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    Small Bowel

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    Tabs Nuñez
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    Small Bowel

    Uploaded by

    Tabs Nuñez
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    small bowel

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    small bowel

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    26 views42 pages

    Small Bowel

    Uploaded by

    Tabs Nuñez
    small bowel

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 42

    REVIEW OF SMALL BOWEL

    OBSTRUCTION: THE DIAGNOSIS


    AND WHEN TO WORRY
    Presented by:
    Stephanie F. Nuñez
    Pre-res
    LEARNING OBJECTIVES

    • Discuss the role and accuracy of abdominal


    radiography in the evaluation of SBO

    • Discuss the specific findings of SBO on supine and upright


    abdominal radiographs

    • Discuss CT techniques in patients suspected to have SBO

    • Discuss the CT findings of SBO

    • Discuss the complications of SBO detected by using CT


    SMALL BOWEL OBSTRUCTION:
    GENERAL CONSIDERATIONS
    • Mechanical obstruction to the passage of the
    bowel contents

    • No fluid or gas passes beyond the site of


    obstruction
    SMALL BOWEL OBSTRUCTION:
    GENERAL CONSIDERATIONS
    • Incomplete or partial obstruction
    • some fluid or gas pass beyond the obstruction

    • Strangulated obstruction
    • blood flow is compromised

    • Closed-loop obstruction
    • Bowel is obstructed at two points
    • Results in progressive accumulation of fluid in gas within the
    isolated loop
    CAUSES OF SBO

    • Adhesions – 60% (75% in Brant)


    • Hernias – most often femoral or inguinal
    • Intussusception
    • Volvulus
    • Tumors
    • Wall lesions such as leiomyomas or strictures
    • Crohn’s disease
    • Foreign bodies
    • Gallstones
    CLINICAL FINDINGS

    • Crampy abdominal pain


    • Distention
    • Vomiting,
    • High-pitched or absent bowel sounds
    • Leukocytosis
    • Elevated serum amylase / lactic acid
    MANAGEMENT OF SBO

    • Initial radiography
    • Decompression
    • Follow-up radiography
    • Surgery
    MANAGEMENT OF SBO
    ABDOMINAL RADIOGRAPHY

    • Accurate - varies from 69% to 93%


    • Sensitivity and specificity of 82% and 83%
    respectively
    • Widely available
    • Inexpensive
    RADIOGRAPHIC SIGNS OF SBO

    Type of Radiograph Specific Signs


    SUPINE OR PRONE 1. Dilated gas or fluid-filled small
    bowel (>3cm)
    2. Dilated Stomach
    3. Small Bowel dilated out of
    proportion to colon
    4. Stretch sign
    5. Absence of rectal gas
    6. Gasless abdomen
    7. Pseudotumor sign
    UPRIGHT OR LEFT LATERAL 1. Multiple air-fluid levels
    DECUBITUS 2. Air-fluid levels longer than 2.5
    cm
    3. Air fluid levels in the same loop
    of small bowel of unequal
    heights
    4. String of beads sign
    RADIOGRAPHIC SIGNS OF SBO
    RADIOGRAPHIC SIGNS OF SBO
    “STRETCH SIGN”
    “PSEUDOTUMOR SIGN”
    CT USE IN SBO

    • Multi-detector CT - single best imaging tool for


    suspected SBO

    • Sensitivity and specificity of 95% for the diagnosis of


    high-grade SBO
    ADVANTAGES OF CT OVER
    RADIOGRAPHY
    • Identification of the transition zone
    • site where dilated bowel transitions to decompressed bowel

    • Accuracy of detection of the transition zone - 63%


    to 93%

    • Evaluation of the bowel wall, vessels, and adjacent


    mesentery

    • Evaluation for the presence of bowel perforation


    and the presence of free extraluminal gas
    CT TECHNIQUES USED IN SBO

    • Administration of intravenous contrast material is


    recommended versus traditional oral barium/iodine
    contrast

    • Beneficial to assess for the presence of signs of


    inflammation and ischemia

    • Coronal and/or sagittal multiplanar helpful to


    identify the transition point and to assess for
    evidence of a volvulus or closed-loop
    CT TECHNIQUES USED IN SBO

    • 64-section multi-detector CT protocol for suspected


    SBO:

    1. 150 mL non-ionic iodinated contrast material


    injected at 3 mL/sec
    2. 60-second scan delay
    3. 64 x 0.625 detector configuration
    4. 3–5-mm reconstruction in axial and coronal
    planes
    SIGNS OF SBO ON CT

    • Hallmark is dilated (2.5 cm) proximal small bowel


    with decompressed distal small bowel and colon.

    • Air-fluid levels

    • String of beads sign

    • Small-bowel feces sign


    CT CRITERIA FOR DIAGNOSIS OF SBO

    CRITERIA SPECIFIC CRITERIA


    Major 1. Small bowel dilated to 2.5 cm or
    greater and colon not dilated
    (< 6cm)
    2. Transition point from dilated to
    non-dilated small bowel
    Minor 1. Air fluid levels
    2. Colon Decompressed
    Axial unenhanced CT scan shows dilated loops of ileum filled with contrast
    material (arrow). Note the contrast material does not pass into
    decompressed distal loops of small bowel (arrowhead).
    ADHESIONS

    • Abrupt transition from dilated to collapsed bowel


    without an identifiable cause at the transition zone

    • Compress the bowel extrinsically, often cause an


    abrupt tapering or “beak” at the site of obstruction
    CT demonstrates
    the small bowel
    feces sign (small
    arrows) just
    proximal to the
    transition point
    (large arrow) of
    a small- bowel
    obstruction due
    to an adhesion.
    HERNIAS

    • Second most frequent cause of SBO

    • Can occur throughout the abdomen and pelvis

    • Most frequently involve the inguinal canal or


    anterior abdominal wall

    • Hallmark - presence of dilated bowel up to the


    hernia sac followed by decompressed bowel
    exiting from the sac
    Unenhanced axial CT scan at the level of the pubic symphysis shows
    protrusion of ileum (arrow) into the obturator canal.
    Unenhanced axial CT scan shows ileum trapped in the obturator canal
    between the obturator externus and pectineus muscles (arrow).
    Coronal reformation
    shows the herniated and
    obstructed ileum
    protruding into the
    obturator canal (arrow).
    TUMORS / NEOPLASMS

    • Dilated fluid-filled small bowel


    (large arrow) with
    decompressed distal small
    bowel (arrowhead) and colon
    consistent with obstruction in a
    stage III ovarian CA px

    • Peritoneal-based mass (lower


    small arrows) identified at the
    point of transition.
    GALLSTONES
    Dilated fluid-filled small bowel and decompressed
    distal small bowel consistent with obstruction. The
    point of transition corresponds to a high-attenuation
    intraluminal filling defect (arrow)

    Contrast-enhanced axial image shows


    gas in the gallbladder (arrow), a result of
    the fistulous communication to the small
    bowel.
    CLOSED-LOOP OBSTRUCTION

    • Implies a segment of bowel that is obstructed at


    two points along its course

    • Sites of obstruction are adjacent to each other

    • May be best seen in the coronal or sagittal plane


    (a) Dilated and fluid-filled jejunum (arrow) with beak-like narrowing
    (arrowheads) both proximally and distally

    (b) Superimposed schematic shows a closed-loop obstruction caused by an


    adhesion that isolates a loop of fluid-filled bowel.
    COMPLICATIONS OF
    CLOSED-LOOP OBSTRUCTION
    • Isolated segment continues to secrete fluid and
    becomes progressively dilated and fluid-filled
     ISCHEMIA

    • Bowel proximal and distal to the dilated segment


    continues to produce peristalsis around its narrow
    point of obstruction
    •  VOLVULUS
    CT FINDINGS OF A CLOSED-LOOP
    OBSTRUCTION
    • Depend in part on the orientation of the loop
    relative to the plane of imaging

    • Within plane of imaging


    • Appear as a “U,” “C,” or “coffee bean” configuration
    pointing to the site of twist

    • Orthogonal to the plane of imaging


    • Appear as dilated bowel in a radial configuration may
    appear
    C-shaped fluid-filled
    jejunum with a
    heterogeneously
    enhancing thickened wall
    (arrow), with
    associated mesenteric
    edema (arrowhead).
    Closely opposed
    mesenteric vessels near
    the site of a volvulus
    associated with a
    closed-loop obstruction,
    with a whirl sign
    (arrow)

    60% SENSITIVITY
    AND 80% POSITIVE
    PREDICTIVE VALUE
    IN PATIENTS
    REQUIRING
    SURGERY FOR SBO
    ISCHEMIA

    • Increases the morbidity and mortality associated


    with SBO

    • Mortality rate as high as 25% (compared with those


    with SBO without strangulation - as low as 2%)

    • Requires immediate surgery to avoid transmural


    necrosis and perforation
    CT FINDINGS IN ISCHEMIA

    1. Bowel wall thickening ( > 3 mm)


    2. Mesenteric edema
    3. Fluid in mesentery and/or peritoneal cavity
    4. Abnormal bowel wall enhancement, either
    increased or decreased
    5. Occlusion of mesenteric vessels
    6. Engorged mesenteric veins
    7. Whirl Sign
    8. Closed-loop obstruction or volvulus
    9. Pneumatosis
    10. Mesenteric venous gas
    11. Portal venous gas
    C-shaped closed loop
    (arrow). The thickened
    wall, heterogeneous
    enhancement,
    mesenteric edema, and
    free intraperitoneal
    fluid are associated
    with bowel ischemia
    Dilated fluid and gas-
    filled small bowel
    consistent with SBO

    Incarcerated loop
    of small bowel
    (arrowhead) within a
    ventral hernia.

    Note rim of fluid


    (open arrow)
    abutting the
    incarcerated
    bowel.

    A decompressed
    loop of small bowel
    (solid arrow) exits
    the hernia sac.
    Coronal
    reformation shows
    SBO with
    pneumatosis
    (arrow)

    Note the
    gas in adjacent
    mesenteric veins
    (small arrows).
    CONCLUSION

    • When evaluating a patient suspected for SBO, know the


    patient’s history and physical examination, look for the
    actual SBO, site, cause, and presence of complications!

    • Always search for evidence of volvulus and closed-loop


    obstruction.

    THANK YOU!
    REFERENCES

    • Paulson E. and Thompson W. Review of Small-Bowel


    Obstruction: The Diagnosis and When to Worry.
    Radiology: Volume 275: Number 2 – May 2015 Accessed
    from: Radiology.rsna.org
    • Jeffrey RB. Small bowel obstruction. In: Federle MP,
    Jeffrey RB, Woodward PJ, Borhani AA, eds. Diagnostic
    imaging: abdomen, 2nd ed. Salt Lake City, Utah:
    Amirsys, 2010; 44–47.
    • Frager DH, Baer JW. Role of CT in evaluating patients
    with small-bowel obstruction. Semin Ultrasound CT MR
    1995;16(2):127–140.
    • Barnett RE, Younga J, Harris B, et al. Accuracy of
    computed tomography in small bowel obstruction. Am
    Surg 2013;79(6): 641–643.

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