SBO vs Ileus/ partial SBO

KUB
Heidi Ramos, PGY-2
Oakwood Hospital Radiology

Normal
Normal Gas in Bowel
Always in stomach
Two or three loops small bowel (<2.5cm)
Almost always in rectum/ sigmoid (<6cm) (c<9cm)

Normal Air Fluid Levels

Always in stomach
Two or three in small bowel
Never in colon

Small Bowel Obstruction

X-ray findings:
Bowel proximal to point of obstruction dilates
Swallowed air and continuous secreted fluid/ mucus

Dilated sb >2.5 to 3 cm
Air-fluid levels (think step ladder from left to right )
Vomiting will release some proximal dilatation

Bowel distal to point of obstruction collapses

Empties over time until collapse

Absence/ paucity of gas in distal colon

Small Bowel Obstruction

CT findings:
Proximal
Dilated, air/fluid filled loops

Distal
Collapsed bowel

Small Bowel Feces Sign

Air mixes with stagnant food bolus

Small Bowel Obstruction vs

Ileus/ partial Small Bowel Obstruction
SBO

Ileus

Etiology

Prior surgery (weeks to yrs) Recent (hrs) post op

Pain

Colicky

Not a prominent feature

Abdominal distension

Frequently prominent

+/-

Bowel sounds

Usually increased

Usually absent

Small bowel dilatation

Present

Present

Large bowel dilatation

Absent

Present

Ileus/ partial SBO

Localized ileus
Sentinel loop (s)
One/two persistently dilated loops
Gas in sigmoid/ rectum

Generalized adynamic ileus

Persistently dilated small and large bowel loops
Post op inpatient (not an ER/ outpatient)

Small Bowel Obstruction

Small bowel
obstruction
SB 5cm
No distal gas
Evidence of
prior sx
(sutures)

Paralytic/ Diffuse Ileus

Post op Ileus
Evidence of surgical wound
Air in distal colon
Evidence of recent surgery

Small Bowel Ileus

Focal Ileus
Sentinel loop
Patient with
known acute
pancreatitis

Obstruction (partial)
Large Bowel
Obstruction
Colon dilated to distal
descending
Soft tissue density
likely colon mass
causing partial
obstruction
Not complete
obstruction (air still in
rectum)

Large Bowel Obstruction

Sigmoid volvulus LBO
Coffee bean
Fixed point in left iliac
fossa
Birds Beak on BE

Large Bowel Obstruction

Cecal volvulus LBO
Massively dilated cecum
Displaces small bowel
SB now in RLQ (valvulae
conniventes)

Bowel Inflammation
Mucosal edema
Distance between
loops of bowel
increased
Haustral folds are
very thick
thumbprinting

Ulcerative Colitis vs. C. diff

Pseudomembranous Colitis
Toxic Megacolon
Dilated colon + Mucosal
Edema + Mucosal islands

Obstruction
SBO
SB dilated:
Yes

LB dilated:
No

Rectal air:
No

Other clues:
Evidence sx

Gallstone Ileus
SBO
SB dilated:
Yes

LB dilated:
No

Rectal air:
No

Other clues:
Riglers triad:
Biliary gas
SBO
Gallstone

Round calcific
density in RLQ/ TI

Obstruction
SBO
SB dilated:
Yes

LB dilated:
No

Rectal air:
No

Other clues:
Air-fluid levels
Too many/
stepladder

Small Bowel Obstruction

Spot the
transition
point.

Focal Ileus
Ileus
SB dilated:
Yes, focal loop

LB dilated:
No

Rectal air:
Yes

Other clues:
RLQ tenderness
Acute appendicitis

Paralytic ileus
SBO
SB dilated:
Yes

LB dilated:
Yes

Rectal air:
Yes

Other clues:
F/u studies recovery time:
Small intestine: 0-24h
Stomach: 24-48h
Colon: 48-72h

Inpatient / Recent Postop

Large Bowel Obstruction

Sigmoid volvulus:
Birds beak on BE
Abrupt cut off

Large Bowel Obstruction

LBO:
Obstructing
intraluminal mass
Apple Core on plain
film and BE

Obstructive Uropathy
Uterine fibroid
Degenerating (ca)
Ureteral stent
demonstrates not
calcified bladder
wall
Tricked you:
This ones GU
not GI!

Small Bowel Obstruction

Spot the transition point.

Gastric Volvulus
Last thing we think to volvuse
Yes, if we use it in Radiology then its a word.

Organoaxial makes a C shape.

Mesoaxial twist to an 8 shape.

Gastric volvulus
Presentation:
Triad of Borchardt
Severe sudden epigastric pain
Intractable retching without vomiting
Inability to pass NG tube

Gastric Volvulus

Herniation of bowel
into chest cavity.

Note: two gastric air

bubbles

Need f/u Upper GI

fluoroscopy study vs. CT
ab/pelv WITH contrast
to exclude other
differentials such large
abscess or esophageal
diverticulum.