Recognizing bowel obstruction

and ileus
 CT is superior in revealing the location,
degree, and cause of an obstruction and in
demonstrating any sign of reduced bowel
viability
 Key questions
Are there dilated loops of small and/or large
bowel?
On CT, is there a transition point?
On plain films, is there air in the rectum or
sigmoid?
Abnormal gas pattern
Functional Mechanical
ileus obstruction

Localized
SBO
ileus

Generalized
adynamic LBO
ileus
 Functional ileus
Localized ileus affect only one or two loops
of (usually small) bowel sentinel loop
Generalized adynamic ileus affect all loops
of large and small bowel and frequently the
stomach.
Law of the gut
Obstruction occurs

Peristalsis continues
This can occur with
few hours of a comp
SBO
Loop proximal soon become
dilated with air and/or fluid

Loop distal become

decompressed or airless

The transition point !!

 Clinical manifestation
Mechanical obstruction
Abdominal pain
Abdominal distention
Constipation
Vomiting
Early in proximal SBO
Late in distal SBO

Prolonged obstruction elevated intraluminal pressure vascular compromise

necrosis perforation.
 4 abnormal bowel gas pattern
Pathophysiology
Causes
Key imaging features
Diagnostic pitfalls
Table 16-1 Abnormal gas patterns
FUNCTIONAL ILEUS : LOCALIZED
SENTINEL LOOPS
 Pathophysiology
Focal irritation occurs most often from
inflammation of an adjacent visceral organs
Loops affected are almost always loops of
small bowel
Irritation lose normal function
aperistaltic dilatation
Air is visible in the rectum or sigmoid
 Causes
Table 16-2 Causes of a localized ileus
 Key Imaging Small bowel loops > 2,

Coventional radiographs
There are one or two persistently dilated loops of
small bowel
There are frequently air fluid levels
There is usually gas in the rectum or sigmoid

these same loops remain

dilated on multiple views of
the abdomen
 Pitfalls
Localized ileus vs early SBO
Early means the patient has had symptoms for a
day or two
Solution : combination clinical and lab findings, ct
scan abdomen
GENERALIZED ADYNAMIC ILEUS
 Pathophysiology
Entire bowel is aperistaltic or hypoperistaltic
Swallowed air dilates and fluid fills most loops
of both small and large bowel.
Almost always the result of abdominal or
pelvic surgery
 Causes
Table 16-3
 Key Imaging
The entire bowel is usually air containing and
dilated, the stomach may be dilated as well.
Many long air fluid levels in the bowel
There should be gas in the rectum or sigmoid
There is no transition point !
BU are frequently absent or hypoactive
Pitfalls
SMALL BOWEL OBSTRUCTION (SBO)
Pathophysiology
 Causes
Table 16-4
 Key Imaging
Conventional radiographs : there are multiple
dilated loops of small bowel proximal to the
point of the obstruction (> 2,5 cm)
As they begin to dilate small bowel loops stacks up
on one another forming a step ladder appearance
usually beginning in the LUQ to RLQ
The more proximal the obstruction, the fewer the
dilated loops there will be
The more distal the obstruction, the greater the
number of dilated small bowel loops
 Key Imaging
Upright or decubitus radiographs
numerous air fluid levels in the small bowel
proximal to the obstruction
There will be little or no gas in the colon esp
in the rectum if enough time to
decompress and empty the bowel distal to the
point of obs.
In mechanical SBO there should always be a disproportionate dilatation of
small bowel compared with the collapsed large bowel
 Pitfalls
Partial SBO vs localized adynamic ileus
CT scan without oral contrast
Partial SBO occurs more often in patients in whom
adhesions are the etiologic factors
CT is the most sensitive study for diagnosing the
site and cause of mechanical SBO
With or without contrast
Oral contrast (barium or iodinated contrast)
identifying dilated loops of bowel and in finding
the transition point
IV contrast detecting complications of bowel
obs such as ischemia and strangulation
 CT findings of SBO
Fluid filled and dilated loops of small bowel (>
2,5 cm in diameter)
Transition point
Collapsed small bowel and/or colon distal to
the point of obstruction
Small bowel feces sign
Closed loop obstruction
Strangulation
LARGE BOWEL OBSTRUCTION
Pathophysiology
 Causes
Table 16-5
 Key Imaging
The colon is dilated to the point of obstruction
The site of obstruction sometimes as the last air containing
segment of the colon
The caecum is often the most dilated segment of the colon
When the caecum reaches a diameter > 12 to 15 cm, there is
danger of cecal rupture.
The small bowel is not dilated unless the ileocecal valves
is incompetent
The rectum contains little or no air
There are usually no or very few air fluid levels in the
large bowel
 Pitfalls : LBO can mimic an SBO
Incompetent ileocecal valve
Disproportionate dilatation of the small bowel
compared with the decompressed large bowel
Solution CT scan of the abdomen. Barium is
not administered by mouth.
LBO in CT
Volvulus of the colon
 Intestinal pseudoobstruction
(Ogilvie syndrome)
= acute intestinal pseudoobstruction