ileum. There is a thickened
bowel wall with a stratified echo pattern (arrows) and ascites (A).

Finding in Multidetector CT
1. Is the Small Bowel Obstructed?
2. How Severe Is the Obstruction?
3. Where Is the Transition Point?
4. What Is the Cause of the Obstruction?
5. Is the SBO Simple or Complicated?

1. Is the Small Bowel

Obstructed?
CT criteria for SBO
are the presence of
dilated small bowel
loops (diameter
>2.5 cm from outer
wall to outer wall)
proximally to
normal-caliber or
collapsed loops
distally (Fig 4)
Figure 4. CT criteria for SBO. Axial CT scan shows a disparity in
caliber between distended proximal small bowel loops
(diameter >3 cm) (dotted line) and collapsed distal small
bowel loops (arrows).

Figure 5. Simple complete SBO secondary to intussusception. Axial

CT scan shows distended small bowel loops with intraluminal positive
contrast material (arrows) proximal to an intussusception with a
target like appearance (*). Completely collapsed bowel loops

Figure 6. Low-grade partial SBO. Axial CT scan shows distended

jejunal loops (arrows) proximal to an intussusception (*) filled with
intraluminal positive oral contrast material. There is sufficient flow of
contrast material through the intussusception to fill distal small bowel

2. How Severe Is the

Obstruction?
The presence of high-grade versus incomplete
obstruction can be determined by:
Degree of distal collapse
Proximal bowel dilatation
Small bowel feces sign

Figure 7. Small bowel feces sign in a patient with high-grade SBO

secondary to postoperative adhesions. Axial CT scan shows gas bubbles
mixed with particulate matter (*), a finding that represents the small
bowel feces sign. Note the collapsed bowel loops (arrow) distal to the

3. Where Is the Transition

Point?
The transition point
is determined by
identifying a
caliber change
between the
dilated proximal
and collapsed
distal small bowel
loops (Fig 8)

Figure 8. Identification of the transition point in an SBO secondary to

postoperative adhesions. Axial CT scan shows dilated small bowel loops
(S). There is an abrupt change in caliber (arrow) between the proximal
dilated bowel loops and collapsed distal bowel loops (C). The change in

 Retrograde approach: start at the rectum and

proceeding proximally toward the cecum,
ileum, and jejunum.
Antegrade approach: if the transition point is
located proximally (jejunum or duodenum),
starting at the stomach
Small bowel feces sign : usually present at the
transition point.

4. What Is the Cause of the

Obstruction?

 Intrinsic cause
Bowel lesions are seen at the transition point
and manifest as localized mural thickening.

Extrinsic causes
Adjacent to the transition point and usually
have associated extraintestinal manifestations.

Intraluminal causes
Manifest as endoluminal foreign objects with
imaging characteristics different from those of
the remaining enteric content.

Etiology
Intrinsic Causes of
SBO

Crohn Disease
Neoplasia
Intussusception
Radiation Enteritis
Hematomas
Vascular causes

Extrinsic Causes of SBO

Adhesions
Hernias
Endometriosis

Intraluminal Causes of SBO

Gallstone Ileus
Bezoar
Distal Intestinal
Obstruction Syndrome
Other Intraluminal
Causes

Intrinsic Causes of SBO

Crohn Disease
Manifestation:
Acute presentation Fig.10
Cicatricial stenosis of affected segments Fig.11
Secondary to adhesions, incisional hernias,
exacerbation of the inflammatory condition, or
postoperative strictures in patients who have undergone previous intestinal surgery

Figure 10. SBO secondary to the acute presentation of Crohn disease.

Axial CT scan shows a dilated small bowel loop with a diameter of
more than 2.5 cm (S) proximal to the thickened terminal ileum

Figure 11a. SBO due to

the stenotic phase of
Crohn disease. (a) Axial
CT scan shows fluid-filled
dilated small bowel
loops with intraluminal
positive contrast material
of different dilutions (*).
At the terminal ileum, a
transition point with a
thickened bowel wall
and mural stratification
(arrowheads) and
perienteric
hypervascularity are
identified. (b)
Photograph of the gross
specimen shows the
narrowed lumen of the
involved segment
(arrowheads) and a
dilated bowel loop

 Neoplasia
Primary neoplastic rare Fig.12
Metastatic cancer - common
Peritoneal carcinomatosis frequent
Isolated metastases extremely rare
Cecum and colon Fig.13

Figure 12. SBO

secondary to
adenocarcinom
a. Axial CT scan
shows
asymmetric
and irregular
mural
thickening of
an ileal loop
(arrow), which
causes
dilatation of
the proximal

Figure 13a. SBO

secondary to
adenocarcinoma of
the cecum with
ileocecal valve
involvement. (a) Axial
CT scan shows
dilatation of small
bowel loops (S) and
the cecum (*)
proximal to a stenotic
cancer of the cecum
(arrow) that involves
the terminal ileum. (b)
Photograph of the gross
specimen shows
involvement of the
ileocecal valve
(arrow) by the
neoplasm (dotted

 Intusseption
Rare in adults
Appears in neoplasm, adhesion, foreign
bodies
At CT: bowel-within-bowel with or without
mesenteric fat and vessels pathognomonic

 Radiation enteritis
Cause obstruction in the late phase 1 year
after radiation therapy
Because adhesive producing and fibrotic
changes in mesentery
Radiation serositis luminal narrowing and
dysmotility

 Hematoma
Secondary causes:
Anticoagulant therapy
Iatrogenic intervention
Trauma

Luminal narrowing nonenhanced CT

performed spontaneously
hyperattenuating clot

 Vascular causes
Occlusion or stenosis bowel ischemia
wall thickening SBO
CT shows thrombosis or occlusion on
messenteric vessel and thickening of the
bowel wall in the affected loop with
noncircumferential or asymmetric wall
enhancement

 Adhesion
Main cause SBO
Adhesive bands not
seen at conventional
CT, only an abrupt
change in the caliber
bowel

 Hernia
Second most common
cause SBO
Classified according to
the anatomic location
Broadly classified as:
Internal hernia :
diagnosed most always by
radiologic
External hernia : mostly
according to clinical
examination

 Endometriosis
typically located on the
antimesenteric edge of
the bowel
Typical appearance: solid
nodule with positive
enhancement contiguous
with or penetrating the
thickened bowel wall
When infiltrates to
submucosa: a
hypoattenuating layer
between the muscularis
and the mucosa

Intraluminar cause of
SBO
A. Gallstone illeus
Rare complication
of recurrent
cholecystitis.
Findings
radiographic triad
of pneumobilia,
ectopic gallstone,
and SBO.

Gallstone

http:// www.eurorad.org/eurorad

2. Bezoar
SBO secondary to a bezoar is rare
At CT, a bezoar appears as an
intraluminal mass with an ovoid
shape and a mottled gas pattern.

radiopaedia.org/articles/be
zoar

3. Distal Intestinal
Obstruction Syndrome
Cause of SBO that usually
occurs in older children and
adults with cystic fibrosis.
The obstruction is secondary to
impaction of thick stool, which
is probably related to
inadequately controlled
intestinal absorption secondary
to pancreatic insufficiency.
Because this condition
responds to medical treatment,
it is important to recognize it.
Findings consist of SBO with
feculent filling defects in the
small bowel.

4. Other Intraluminal
Causes
Intestinal obstruction
caused by a foreign
body usually occurs in
children or in
emotionally disturbed
or mentally disabled
patients.
Findings consist of SBO
with evidence of a
foreign body at the
transition point.

5. SBO
Simple or Complicated?
SBO

Simple
obstuctio
n

Closeloop
obstructi
on

 Findings of a closed-loop obstruction depend on

the length, degree of distention, and
orientation of the closed loop in the abdomen.
The configuration can be U-shaped or C-shaped

 At CT, a beak sign

is seen at the site of
the torsion as a
fusiform tapering, and
occasionally a whirl
sign can be seen.

Strangulation
Strangulation: associated with intestinal ischemia.
Seen in approximately 10% patients
mainly when there is a delay in establishing the correct
diagnosis and subsequent surgical treatment.

Not specific finding

thickening and increased attenuation of the affected
bowel wall,
a halo or target sign
pneumatosis intestinalis, and
gas in the portal vein

Spesific finding
lack of wall enhancement
asymmetric enhancement or even
delayed enhancement may also be found.

Conclusions
Historically, Acute SBO was surgically treated
relatively early owing to the difficulty of
confidently excluding -on clinical and imaging
grounds complicated SBO.
Today, with increased evidence that some
obstructions resolve with conservative
management and that the latest modalities of
abdominal imaging allow confident diagnosis,
early surgery is now performed more selectively.
The role of the radiologist as a consultant to the
surgeon is a critical one. Therefore, a full
understanding of which imaging modalities to use,
when to use them, and what imaging findings to
look for to allow an individualized treatment.

THANKYOU