Koas Radiologi Audriana Jurding Ileus22

JOURNAL
READING
Review of Small-Bowel
Obstruction Pembimbing:
“The Diagnosis & dr. Partogi, Sp.Rad
When to Worry”
Oleh:
Audriana Hutami Putri (030.12.039)
Mutiara Riahna Sitepu (030.12.179)
INTRODUCTION
A challenge in the
Small-bowel clinical  clinical
obstruction (SBO) presentation,
This uncertainty has
physical
led  use of
Cause of examination finding
imaging to not only
morbidity and & laboratory tests
diagnose SBO but to
mortality  2-8% are neither
detect
 25% (ischemia sufficiently sensitive
complications that
nor specific  which
and delay in patients with SBO
require prompt
surgical surgery.
have coexistent
management) strangulation/
ischemia
DEFINITION
Complete or high- Incomplete or

grade obstruction partial obstruction
Strangulated Closed-loop
obstruction obstruction
CLINICAL ISSUES
Clinical finding :
abdominal pain, distention, vomiting, and high-pitched or
absent bowel sounds
Laboratory :
Leukocytosis or an elevated serum amylase and lactic acid
levels suggest a complication
The management of SBO
Nasogastric tube de-

Prompt surgical
compression
ETIOLOGY ADHESIO
NS
TRAUMA HERNIAS
FOREIGN MALIG
BODIES NANCIES
GALL CROHN
STONES DISEASE
INTUSSU
CEPTION
,VOLVUL
US
RADIOGRAPHY
Abdominal radiography  The diagnosis of SBO is

modality in patients suspected improved substantially if
radiographs are obtained in
of having SBO  widely both dependent (spine or
available, inexpensive, and has prone) and nondependent
an accuracy of 50–86%. (upright or decubitus) views.
A general algorithm for evaluation of
patients suspected of having SBO
The radiographic findings of SBO
CT TECHNIQUE
Many groups have omitted
the routine of high
attenuation oral contrast a 64-section multidetector
material : CT protocol for suspected
SBO:
(a) patients with SBO are
Traditionally, high- nauseated and may vomit Administration of 1. 150 mL nonionic
attenuation oral  aspiration intravenous contrast iodinated contrast material
injected at 3 mL/sec
contrast material (b) contrast material rarely material is
opacities the bowel just 2. 60-second scan delay
was routinely proximal to the transition
recommended as a (or automated scan delay
adminis- tered in point in a high-grade routine unless there based on hepatic
patients suspected obstruction is a attenuation)
of having SBO. (c) the low-attenuation contraindication. 3. 64 X 0.625 detector
fluid and gas within the configuration
obstructed lumen provide 4. 3–5-mm reconstruction
excellent contrast relative in axial and coronal planes.
to the normally enhancing
bowel wall
CT findings
It has a sensitivity and

Multidetector CT is the specifity of 95% for the
single best imaging tool diagnosis of highgrade
for suspected SBO. SBO and is less accurate
in partial obstruction
• Airfuid levels will be present and a string of beads sign may be
identified.
• In high-grade obstruction or in chronic obstruction, stasis and
mixing of small- bowel contents with gas creates an appearan
ce analogous to feces in colon, the “small-bowel feces” sign
Advantage of CT over radiography
CT provides an
Increased
excellent evaluation
confidence of CT also provides an
of the bowel wall,
identification of the excellent evaluation
its vessels, and
transition zone, for the presence of
adjacent
which is the site bowel perforation
mesentery, which
where dilated and the presence of
permits the
bowel transitions to free extraluminal
identification of
decompressed gas.
coexistent ischemia
bowel
and/or infarction.
Adhesions
Adhesions represent bands of fibrous

tissue that obstruct the lumen and are
60 to 70% of SBOs are caused by
a consequence of the postoperative
adhesions which are usually the result
inflammatory process. They may lead
of prior abdominal surgery, whether
to bowel obstruction in the early
open or laparoscopic.
postoperative period or may obstruct
years later.
External hernia
Are the second most

The hallmark of SBO due to
frequent cause of SBO .
hernia is the presence of
They can occur throughout
dilated bowel up to the
the abdomen and pelvis,
hernia sac followed by
but most frequently involve
decompressed bowel
the inguinal canal or
exiting from the sac.
anterior abdominal wall.
Primary Tumors
In patients with known primary tumors and SBO, the most likely
cause is metastatic disease either involving bowel or peritoneum
. Surgeons hesitate to operate on these patients because while o
ne metastasis may be the cause of the obstruction, multiple abd
ominal metastases are usually present, and it is not generally fea
sible or appropriate to address all of these metastases surgically
Other causes of SBO include internal hernia, acute infl
ammation such as diverticulitis, acute appendicitis, ab
scess, chronic inflammation such as Crohn disease, or
other causes, including obstruction from objects such
as capsular endoscopes or gallstones
Closed-loop obstruction
• A closed-loop obstruction implies a segment of bowel
that is obstructed at two points along its course essen
tially isolating the obstructed segment from the remai
nder of the gastrointestinal tract
• The sites of obstruction are adjacent to each other, oft
en the result of a single constricting lesion that occlud
es the bowel and affects adjacent mesentery
• The isolated segment continues to secrete fluid and it
therefore becomes progressively dilated and fluid fill
ed, which can impair venous return resulting in ischem
ia.
• Most commonly, the closed loop is caused by a single
adhesive band, but internal hernias or congenital or i
atrogenic defects in the mesentery or omentum may
serve to trap a segment of the bowel leading to a clo
sed- loop obstruction
Ischemia
• Ischemia is the complication that increases the mor
bidity and mortality associated with SBO
• Specifically, the mortality rate in patients who unde
rgo surgery for SBO with ischemic bowel is as high a
s 25% compared with those with SBO without stran
gulation, which may be as low as 2% (2–5).
• When ischemia is suspected, immediate surgery is r
equired to avoid transmural necrosis and perforatio
n.
Conclusion
• When interpreting imaging findings in patients suspected of having SBO, it is

important to not only assess for the presence of ischemia, but to carefully se
arch for causes of obstruction associated with strangulation and ischemia.

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JOURNAL

Complete or high- Incomplete or

The management of SBO

Nasogastric tube de-

Abdominal radiography  The diagnosis of SBO is

It has a sensitivity and

Adhesions represent bands of fibrous

Are the second most

• When interpreting imaging findings in patients suspected of having SBO, it is

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