AJR:168, May 1997 1171

Review Article
The Role of Radiology in the Diagnosis of Small-Bowel
Obstruction
Dean 0. T. Maglinte1, Emil J. Balthazar2, Frederick M. Kelvin1, Alec J. Megibow2
T he patient with acute abdominal
pain represents one of the most
common, most important, and most
difficult practical problems that the general sur-
geon has to face [I]. Intestinal obstruction is
responsible for approximately 20% of surgical
admissions for acute abdominal conditions [2].
The small bowel is involved in 60-80% of
cases of intestinal obstruction. In spite of
advances in imaging and a better understanding
of the pathophysiology of the small bowel, its
obstruction is still frequently misdiagnosed [3].
The value of diagnostic imaging in such
assessments lies in its ability to answer ques-
tions relevant to the clinical management of
patients. According to Herlinger and M aglinte
[4], the issues of concern to the surgical man-
agement of small-bowel obstruction that diag-
nostic procedures must address are the
confirmation or exclusion of obstruction; the
identification of the site, severity, and cause of
the obstruction; and the possible presence of
strangulation. Underlying these questions is
the pivotal issue of whether early laparotomy
is indicated or whether a trial of nonoperative
management should be instituted. Radiology.
because it is able to supply relevant answers to
many of these questions, assumes considerable
importance in this decision. The issue of how
to use imaging resources in the midst of the
ongoing changes in health care delivery has
considerable practical importance. An errone-
ous choice of diagnostic procedures adds to
the costs of workup and may delay diagnosis.
This review examines the recent contributions
of radiology, addresses controversies. and rec-
ommends an approach for the diagnostic triage
of patients with possible intestinal obstruction.
Clinical Considerations and Controversies
in Management
To function as consultants, radiologists
must understand surgical tenns, the clinical
limitations in diagnosing intestinal obstruc-
tion, and the controversies in the surgical man-
agement of this condition.
Some of the most frequently used descrip-
tive terms by surgeons [2] are simple obstruc-
tion, in which the blood supply to the affected
area of bowel is intact; strangulation obstruc-
tion, in which the obstructed bowel is isch-
ernie because of its entrapment in a confined
space. which in turn interf’eres with the
venous or arterial circulation to the involved
segment; partial obstruction, in which some
gas and intestinal contents pass through the
point of obstruction; complete obstruction, in
which the lumen is totally occluded; closed-
loop obstruction, or occlusion of a segment of
bowel at both ends (usually associated with
strangulation); low small-bowel obstruction,
situated in the distal small bowel; high
small-bowel obstruction, involving the proxi-
mal small intestine; obturation obstruction,
caused by an intraluminal mass such as a
bezoar or gallstone; and functional obstruc-
tion, in which symptoms of mechanical
obstrt.iction occur without actual occlusion or
compression of the intestinal lumen. Func-
tional or pseudoobstruction can be associated
with niotility disorders. can occur as a
response to extrinsic factors (i.e., peritonitis),
or niay he idiopathic.
The pattern of major causes of small-bowel
obstruction has changed during the last live
decades I I 1. Adhesions and hernias are the two
major causes, closely followed by rnalignan-
cies-most of them nieta.stases. For all practical
purposes. these three entities account for
approximately 80’/c of all cases [2). with adhe-
sions accounting for as high as 79m / in some
reports [5-81. In a report of patients with small-
bowel obstruction after abdominal surgery (or
malignancy, 62% had cancer-related obstruc-
tion and 38#{176}7c had nonmalignant obstruction 9).
A miscellaneous group of causes of small-
bowel obstruction includes inflammatory pro-
cesses. intussusception, volvulus, congenital
lesions. gallstones. foreign bodies or bezoars.
trauma, and the occasional iatrogenic obturation
obstruction by a distended hallixin of a feeding
or decompression tube 141-
The diagnosis of intestinal obstruction
depends on the classic tripod: a carefully taken
history. a meticulous physical examination.
and special investigations 111. Of the last, radi-
ology is the most iniportant.
The clinical accuracy of diagnosing
mechanical small-bowel obstruction is high
when the findings of’ crampy abdominal pain.
distention, vomiting. and obstipation are
Received June 27, 1996; accepted after revision September 16, 1996.
1 Department of Radiology, Methodist Hospital of Indiana and Indiana University School of Medicine, 1701 N. Senate Blvd., Indianapolis, IN 46202. Address correspondence to D. D. T.
Maglinte.
2Department of Radiology, New York University Medical Center, New York, NY 10016.
AJI? 1997;168:1 171-1180 0361-803X/97/1685-1 171 © American Roentgen Ray Society
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-r
1172 AJR:168, May 1997
present together with plain film findings of
small-bowel distention with multiple air-fluid
levels and decreased gas and fecal material [ I I.
Unfortunately. in approximately one third of
cases, plain abdominal radiography does not
confirm the clinical findings to allow a confi-
dent diagnosis of mechanical small-bowel
obstruction and. in addition, often fails to
answer questions about management. If the
plain film finding is unrevealing or ifearly sur-
gical intervention is not performed in patients
with probable obstn.iction, further imaging is
often indicated (4. 10).
The nianagement of patients with adhesive
small-bowel obstruction remains a controver-
sial subject. If the ohstn.iction is partial. an
initial trial o)f intestinal decompression is fre-
quently recommended by surgeons in the
belief that this approach is safe and that the
need for surgery can he avoided 5- J. Other
surgeons believe that early surgical interven-
tion is necessary. especially with complete
obstruction, both because of the difficulty in
distinguishing simple from strangulated
obstruction and because of the high compli-
cation rate associated with delayed operative
intervention 111-141. The timing of such sur-
gery is probably most controversial in
patients with adhesive obstruction because
the success rate of avoiding operation by the
use of gastrointestinal tithe decompression in
these patients is high 12. 15. 161. The current
mortality rate o)f patients with adhesive
obstruction is in the l-2 /c range 116. 171.
suggesting that the risks associated with con-
servative management may be acceptable
provided that the operation can be promptly
performed when deterioration or strangula-
tion is clinically evident. Unfortunately. clini-
cal experience has shown that simple
mechanical obstruction cannot be reliably
differentiated from strangulated obstruction
on the basis of clinical, laboratory. and plain
film findings 18. 12. 14, 18-211. Of patients
with surgically proven strangulation. the pre-
operative diagnosis is unreliable in 50_85C/c
IS. 22-261. The mortality rate of strangula-
tion complicating small-bowel obstruction is
approximately 25% . Thus, mortality and
morbidity from intestinal obstruction con-
tinue to be significant [21.
Fig. 1.-Sudden onset of constant ab-
dominal pain and nausea in 54-year-old
man who had undergone laparotomy.
A and B, Emergent supine (A) and up-
right (B) abdominal radiographs show
normal intestinal gas pattern.
C, Emergency CT study reveals residual
air in right colon (open arrow) and tran-
sition zone with collapsed loop of ileum
(so/id arrows) suggestive of high-grade
small-bowel obstruction. Seen in left
lowerabdomen are fluid-filled distended
closed loops (c) and extraintestinal fluid
indicating hemorrhage in mesentery at-
tached to distended loops (H), features
highly suspicious for strangulation. At
surgery, adhesions and closed-loop ob-
struction were identified and segment of
ischemic bowel was resected.
Plain Abdominal Radiography
In spite of advances in imaging. plain film
examination has remained the starting point
in the radiologist’s involvement in the
workup of patients with intestinal obstruction
1271. Plain film findings are estimated to be
diagnostic in about 50-60% of cases; equivo-
cal in about 20-30% ; and normal, nonspe-
cific. or misleading in 10-20% of cases 15,
18-20]. The lack of a definition for the vari-
ous terms used in describing intestinal gas
patterns on plain films has resulted in consid-
erable confusion [28, 291. Emergency physi-
cians frequently use the term “nonspecific
abdominal gas pattern” to mean normal [3].
One survey showed that 70% of radiologists
used the term 128]. Sixty-five percent of these
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Diagnosis of Small-Bowel Obstruction
AJR:168, May 1997 1173
interpreted this to mean normal or probably
normal. whereas 22% interpreted this to
mean cannot tell if normal or abnormal and
I 3% interpreted this to mean abnormal but
cannot tell if it represents mechanical
obstruction or adynamic ileus.
In a recent analysis of plain film examina-
tions in diagnosis of small-bowel obstruction
by experienced gastrointestinal radiologists.
a sensitivity of only 66% was found 1101.
This report dif’f’ered from other studies in that
the various plain film patterns were delined
and a follow-up for every defined interpre-
tive category was given. In this report 62c/c
of the patients clinically suspected of having
small-bowel obstruction did not in fact have
obstruclion. Of patients with plain films
interpreted as having normal findings. 21 C4
had low-grade small-bowel obstruction: of
those patients with findings interpreted to he
abnormal hut nonspecific. 13% had low-
grade and 9% had high-grade small-bowel
obstruction; and of those patients with find-
ings interpreted to show probable small-
ho vcl obstruction. 37% had low-grade and
I 6 / had high-grade small-bowel o)hstntc-
tioti. No) complete siiiall-ho vel o)hstructions
were seen in the lhree categories. Ofthe find-
ings interpreted as showing definite small-
bowel o)hstructlon. 26’4 had low-grade uul
23C4 had high-grade sinaI I-bowel obstruction
itid I 3Yc had complete small-bowel ohstnic-
tion. This report indicates a pattern that is
neither normal nor fits the categories of
probably or deli n itely obstructed. (amm ill
and Nice [301 recogniied this pattern to
mean ileus (i.e.. the small bowel is unable to)
push fluid along). Indeed, the word “iletis”
means stasis and does 1101 differentiate
het v CC1 mechanical and no)nnlechanio.’al
causes. “Small-bowel” stasis has been pro-
posed to describe this pattern. o)r if the term
“nonspecific abdominal gas pattern” is used
at all. it should he qualified as abnormal 3l[.
This interpretation satisfies a group of plain
film findings that does not fit the normal and
dcli ii i telv ahnornial categories and has c I i ii i -
cal i nipl ications.
The literature clearly docunients significani
liiiiitations o)fthe phtin filni esaiiiinatioii iii the
diagnosis and tsscssnlent of degree of intestin tl
o)hstructio)n [4[. Niost pltieilts with stispected
siii l I -ho vel ohstriiction iiioi a norni l ptttenl
o)r dii abnormal but no)nspecific pllteril ill
have no o)hstnict oil or lo v-giadc )hsi ruct i ni
1 10[. A nlulo)rity. however, have high-grade
o)hstflictions atid i ccasional lv strangulating
obstruction (Fig. 1). In addition to) having a
low sensitivity to) detectio)n on plain film radi-
ography, m echanical and functional colonic
o)hstniction can present with radiographic
findings suggesting small-bowel obstruction
132 I. Isolated d istent ion of the small h wel
has been observed in I 6 4 o)f paticilts with
o)hstnicting colon carcinoma (Fig. 2. and dis-
tention together with air-fluid levels in the
small bowel has been shown in 26C4 of
patients with colonic pscudoohstniction 133.
341. The diagnosis of small-bowel obstruction
Fig. 2.-Abdominal pain and right lower quadrant fullness in 61-year-old
man who had never undergone laparotomy.
A and B, Supine (A) and erect (B) abdominal radiographs show dilated small
bowel with air-fluid levels and empty colon consistent with mechanical
small-bowel obstruction.
C, CT scan obtained after A and B reveals distended loops of small bowel
with air -fluid levels (s( and extensive circumferential thickening of wall of
cecum (c), compatible with cecal carcinoma. Inflammatory changes and
fluid are seen in adlacent mesentery (I). At surgery, 10-cm cecal carcinoma
with pericolic inflammation and edema was resected.
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Maglinte et al.
1174 AJR:168, May 1997
Ofl plain films when the loops are predomi-
nantly fluid-filled is an acknowledged inter-
pretive dilemma. Inability to appreciate subtle
plain film evidence of’ fluid-filled small bc,wel
(string-of-pearls sign, stretch sign, or pseudo-
tumor sign) is still common in practice [3].
Thus, the detection of pertinent plain film
findings (air-filled distended small bowel, dif’-
ferential fluid levels. empty colon. free air in
peritoneal cavity) has significant clinical
value that greatly contributes to the initial
diagnostic and therapeutic decision making.
However, the absence of these findings is
associated with a low negative predictive
value and cannot be relied on in clinical prac-
tice. In the workup of patients with suspected
intestinal obstruction, plain films interpreted
as showing noniial findings or small-bowel
stasis (abnormal but nonspecific) are not
reliable and should be used with caution in
the context of a comprehensive clinical evalu-
ation. If’ the clinical suspicion of intestinal
obstruction is high or if a variety of other
abdominal conditions that can mimic bowel
obstruction are clinical possibilities. additional
imaging niay be required to explain the clini-
cal presetitation. Despite these limitations.
plain film radiography remains a mainstay in
the evaluation of suspected small-bowel
obstruction because of its high sensitivity in
revealing higher grades of small-bowel ob-
struction, its widespread availability. and its
relative inexpensiveness [271.
Barium Examination in Small-Bowel
Obstruction
Experience accumulated mainly in the last
two decades has shown that the intubation infu-
siOil method of examining the small intestine
(enteroclysis or the small-bowel enema) has
improved the preoperative diagnosis of patients
with suspected small-bowel obstruction 135-
441. The small-bowel follow-through with bar-
ium or water-soluble contrast material, even
when done meticulously, has been shown to
have significant inherent limitations in the
diagnosis of’ small-bowel obstruction [35, 36].
Distensibility and fixation of the small bowel
are difficult to assess. Partially obstructing
lesions may pnx.luce only a fleeting moment of
prestenotic dilatation, which can be difficult to
appreciate with limited fluoroscopy. In higher
grades of obstruction, contrast material is often
retained in the stomach and filling of the small
bowel is delayed and incomplete. Because of
retained fluid in the small bowel proximal to
the site of obstruction, contrast material is
increasingly diluted and mucosal detail is mad-
Fig. 3.-Unexplained recurrent nausea, abdominal pain,
and weight loss in 45-year-old woman who had under-
gone hysterectomy 5 years earlier and in whom plain film
radiography, conventional small-bowel follow-through,
and CT had been unrevealing. Radiograph obtained dur-
ing enteroclysis shows mild distention of small bowel up
to segment in right lower abdomen (curved arrow)
where fixation and diminished caliber of more distal pel-
vic segments are consistent with partial obstruction.
Scattered areas of peritoneal adhesions manifested by
abrupt angu)ation or tenting (straight arrows) and adhe-
sive band fixation (arrowhead) are seen. All folds are de-
fined clearly, indicating low-grade partial obstruction
associated with diffuse pelvic adhesions. Findings at sur-
gery for recurrent symptoms confirmed diagnosis. (Re-
printed with permission from 138])
equate. Therefore, the value of the small-bowel
follow-through in patients with suspected acute
mechanical sniall-bowel obstruction is limited.
However. of the different imaging methods that
do not test luminal distention, the small-bowel
follow-through done fluoroscopically is a via-
ble alternative to enteroclysis in the assessment
of low-grade obstruction because fixation of
segments can be tested during intermittent fiuo-
roscopy [36, 371.
The frequent intennittent fluoroscopic moni-
tonng during enteroclysis contrast infusion
makes assessment of fixed and nondistensible
segments easier to recognize. The effects of
n ild obstruction are exaggerated (Fig. 3). The
level and cause of most obstructing lesions are
precisely shown by enteroclysis. In a recent
report. enteroclysis correctly predicted the pres-
ence of obstruction in l(XY/c of cases, the
absence of obstruction in 88% , the level of
obstruction in 89% , and the cause of obstruc-
tion in 86% 1101. An important advantage of
enteroclysis compared with other imaging
methods is its ability to gauge the severity of’
obstruction objectively 110. 38]. The amount of
contrast material traversing the point of obstruc-
ti()n can be helpful information in deciding
whether to continue nonoperative nianagement
Fig. 4-39-year-old woman with recurrent lower abdo-
men pain who had undergone hysterectomy 5 years ear-
her and in whom plain film radiography, small-bowel
follow-through, and CT had been unrevealing. Enterocly-
sis shows fixed pelvic segments of ileum that were im-
movable during cephalad angled compression at
fluoroscopy (not shown). Scattered areas of peritoneal
adhesions manifested by multiple linear defects
(arrowheads) associated with adhesive band fixation
are seen. Terminal ileum is of smaller caliber than more
proximal segments. Laparoscopy confirmed that small
bowel was fixed to vaginal cuff and posterior wall of un-
nary bladder by multiple adhesions. Laparoscopic lysis of
adhesions resulted in relief of symptoms. C = cecum. (Re-
printed with permission from 137])
Or to perforni iniiiiediate operation. In partial
sniall-bowel obstruction, enteroclysis has been
showii to be approximately 85% accurate in
distinguishing adhesions from metastases,
tumor recurrence. and radiation damage [39[.
Enteroclysis has been advocated as the defini-
tive study in patients about whom the diagnosis
of low-grade inteni ittent small-hciwel obstruc-
tioti is clinically uncertain 1421. Its ability to
both reveal low-grade small-bowel obstruction
and exclude the possibility of small-bowel
obstruction niakes it an in po)rtant tool in this
difficult clinical problem [40-1-t[ (Fig. 4).
The tenhl “closed-loop obstruction” is con-
strued by illOst surgeons as indicating a coin-
plete. acute obstruction. It portends a progression
to infarction, indicating the need for urgent sur-
gery. The clinical diagnosis of this entity is unre-
liable I 19-23[. Ifa patient has clinical findings of
peritoneal irntation. fever. or leukocytosis. (“F
should be the initial choice of imaging. After
CT. however, if additional infonnation is clini-
cally desired (e.g.. how much contrast material is
going through the site of’ obstruction) or if addi-
tional clarification of cause is needed. enterocly-
sis is complementary [27. 451 (Fig. 5).
Enteroclysis has been shown to) reveal partial
closed-loop obstruction [46, 471.
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,f
. ‘ IA
Diagnosis of Small-Bowel Obstruction
AJR:168, May 1997 1175
Fig. 5.-31-year-old woman who had been unrestrained passenger in motor vehicle accident 3 months earlier and
sustained liver and spleen lacerations, multiple pelvic bone fractures, and head injury with subsequent development
of hydrocephalus and presented with vomiting after feedings.
A, Supine abdominal radiograph is unremarkable except for revealing gasless left hemiabdomen and few gas-filled
loops of small bowel in right hemiabdomen. Feeding tube tip seen in proximal jejunum was introduced through non-
functioning endoscopic gastrostomy port. Ventriculopenitoneal shunt is seen in right hemiabdomen.
B, CT study shows multiple dilated small-bowel loops. Transition zone is in right hemiabdomen (arrow points to col-
lapsed but contrast-filled loop distalto obstruction). Findings were consistent with partial small-bowel obstruction as-
sociated with adhesions.
C, Enteroclysis was requested after 2 days of nasogastnic suction to assess severity of obstruction. After positioning
of decompression and enteroclysis tube in jejunum, additional 12 hr of suction was done because offluid retained in
jejunum. Supine radiograph reveals interval passage of fecal debris in colon but persistent distention of small bowel.
D, Infusion of contrast medium after inflation of balloon (straight arrow) distal to feeding tube reveals area of narrow-
ing in proximal jejunum (curved arrow), producing obstruction. Dilated bowel immediately distal to obstruction sug-
gests either closed-loop obstruction or multiple points of obstruction.
E, Delayed radiograph 3 hr later shows second point of obstruction (open arrow) near site of proximal obstruction
(curved arrow) with no contrast material beyond, suggesting either high-grade multiple adhesive band obstruction or
closed-loop obstruction. Surgery revealed two separate high-grade proximal and distal small-bowel adhesive band
obstructions that were lysed. Patient was able to resume tube feedings.
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Maglinte et al.
1176 AJR:168, May 1997
For enteroclysis in patients with small-
bowel obstruction, the use of a catheter
designed to allow decompression has been
helpful for patients who may need continued
mechanical decompression after the enterocly-
sis [48]. Such a catheter spares the patient the
trauma of reintubation with the larger standard
Salem sump nasogastric tube. This tube is bet-
ter tolerated by patients and, as opposed to
other long tubes. can be positioned in the prox-
imaljejunum without difficulty [49].
The main disadvantages of enteroclysis are
the need for nasoenteric intubation and the
slow transit ofcontrast material in patients with
a fluid-filled hypotonic small bowel, that is, in
high-grade obstruction. The need for the radiol-
ogist to be continuously involved with the pro-
cedure and for conscious sedation makes
enteroclysis impractical in the outpatient (non-
hospital) clinic setting. M any institutions also
lack individuals with the proper expertise. If
expertise in performance of enteroclysis is
lacking, a dedicated small-bowel follow-
through with tluoroscopic monitoring every I 5
to 30 mm until the right colon is reached is an
acceptable substitute for the evaluation of
small-bowel obstruction, provided no high-
grade obstruction is present [36. 37].
In patients with unsuspected complete or
high-grade small-bowel obstruction. barium
examinations may be difficult because of the
long time required to complete the examina-
tion. The dilution of barium that occurs proxi-
mal to the site of obstruction makes diagnostic
evaluation suboptimal. M oreover. barium
retained in the small bowel will degrade the
diagnostic quality of subsequent CT examina-
tion. Therefore, in the acute presentation, (“1’
should be the method of examination.
CT in Small-Bowel Obstruction
The recent literature has documented the
growing and important role of CT in the pre-
operative evaluation of patients with sus-
pected intestinal obstruction. Initial reports of
CT in small-bowel obstruction by M egibow et
al. [50J and Fukuya et al. 1511 showed a sensi-
tivity varying from 90% to 96% , a specificity
of 96% , and an accuracy of 95% . These
reports. however, appeared to be mostly on
patients with high-grade obstruction. In a crit-
ical analysis of the reliability of CT by
M aglinte et al. [38], in which an equal number
of patients with high and low grades of small-
bowel obstruction were assessed, less favor-
able results were shown. Overall sensitivity
was 63% ; specificity, 78% ; and accuracy.
66% . However, when small-bowel obstruc-
tion was classified into high and low grades.
CT had a sensitivity of 8 1 % for high-grade
and 48% for low-grade obstruction, thus vali-
dating the accuracy of CT in high-grade
small-bowel obstruction. Further experience
confirms these results [27].
The speed and ability of CT to reveal the
cause ofobstruction makes it particularly valu-
able in the acute setting (Figs. I and 2). CT is
able to correctly reveal the cause of obstruc-
tion in 73-95% of cases [27, 38. 50, 5 1 j and
can show both closed-loop obstruction and
strangulation [52-6 1 1. This concern is most
significant for surgeons who might choose
nonoperative measures to manage a patient
with small-bowel obstruction. Although con-
trast-enhanced CT has a high sensitivity (90% )
in the diagnosis of intestinal ischemia, its spec-
ificity is low (44% ) [61]. The negative predic-
tive value of 89% reported in a prospective
study by Frager et al. [61] is encouraging. A
high negative predictive value in diagnosing
closed-loop obstruction and strangulation
should help resolve the controversy about
whether urgent operation or longer nonsurgi-
cal measures are appropriate in patients with
adhesive small-bowel obstruction 1621. Early
reports on the ability ofCT to differentiate var-
ious causes of bowel distention were promis-
ing [50, 51]. M ore recent reports document the
ability of CT to differentiate small-bowel
obstruction from ileus or other causes of
small-bowel dilatation [63, 64]. The report by
Gazelle et al. [63] on the efficacy ofCT in dis-
tinguishing small-bowel obstruction from
other causes of small-bowel dilatation showed
a retrospective sensitivity of 84% . In high-
grade small-bowel obstruction. Frager et al.
[64] showed the sensitivity of CT to be 100%
compared with 46% for plain film radiogra-
phy. The impact of CT in the management of
small-bowel obstruction in the acute setting
was recently addressed in a clinical study by
Taourel et al. [53]. By differentiating paralytic
ileus from obstruction, radiologists used CT
findings to modify management in 21% of
patients either by changing conservative man-
agement to a surgical one (18% ) or by chang-
ing surgical management to a conservative one
(Fig. 6). Thus, Cl’ can expedite the need for
surgery and also avoid unnecessary operation,
an important goal in the management of adhe-
sive small-bowel obstruction. The importance
of CT in the acute clinical setting has been
recently emphasized by Balthazar [54]. CT is
particularly helpful and should be used as the
primary imaging technique in patients in
whom the obstructive symptoms are associ-
ated with specific medical conditions such as
previous abdominal malignant tumors, known
inflammatory bowel disease, palpable abdomi-
nal mass. or sepsis.
W hether oral contrast material should be
routinely given for CT has not been ade-
quately addressed in the current literature. If
CT is performed when plain film radiography
shows definite or probable small-bowel
obstruction, oral contrast material may not be
necessary. A scrutiny of the illustrations in
reviewed citations that show CT images of
higher grades of small-bowel obstruction mdi-
cate that fluid is already present in large
amounts in the small bowel and acts as an
inherent contrast agent. The presence of
intraluminal fluid and the increased attenua-
tion of the intestinal wall following the
administration of IV contrast agents allows a
more accurate assessment of the thickness of
the intestinal wall [65] (Fig. 1C). The use of
oral contrast material increases the attenuation
of intraluminal fluid and may occasionally
make difficult the determination of wall thick-
ening (Fig. SB). The use of oral contrast mate-
rial can also delay examination in this
emergent situation. In addition, in the subset
of patients with high-grade obstruction, oral
contrast material will not usually reach the
site of obstruction at the time of examination
(Fig. 2C). Furthermore, these patients have
been vomiting and the administration of addi-
tional fluid should be discouraged. However,
when CT is performed on patients with nor-
mal or abnormal but nonspecific plain film
findings. oral contrast material administered
through a decompression tube is recom-
mended. Its use enhances the accuracy of
diagnosing neoplastic or inflammatory intesti-
nal lesions, or intraabdominal abscesses, and
allows better evaluation of the degree of
obstruction in patients with partial small-
bowel obstruction. In the patient with the
probable small-bowel obstruction pattern,
when the clinical background is vague, CT
should be performed before fluoroscopic
studies. In this way, it will not interfere with
subsequent enteroclysis if needed.
Significant advantages of CT over enterocly-
sis are that CT is readily available, rapid, does
not require technical expertise, is noninvasive,
and allows a global evaluation of the entire
abdomen and alimentary tract. The last advan-
tage is of considerable importance, particularly
in the acute setting, because intestinal obstruc-
tion is only one of the more common differential
diagnoses in the patient presenting with acute
abdominal pain. The impact of CT on the diag-
nosis and treatment of the acute abdomen has
been shown by Siewert and Raptopoulos [66].
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Fig. 6-66-year-old woman with abdominal pain and vomiting who had
undergone hysterectomy 10 years earlier and recent mitral valve surgery.
(Reprinted with permission from 1651)
A, Supine abdominal radiograph following 24 hr of nasogastnic suction re-
veals findings unequivocal for small-bowel obstruction. Enteroclysis was
ordered to gauge severity of presumed adhesive obstruction. CT was in-
stead recommended by radiologist following placement of long tube for
further decompression.
B and C, CT sections through upper (B) and lower (C) pelvis show fluid-filled
dilated small bowel and collapsed colon. Small-bowel dilatation terminated
at incarcerated obturator hernia (arrow, C). Demonstration of internal her-
nia changed planned medical regime to urgent surgical intervention. Find-
ings were confirmed at surgery. No strangulation was present
Diagnosis of Small-Bowel Obstruction
AJR:168, May 1997 1177
However, a learning curve is associated with the
interpretation of CT in intestinal obstruction.
The CT examination should be closely moni-
tored, and additional sections should be obtained
at the transition zone (the area of sudden change
of caliber of small-bowel loops from dilated to
collapsed or normal. indicating the site of
obstruction) to elucidate the cause of obstruction
if unclear with the contiguous axial 10-mm sec-
tions. Identifying the transition zone is not diffi-
cult in higher grades of obstruction. In low-grade
partial obstruction. however, identifying the
transition zone can be difficult as a result of con-
fusion in following the bowel loops in and out of
the axial images [67]. Cine paging has been sug-
gested by M emel and Berland [681 as an aid in
diagnosis. W here difficulty exists in identifying
the site and cause of obstruction by CT. entero-
clysis is informative [37].
CT enteroclysis. a method whereby water-
soluble contrast material is infused fluoroscop-
ically and continued during cross-sectional
imaging. has been recently described by
Bender et al. [691. Theoretically. the technique
overcomes the low reliability of CT for the
diagnosis of low-grade small-bowel obstruc-
tion and uses the ability of CT to reveal the
cause of obstruction. which has potential clini-
cal application for small-bowel obstruction.
Additional clinical experience is needed to
define the role of this method.
Although the evidence is preliminary, the
ability of CT to reveal closed-loop obstruction
and to show evidence of infarction is likely to
be the most significant contribution of imaging
in the management of acute small-bowel
obstruction. If CT is used appropriately, its ini-
tially higher cost may result in overall cost
savings within an episode of care by expedit-
ing or avoiding surgery and reducing comor-
bidity and length of stay.
Recommendations
In the workup of small-bowel obstruction,
the radiologist, clinician, and surgeon should
communicate directly with one another. Selec-
tion of imaging techniques is based on full
knowledge of the clinical background. history.
physical examination, and laboratory exami-
natio)n as well as plain film findings.
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Clinical Background
Patient history. physical and laboratory examinations
.1
Suspected Intestinal Obstruction
I
Plain Abdom inal Radiography
Normal or Abnormal but
and “Probable” SBO 1
a
+
CT
‘-En iocIsis s “-:: tiif
- if i t L enteroclysis not
infbnnatiye infbnnative
1178 AJR:168, May 1997
Fig. 7.-Diagram shows algorithm for diagnostic triage of patients with suspected intestinal obstruction. SBO = small-bowel obstruction.
The acknowledged limitations of the plain
film examination. the advantages and limita-
tions of bariuni examinations and CT. and
the lack (if specificity and reliability of clini-
cal and laboratory findings form the basis of
the algorithni we propose for the evaluation
of patients with suspected intestinal obstruc-
tion (Fig. 7). Barium small-bowel and abdomi-
nal CT examinations are not competitive but
complementary studies. The dilemma that
faces radiologists is not to select one tech-
nique and eliminate the other but to decide
which to use first in the context of the clini-
cal presentation and abdominal plain film
findings 154. 65).
An interpretation of definite small-bowel
obstruction on plain film radiography con-
firms the clinical diagnosis and helps in the
decision on whether to perform surgery or use
a trial of conservative therapy. This decision
is largely based on the clinical evaluation (his-
tory. physical examination, and laboratory
examination), and many of these patients have
laparotomy without an additional imaging
study. Factors that may lead to eai’ly sui’gical
exploration include an incarcerated hernia,
absence of previous abdominal surgery. coin-
plete small-bowel obstruction, and clinical
signs suspicious for strangulation such as con-
stant abdominal pain. fever. elevated W BC.
increased serum amylase. and metabolic aci-
dosis. Factors that tend to delay or obviate
surgical intervention are partial small-bowel
obstruction, previous small-bowel obstruction
with adhesions. a history of resected abdoini-
nal tumor. and a history of’ inflamiiiatory
bowel disease. W hen initial conservative
management is entertained. CT examination
is helpful in evaluating the presence and
extent of neoplastic or inflammatory disease
and in excluding strangulating obstruction
(Fig. 6). Postsurgical patients presenting with
abdominal distention are treated conser a-
tively for a few days. and CT examination is
advised only if the clinical and plain film find-
ings do not improve or signs of sepsis or pan-
creatitis develop. Barium examination should
be used after the CT study only if additional
iimnagement questions are left unanswered
[27. 47] (Fig. 5).
If the plain film shows colonic distention in
addition to small-bowel dilatation, we still
advise the use of contrast enema as the next
imaging technique (Fig. 8). In this group of
patients. CT is used as a complementary tech-
nique. particularly in elderly infirm patients. in
individuals with sepsis. and in patients with a
history of previously resected colon carci-
noma. CT is also useful in the acute setting in
patients with poor anal sphincter tone 134 I-
W hen the disparity between the clinical
presentation and the plain film fiuidiiigs is
striking, an additional imaging study is indi-
cated to elucidate the diagnosis amid plan for
surgical or medical therapy. In patients with
normal o r with abnoriiial but nonspecific
(sniall-bowel stasis) plain film findings who
present with acute abdominal symptoms
(emergency patients). we advise the use of
CT. CT has been reliable in showing acute
abdominal conditions that can mimic small-
bowel obstruction. has a high sensitivity for
high-grade or complete obstruction. and can
reveal closed-loop and strangulating obstruc-
tioil (Figs. I and 2). W hen the CT examina-
tiOfi is not diagnostic. enteroclysis or a
fluoroscopy-based barium small-bowel study
can be performed as a complementary exami-
nation (Fig. 5). On the other hand, patients
complaining of niild. intermittent abdominal
pain. often labeled as irritable bowel syn-
drome (outpatient. clinic environment), with-
out a pertinent history except for previous
laparotomy. should have enteroclysis or a flu-
oroscopy-based small-bowel follow-through
examination as the next imaging technique.
Low-grade obstructions. intraluminal tumors,
small ulcerations, and mucosal inflammatory
changes can often be detected and better eval-
uated with this technique (Figs. 3 and 4). In
these individuals, CT can be performed later
if the barium small-bowel examination is not
informative or is uncertain.
The indications for ordering diagnostic pro-
cedures are undergoing intense scrutiny
because of the need to control health care costs
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Diagnosis of Small-Bowel Obstruction
AJR:168, May 1997 1179
Fig. 8.-Use of contrast enema for intestinal obstruction in 65-year-old man with abdominal distention, pain, and constipation and prior sigmoid resection for diverticulitis. (Reprinted
with permission from [651)
A, Supine abdominal radiograph shows gas-distended cecum (arrow) in addition to small-bowel distention.
B, Single-contrast barium enema shows obstructing carcinoma (arrow).
without comproniising a high standard of
patient care. Radiologic services are now eval-
uated by criteria that assess whether the use of
a particular diagnostic method influences din-
ical nianagement. improves patient outcome.
and lowers niedical costs )70. 7 1 1. Erroneous
application of imaging studies is frequent in
clinical practice.
The recent development and improvements
in technique and interpretation of CT and
enteroclysis have changed the approach to the
evaluation (if patients suspected of having
small-bowel obstruction. In addition to) plain
film radiography. CT and enteroclysis play a
complementary but essential role in the initial
diagnosis and guidance for therapy. The
strength and limitations o)f alternative imaging
approaches must be well understood by both
radiologists and clinicians to achieve the goal
of providing the best clinical management at
minimal cost. At this time we advise the initial
use of abdominal CT in the context of the acute
abdomen (emergency patient) and the initial
use of enteroclysis or a fluoroscopy-hased
small-bowel follow-through study in mildly
symptomatic patients with chroinic complaints.
Our recommendations are based on continuing
radiologic observations and clinical and radio-
logic data reported in the literature over the last
one and a half decades. As additional experi-
ence with new iniaging techniques is gained.
this experience should be incorporated into the
recommendatio)ns. W e hope that our proposed
algorithiii will expedite diagnosis. decrease
morbidity and niortality rates. and decrease the
cost of workups for patients with suspected
small-bciwel obstruction.
Acknowledgment
W e thank Fran Shaul for secretarial
assi stance.
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