U Nordic Forum – Trauma & Emergency Radiology U Lecture Objectives

Bowel Obstruction
• To illustrate the spectrum of acute obstruction of the
small and the large bowel

• To explain how these bowel obstructions may present

radiologically, with an emphasis on MDCT

• To discuss complications of acute bowel obstruction

Borut Marincek
Institute of Diagnostic Radiology
University Hospital Zurich, Switzerland

U Bowel Obstruction: Etiologies U Bowel Obstruction: Four Relevant Questions

= 20% of surgical hospital admissions for acute abdomen
Small bowel obstruction (SBO) (80%)
• Postoperative adhesions (50-75%)
• Primary & metastatic neoplasia (10-15%)
• External/internal hernia (8-15%)
• Other: Crohn disease, intussusception, hematoma,
gallstone, bezoar
Large bowel obstruction (LBO) (20%)
• Carcinoma (60%, most frequently sigmoid)
• Volvulus (10-15%, sigmoid > cecum)
• Diverticulitis (10%)
• Other: intussusception, fecal impaction, ischemia,
foreign object, extrinsic compression
1. Is mechanical obstruction present ?
DDx: adynamic ileus (laparotomy, pancreatitis,
peritonitis, mesenteric ischemia, neuroleptics, opiates)
2. What is the site (small bowel / large bowel) ?
3. What is the cause ?
4. Any complications ?
Simple (wall viability not compromised) or
strangulation obstruction (compromised vascular
supply  intestinal ischemia) ?
Urgent surgery or conservative management ?

U Bowel Obstruction: Traditional Role of Imaging U Abdominal Plain Film (APF) vs CT

Sensitivity (%)

APF CT
(N=871) (N=188)
Bowel obstruction 49 75

Urolithiasis 9 68

Pancreatitis 0 60

Appendicitis 0 50

Pyelonephritis 0 40

Diverticulitis 0 25

Intraabdominal foreign body 90

(Ahn, Radiology 2002)

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U Bowel Obstruction: Imaging Modalities U Bowel Obstruction: Imaging Modalities

APF: Problems APF: Problems

• Nondiagnostic or misleading in approx. 50% • Nondiagnostic or misleading in approx. 50%
• Poor predictor of site or cause of obstruction • Poor predictor of site or cause of obstruction
• Frequently fails to demonstrate findings of ischemia or or ies
• Frequently fails to demonstrate findings of ischemia or
P d
AF stu
infarction infarction
Antegrade contrast studies: Problems f
Antegrade contrast studies: Problems
o t
• Slow transit, prolonged retention of barium
d tras
• Slow transit, prolonged retention of barium
a
• Water-soluble contrast usually diluted by SB fluid e
• Water-soluble contrast usually diluted by SB fluid
CT: Advantages CT: Advantages
nst con
• Demonstrates site & cause of obstruction, extraluminal i e
• Demonstrates site & cause of obstruction, extraluminal
abnormalities CT rad
abnormalities
g
• Provides information about state of bowel wall (i.e.
te
• Provides information about state of bowel wall (i.e.
strangulation)
an
strangulation

U Large Bowel Obstruction U LBO: Annular Sigmoid Carcinoma

• Less common than SBO

• Different in other ways:
- etiology: cancer most common
- symptoms: insidious
- right-sided mimics SBO
• APF:
- dilated colon >5-6 cm, cecum largest
- rectal gas?
• CT interpretation:
- look at scout views CT confusing ?
- start in pelvis Rectal contrast
= key for LBO
- find cecum and terminal ileum
diagnosis
- find transition zone, look for etiology - masses, etc

U LBO: Metastasis Breast Carcinoma U Fecal Impaction (Coprostasis) ? (61 yo, m)

Retroperitoneal
infiltration

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U Decompensated LBO (61 yo, m) U LBO: Fecal Impaction (Coprostasis)

Colon distended >6 cm,

cecum largest

Adenocarcinoma transverse colon

Ischemic distention colitis of cecum

U LBO: Fecal Impaction (Coprostasis) U High Grade LBO: Diverticulitis or Carcinoma?

Most commonly in laxative Findings typical of diverticulitis:

abusers, psychiatric patients, • Long segment involved (>5 cm)
severe generalized athero- • Pericolic inflammation
sclerosis / cerebral sclerosis • Symmetric wall thickening (75%)

Findings typical of carcinoma:

• Short segment involved
• Pericolic lymph nodes

Sigmoid
diverticulitis

U LBO: Sigmoid Volvulus (= Closed Loop Obstruction) U LBO: Cecal Volvulus (= Closed Loop Obstruction)

“Northern exposure” sign “Coffee bean” sign

(Javors, AJR 1999) (inverted U-configuration)

CT „whirl sign“
 indicative of
volvulus

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U LBO: Cecal Volvulus with Ischemic Complication U LBO: Ischemic Radiation Colitis

58 yo, f: ischemic necrosis cecum

Torsion of involved colon around

mesocolon = „whirl sign“ on CT:
stretching and engorgement
of ileocecal artery & vein in cecal
volvulus (in sigmoid volvulus 
IMA & IMV)
Ovarian carcinoma,
surgery & radiotherapy 23 yrs ago:
ischemic radiation colitis
of rectosigmoid

U LBO: Ischemic Radiation Colitis U LBO: Sigmo-Sigmoid Intussusception

Bowel within bowel

 mesenteric fat, enhancing
Cervical carcinoma, mesenteric vessels
surgery & radiotherapy 10 yrs ago:
ischemic radiation colitis Lead point = polyp
of rectum and sigmoid (adenocarcinoma T2N0)

U LBO: Colo-Colic Intussusception U LBO: Endometriosis

40 yo, f:
rectosigmoid
& cecum

Submucosal lipoma of
ileocecal valve Cecal perforation

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U Small Bowel Obstruction U SBO: Multiple Postoperative Adhesions

Kidney-TPL 1 month ago

• More common than LBO
SB: distended (>2.5 cm) &
• APF:
collapsed loops
- multiple gas-fluid levels unequal heights
• CT technique: No mass at transition zone
 adhesive SBO: adhesive
- oral contrast not necessary
bands unidentified on CT
- iv contrast critical
(diagnosis of exclusion)
• CT diagnosis:
- dilated SB >2.5 cm
- transition zone, maybe hard to find
- small bowel feces sign
- coronal & sagittal MPRs can help

U SBO: Multiple Postoperative Adhesions U SBO: Neoplasia

Circumferential adenocarcinoma
Ventral incisional hernia; distal ileum
SB faeces sign (phytobezoar) =
indicator of SBO when
associated with SB dilatation

curved MPR

U Hernias: External & Internal U SBO: Incarcerated Femoral Hernia

External: herniation of viscera through defect (congenital

weakness or previous surgery) in abdominal or pelvic
wall (inguinal, femoral, ventral, lumbar, obturator,
incisional)
 in most cases visible or palpable, CT for detection
of unsuspected sites, in obese patients

Internal: less common, herniation of viscera through

developmental or surgically created defect of
peritoneum or mesentery into a compartment within
peritoneal cavity
 diagnosis always based on radiology
• Incarceration  irreducible hernia (irreducible sac of
jejunal loop)
• Incacerated hernia may strangulate, clinical diagnosis
difficult in obese patients

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U SBO: Incarcerated Obturator Hernia U SBO: Incarcerated Ventral (Paraumbilical) Hernia

Obturator hernia
• f:m = 5:1
• 7th-8th decade
of life

Paraumbilical hernia:
• Related to diastasis of rectus abdominis muscle
• Risk factors: multiple pregnancies, obesity
• High prevalence for incarceration & strangulation

U SBO: Incarcerated Ventral Incisional Hernia U SBO: Ventral Incisional Hernia

Multiple laparotomies after

10 days after abdominal
resection of sigmoid colon
hysterectomy

Incarceration?

U SBO: Ventral Incisional Hernia U SBO: Internal Hernias

A paraduodenal
B foramen of Winslow
C intersigmoid
D pericecal
E transmesenteric
F retroanastomotic

(Martin, AJR 2006)

• Classic older literature: paraduodenal most common,

pericecal second most common
• Increasing incidence of transmesenteric, transmesocolic
No incarceration
& retroanastomotic  new surgical procedures
(reducible hernia)
(Roux-en-Y loop in liver TPL & gastric bypass)

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U SBO: Pericecal Hernia U SBO: Retroanastomotic Hernia After Gastric Bypass

Mesenteric swirl best

single predictor
(Lockhart, AJR 2007)

U SBO: Crohn Disease U SBO: Intussusception

Mesenteric fat & vessels in bowel lumen

(„bowel-within-bowel appearance“)
Lead point: jejunal melanoma metastasis
Crohn disease:
typically partial
obstruction

Terminal ileum:
wall thickening &
layering enhancement
 active disease Subdiaphragmatic melanoma metastasis, left renal cyst

U SBO: Diagnosis? U SBO: Impacted Gallstone

Rigler Triad: SBO, pneumobilia, ectopic gallstone

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U SB Strangulation Obstruction
Our most important job in SBO is answer to the question:
Simple or strangulation obstruction? Is ischemia present?
Strangulation obstruction (10% of SBO):
- most are closed loop (= bowel loop occluded at
two adjacent points along its course)
- vascular compromise  venous mesenteric blood
flow compromised first, causing increasing vascular
pressure and vessel engorgement with continuing
arterial influx; hemorrhage into bowel wall and lumen
can occur; finally arterial supply ceases, due to arterial
spasm following increasing vascular resistance
U SBO: Strangulation Ischemia
Appendectomy & cholecystectomy 54 yrs ago
Segmental ischemia & infarction of jejunum
secondary to adhesive band
U SBO: Strangulation Ischemia
Appendectomy & cholecystectomy several yrs ago
CT „whirl sign“: strangulating SB volvulus
 ischemia & infarction of jejunum
secondary to adhesive band
U SB Strangulation Obstruction
CT findings:
• Bowel wall thickening >3 mm (non-specific)
• Abnormal bowel wall enhancement ( or )
• “Target sign”: alternating hypo- / hyperdense layers
 submucosal edema / hemorrhage
• Pneumatosis intestini & portomesenteric gas
• Mesenteric edema
• Ascites
U SBO: Strangulation Ischemia
Appendectomy 1 yr ago
Venous ischemia of ileum
secondary to adhesive band
U Bowel Obstruction: Summary
• Remember 4 questions
• MDCT instead of APF for accurate diagnosis
• MDCT: MPRs improve visualization of transition zone
prestenotic / poststenotic bowel  better determination
of site and cause of obstruction
• MDCT: improved visualization of ischemia in
suspected small bowel strangulation obstruction