You are on page 1of 11

Nicolaou et G a s t ro i n t e s t i n a l I m ag i n g • P i c t o r i a l E s s ay

al.
Imaging of
Acute Small-
Bowel
Obstruction

Imaging of Acute
Small-Bowel Obstruction
Savvas Nicolaou1 OBJECTIVE. The objective of this pictorial essay is to review the different imaging tech-
Brian Kai2 niques used for diagnosing small-bowel obstruction.
Stephen Ho3 CONCLUSION. Small-bowel obstruction is a common presentation, for which safe and
Jenny Su4 effective management depends on a rapid and accurate diagnosis. Conventional radiographs re-
Karim Ahamed5 main the first line of imaging. CT is used increasingly more because it provides essential
diagnostic information not apparent from radiographs. MRI may play a role in the future as
Nicolaou S, Kai B, Ho S, Su J, Ahamed K technology improves and it becomes more readily available.
American Journal of Roentgenology 2005.185:1036-1044.

he morbidity and mortality associ- caused by slow resorption of intraluminal air

T ated with acute small-bowel ob-


struction continue to be signifi-
cant. It accounts for 12–16% of all
leaving small bubbles trapped between the
folds of the valvulae conniventes. Except for
inguinal hernias [3] and gallstone ileus
surgical admissions in patients with acute ab- (Fig. 2), the cause of obstruction is often indis-
dominal conditions [1]. Small-bowel obstruc- cernible on radiographs. Strangulation may be
tion is caused by postoperative adhesions in indicated by edematous folds, pneumatosis in-
70% of all cases [2]. Other common causes in- testinalis (Fig. 3A), and gas in the portal vein
clude hernias, neoplasms, and Crohn’s disease (Fig. 3B), but these features are rarely seen. If
[1, 2]. The important question in small-bowel a high clinical suspicion of obstruction exists,
obstruction management lies in determining additional imaging is required even if radio-
whether early laparotomy is required or graphs are reported to show normal findings.
whether a trial of nonoperative management Despite its limitations, conventional radiogra-
should be instituted [1]. Clinical examination phy continues to be the initial imaging exami-
DOI:10.2214/AJR.04.0815 findings and laboratory values are often non- nation for patients with suspected small-bowel
specific and unreliable at differentiating sim- obstruction because of its sensitivity in reveal-
Received May 24, 2004; accepted after revision ple mechanical obstruction from strangulated ing high-grade obstruction [1], wide availabil-
November 19, 2004.
bowel. Imaging in the acute setting plays a key ity, and relatively low cost.
1Department
role. It can indicate the location, degree, and
of Radiology, Vancouver General Hospital,
899 W 12th Ave., Vancouver, BC, V5Z 1M9, Canada.
cause of an obstruction and assess for the pres- Contrast Studies
Address correspondence to S. Nicolaou ence of ischemia [3]. This pictorial essay aims Oral contrast studies such as a small-bowel
(snicolao@vanhosp.bc.ca). to review the various imaging techniques used follow-through can offer additional informa-
in establishing the diagnosis of acute small- tion regarding the degree of obstruction. Find-
2University of British Columbia, Vancouver, BC, Canada.
bowel obstruction. ings suggestive of obstruction include dilated
3Department of Radiology, Gastrointestinal Radiology, loops of small bowel and a delayed transit time
Vancouver Hospital & Health Sciences Centre, Conventional Radiography of barium through a transition point [3]. Limi-
Vancouver, BC, Canada. Abdominal radiography in conjunction with tations of small-bowel follow-through include
4Department
the clinical examination is diagnostic in only the length of time required to perform the study,
of Internal Medicine, University of British
Columbia, Vancouver, BC, Canada.
50–60% of cases [1]. Radiographs have been dilution of barium because of excess residual
shown to be sensitive for high-grade but not intraluminal fluid, and the inability of patients
5Department of Diagnostic Radiology, University of Alberta, low-grade obstructions [1]. Signs of small- to drink the barium in an acute setting [3].
Edmonton, AB, Canada. bowel obstruction on radiographs include dis- Enteroclysis allows areas that are nondis-
AJR 2005;185:1036–1044
tended loops of bowel greater than 3 cm, col- tensible or fixed to be more easily identified
lapsed colon, differential air–fluid levels, and [4]. Enteroclysis is performed by intubating
0361–803X/05/1854–1036
thickened bowel wall (Fig. 1). The string-of- the small bowel and infusing contrast mate-
© American Roentgen Ray Society pearls sign may also be identified (Fig. 1). It is rial, essentially bypassing the stomach. In the

1036 AJR:185, October 2005


Imaging of Acute Small-Bowel Obstruction

Fig. 1—Small-bowel obstruction on radiography.


A, Supine abdominal radiograph in 45-year-old woman
with adhesional small-bowel obstruction shows
multiple dilated loops of small bowel. Valvulae
conniventes appear prominent. In appropriate clinical
context, this would be diagnostic of small-bowel
obstruction.
B, Upright abdominal radiograph in 56-year-old woman
with adhesional small-bowel obstruction shows
multiple air–fluid levels (arrows) and string-of-pearls
sign (arrowhead).

A B
American Journal of Roentgenology 2005.185:1036-1044.

Fig. 2—48-year-old woman presenting with gallstone ileus.


A, Upright abdominal radiograph shows multiple air–fluid levels. Pneumobilia (arrow) is present, as is string-of-
pearls sign (arrowheads).
B, CT scan through upper abdomen shows air in gallbladder (arrow) and proximal cystic duct.
C, CT scan obtained inferior to B shows calcified impacted gallstone (arrow) in distal jejunum with proximal dilated
loops of bowel.
A

B C

AJR:185, October 2005 1037


Nicolaou et al.

Fig. 3—Strangulation.
A, Supine abdominal radiograph in 46-year-old woman
with ischemic colitis shows linear radiolucency
(arrows) along wall of bowel, which is consistent with
pneumatosis intestinalis. Dilated loops of small bowel
are also present.
B, Right-side-up decubitus abdominal radiograph in 69-
year-old woman shows multiple branching
radiolucencies (arrows) in periphery of liver shadow,
which is indicative of portal venous gas. Dilated loops
of small bowel are also present, which is consistent
with small-bowel obstruction.

A B
American Journal of Roentgenology 2005.185:1036-1044.

Fig. 4—Enteroclysis. 54-year-old woman with adhesional small-bowel obstruction.


Spot film from enteroclysis shows small-bowel loop narrowing (arrow) due to
postoperative adhesion.

subacute setting, enteroclysis is very accurate ening supports infarction in the appropriate CT
in diagnosing low-grade and intermittent ob- clinical context [5]. Bowel wall perfusion can If an acute obstruction is suspected, CT is
structions [4] and can serve as an adjunct to also be assessed by Doppler sonography. the technique of choice for several reasons.
CT if more information, such as how much Sonography has been reported to have a First, it does not require oral contrast mate-
contrast material is making its way through sensitivity of 89% compared with 71% for rial because the retained intraluminal fluid
the obstruction, is required [4] (Fig. 4). conventional abdominal radiography in diag- serves as a natural negative contrast agent.
nosing small-bowel obstruction and is supe- Second, when compared with enteroclysis,
Sonography rior in its ability to identify features of stran- CT is rapid, noninvasive, and readily avail-
On sonography, small-bowel obstruction is gulation and to predict the location and cause able [3]. Finally, it also allows extramural ar-
suspected if multiple dilated (> 3 cm), fluid- of obstruction [5]. Although not routinely eas that would not be visible on contrast stud-
filled loops are seen (Fig. 5). The obstructing used, sonography may be indicated in criti- ies to be assessed.
cause can occasionally be visualized if it is a cally ill patients because transfer of the pa- The diagnosis of small-bowel obstruction
tumor or hernia. The presence of aperistalsis, tient to the examination table may be time- on CT involves identifying dilated loops of
fluid-filled bowel distention, and wall thick- consuming and difficult [5]. bowel proximally with normal-caliber or

1038 AJR:185, October 2005


Imaging of Acute Small-Bowel Obstruction

A B
Fig. 5—Sonography features of small-bowel obstruction. Both cases are due to postoperative adhesions.
A, Abdominal sonogram in 40-year-old woman shows dilated, fluid-filled loop of small bowel with prominent valvulae conniventes (arrows).
B, Abdominal sonogram in 62-year-old man shows thickened small-bowel wall (arrows). Real-time scanning showed small bowel to be hyperperistaltic.
American Journal of Roentgenology 2005.185:1036-1044.

A B

Fig. 6—Small-bowel obstruction secondary to adhesions.


A, Axial CT scan through lower abdomen in 54-year-old woman with small-bowel
obstruction secondary to adhesions shows multiple fluid-filled loops of small bowel
(arrows).
B, CT scan obtained inferior to A shows transition point (arrows) with dilated bowel
proximally and collapsed bowel distally. No pathologic process is visualized at
transition point, and transition is smooth. This obstruction was found to be
adhesional in nature.
C, Axial contrast-enhanced CT scan through mid abdomen of 55-year-old man with
small-bowel obstruction secondary to adhesions shows multiple fluid-filled loops
with tapering transition point (arrows), otherwise known as beak sign.
C

AJR:185, October 2005 1039


Nicolaou et al.

A B
Fig. 7—Small-bowel obstruction secondary to Crohn’s disease.
A, Axial CT scan through lower abdomen of 44-year-old woman with small-bowel obstruction secondary to Crohn’s disease shows multiple fluid-filled loops of small bowel
(arrows) and CT equivalent of string-of-pearls sign on radiography.
B, Axial CT scan through lower abdomen in 28-year-old woman with Crohn’s disease shows partially solid material intermixed with air within distal small bowel (arrows),
similar in appearance to feces in colon; this finding is called the “small-bowel feces” sign.
American Journal of Roentgenology 2005.185:1036-1044.

A B
Fig. 8—58-year-old woman with small-bowel obstruction secondary to adhesions.
A, Axial CT scan through lower abdomen shows dilated proximal loop (arrow) and collapsed distal loop (arrowhead).
B, CT scan obtained inferior to A shows narrowing of involved loop of bowel (arrows). Adhesion is inferred to be causing narrowing given history of previous abdominal
surgery and given neither masses nor extrinsic processes are seen to result in narrowing. Multiple dilated loops of small bowel are also seen.

Fig. 9—26-year-old woman with vasculitis and small-bowel obstruction. Axial


contrast-enhanced CT scan through mid abdomen shows thickened loops of small
bowel and target sign (arrows). Free fluid (arrowhead) is also seen.

1040 AJR:185, October 2005


Imaging of Acute Small-Bowel Obstruction

A B
Fig. 10—66-year-old woman with diagnosis of ischemic bowel.
A, Axial contrast-enhanced CT scan through mid abdomen shows multiple dilated
air- and fluid-filled loops of small bowel. There is evidence of pneumatosis
American Journal of Roentgenology 2005.185:1036-1044.

intestinalis and lack of bowel wall enhancement (thin arrow) as compared with
normally enhancing loop (thick arrow). Also seen is intraperitoneal free fluid
(arrowhead). Round radiodensity seen in one loop of small bowel is surgical drain.
B, CT scan obtained inferior to A shows air in mesentery (arrowhead), and lack of
bowel wall enhancement (arrows) is again seen.
C, CT scan obtained superior to A shows air in intrahepatic portal venous vasculature
(arrow).

Fig. 11—57-year-old woman with small-bowel volvulus. Axial CT scan through upper
pelvis shows whirl sign (arrow) signifying volvulus. Volvulus can result if loop of
bowel is able to rotate around its mesentery. If loop sits in axial plane, it will appear
as ⊂ or ∪ shape. If orientation of loop is at right angle to axial plane, appearance will
vary depending on slice.

collapsed loops distally. A small-bowel cali- diagnosis is more certain [6]. The transition been shown to be present in 60% of simple
ber of greater than 2.5 cm is considered di- point often resembles a beak and is described small-bowel obstruction cases [7]. Other reli-
lated [6]. If a transition point is detected, the as the beak sign (Fig. 6). This finding has able features include the string-of-pearls sign

AJR:185, October 2005 1041


Nicolaou et al.

A B
Fig. 12—64-year-old man with small-bowel obstruction secondary to incarcerated right inguinal hernia.
A, CT scan shows incarcerated right inguinal hernia resulting in small-bowel obstruction. Left and right arrows point to dilated loop of small bowel with engorged mesentery
(middle arrow).
B, Inferior transverse CT image obtained at level of symphysis pubis reveals incarcerated thick wall loop of small bowel within right inguinal canal (arrow).
American Journal of Roentgenology 2005.185:1036-1044.

structions [2]. However, when all grades of struction from ileus and determining the
small-bowel obstructions are taken into ac- cause of obstruction (Figs. 11 and 12).
count, the reliability of CT decreases dramat- Multiplanar reformations are now being
ically (sensitivity of 64% and specificity of used in difficult cases. Multiplanar views may
79%) [2]. Therefore, CT is not the ideal tech- help identify the site, level, and cause of ob-
nique for diagnosis of low-grade or subacute struction when axial findings are indetermi-
obstructions and should be complemented by nate [7] (Figs. 13 and 14). CT enteroclysis, a
a contrast study, ideally enteroclysis [6]. relatively new investigational tool for diag-
The most important information that CT nosing small-bowel obstruction, can also be
can provide the surgeon is whether there is an used with multiplanar reconstructions to
associated strangulation. The sensitivity of overcome the unreliability of CT for diagnos-
contrast-enhanced CT for intestinal ischemia ing low-grade obstructions. CT enteroclysis
has been reported to be as high as 90% [1]. has a greater sensitivity and specificity (89%
There are various signs that have been associ- and 100%, respectively) than CT alone (50%
ated with ischemia [3, 7], although their use- and 94%, respectively) [1]. At the same time,
fulness is debatable. These include, first, the 3D imaging provides precise localization
thickened bowel wall (Fig. 9); second, ascites of the pathology [1].
(Fig. 9); third, the target sign, a trilaminar ap-
Fig. 13—80-year-old man with small-bowel obstruction pearance of the bowel wall resulting from IV MRI
secondary to adenocarcinoma of large bowel. Coronal
reformatted 2-mm-thick CT view of abdomen reveals contrast enhancement of the mucosal and MRI provides rapid, accurate identification
small-bowel obstruction is caused by thick annular muscularis layers, plus submucosal edema of small-bowel obstruction [8] and assists in
constricting mass lesion involving hepatic flexure of (Fig. 9); fourth, poor or absent enhancement the determination of cause without exposing
large colon (thin arrows) resulting in proximal dilata-
tion of cecum (thick arrow) and small bowel (arrow- of bowel wall on IV contrast-enhanced scans the patient to radiation. MRI also utilizes in-
heads). Pathology revealed colonic adenocarcinoma. (Figs. 10A and 10B); fifth, pneumatosis in- traluminal air as a natural contrast agent and is
testinalis and gas in mesenteric or portal veins not limited by previous administration of bar-
(Fig. 10C); sixth, the whirl sign, a twisting of ium. The diagnosis of small-bowel obstruction
(Fig. 7A) and the “small-bowel feces” sign the mesenteric vasculature signifying a vol- on MRI is similar to CT and involves identify-
(Fig. 7B). The small-bowel feces sign is a re- vulus (Fig. 11); seventh, tortuous engorged ing dilated loops of bowel proximal to the ob-
sult of stasis and mixing of small-bowel con- mesenteric vessels (Fig. 12A); eighth, mesen- struction, a distinct transition point, and nor-
tents and is present in 82% of cases of small- teric hemorrhage; and, finally, increased at- mal-caliber or collapsed bowel distally.
bowel obstruction [2, 3]. Occasionally, visu- tenuation of bowel wall on noncontrast scans. Multiplanar capabilities of MRI allow visual-
alization of an adhesional band is possible, al- Although these signs are individually in- ization of the cause of small-bowel obstruction
though it is rare to be able to do so (Fig. 8). sufficiently sensitive, they are quite sugges- (Fig. 15). Rapid scanning with MRI using the
CT has a sensitivity of 81–94% and a spec- tive of ischemia when used together [7]. CT is HASTE sequence can, within seconds, evalu-
ificity of 96% for diagnosing high-grade ob- also useful in differentiating small-bowel ob- ate small-bowel obstruction with a high degree

1042 AJR:185, October 2005


Imaging of Acute Small-Bowel Obstruction

Fig. 14—49-year-old man


with incarcerated
abdominal hernia.
A, Axial CT scan shows
defect in lower
abdominal wall (arrow)
that has incarcerated
lower abdominal hernia
within it (arrowhead).
B, Sagittal reformatted
MDCT view depicts
defect in lower abdomi-
nal wall (long thick
arrow) and incarcerated
lower abdominal hernia.
Within hernia sac, thick
wall loop of small bowel
and free fluid (arrow-
head) are noted with
dilated loops of small
bowel proximal (short
thick arrow) to incarcer-
ated small-bowel loop.
Free fluid (star and thin
arrow) is also present in
abdomen, which is an
associated finding in
American Journal of Roentgenology 2005.185:1036-1044.

small-bowel obstruction.
A B

Fig. 15—80-year-old man


with small-bowel
obstruction secondary to
adenocarcinoma of large
bowel.
A, Transverse
gadolinium-enhanced
T1-weighted image
(TR/TE, 400/10) obtained
with fat saturation shows
narrowing of large bowel
(arrow) caused by mass
(small arrowhead) with
B resultant proximal small-
bowel obstruction (large
arrowhead).
A B, Coronal single-shot
fast spin-echo T2-
weighted image
(1,800/103) reveals same
constricting mass seen
in A but with intermediate
signal (thin arrows).
Resultant proximal
dilatation of large (thick
arrow) and small
(arrowheads) bowel is
visualized.
C, Subsequent coronal
image reveals numerous
proximal dilated loops of
small bowel (arrows),
which is consistent with
diagnosis of small-bowel
obstruction.
C

AJR:185, October 2005 1043


Nicolaou et al.

of accuracy [8]. Furthermore, it avoids artifacts cause it is readily available, is cheap, and can small bowel obstruction. Semin Roentgenol 2001;
related to peristalsis and breathing that have be done serially to follow clinical progression. 36:108–117
limited the diagnostic yield of MRI in small- CT can provide additional information such as 4. Maglinte DDT, Balthazar EJ, Kelvin FM, Megibow
bowel obstruction in the past [8]. MRI is un- confirmation of an obstruction, degree and site AJ. The role of radiology in the diagnosis of small-
likely to replace CT for evaluating small- of an obstruction, presence of ischemia, and bowel obstruction. AJR 1997; 168:1171–1180
bowel obstruction because of longer scanning the cause of the obstruction. MRI may have a 5. Schmutz GR, Benko A, Fournier L, et al. Small
time and inferior resolution [8]; however, as role in the future evaluation of small-bowel ob- bowel obstruction: role and contribution of sonog-
availability and technology in MRI continues struction as the technology improves and it in- raphy. Eur Radiol 1997; 7:1054–1058
to improve, it has the potential to be an excel- creases in availability. 6. Furukawa A, Yamasaki M, Furuichi K, et al. Helical
lent diagnostic method for evaluating small- CT in the diagnosis of small bowel obstruction. Ra-
bowel obstruction. dioGraphics 2001; 21:341–355
References 7. Ha HH, Kim JS, Lee MS, et al. Differentiation of
Conclusion 1. Maglinte DDT, Heitkamp DE, Howard TJ, et al. simple and strangulated small bowel obstructions:
Small-bowel obstruction is a common pre- Current concepts in imaging of small bowel ob- usefulness of known CT criteria. Radiology 1997;
sentation, for which safe and effective man- struction. Radiol Clin North Am 2003; 41:263–283 204:507–512
agement depends on rapid and accurate diag- 2. Burkill GJC, Bell JRG, Healy JC. The utility of 8. Regan F, Beall DP, Bohlman ME, Khazan R,
nosis. Imaging can be diagnostic and helpful in computed tomography in acute small bowel ob- Sufi A, Schaefer DC. Fast MR imaging and the
guiding management. Abdominal radiography struction. Clin Radiol 2001; 56:350–359 detection of small-bowel obstruction. AJR 1998;
remains the first-line imaging examination be- 3. Macari M, Megibow A. Imaging of suspected acute 170:1465–1469
American Journal of Roentgenology 2005.185:1036-1044.

1044 AJR:185, October 2005


This article has been cited by:

1. Abdulmalik Dredar, Prem Thanaratnam, Kaiser Hussain, Seth Andrews, Edward Mtui, Tara Catanzano. 2017. Acute Bowel
Computed Tomography. Seminars in Ultrasound, CT and MRI 38:4, 399-413. [Crossref]
2. Daniel J. Ohngemach, Yonah B. Esterson, Naeem Rahman, Ali Noor, John S. Pellerito. 2016. Unexpected Findings During
Evaluation of Acute Pelvic Pain With Transvaginal Sonography. Journal of Ultrasound in Medicine 35:12, 2687-2696. [Crossref]
3. Ryan A. Makar, Mustafa R. Bashir, Clare M. Haystead, Christine Iseman, Nicholas Mayes, Stuart Hebert, Brian C. Allen, Syamal
D. Bhattacharya, Kingshuk R. Choudhury, Tracy A. Jaffe. 2016. Diagnostic performance of MDCT in identifying closed loop
small bowel obstruction. Abdominal Radiology 41:7, 1253-1260. [Crossref]
4. Nazanin Ahmadi, Johan G. Blickman. The Small Bowel 209-236. [Crossref]
5. Claudia Rossi, Mariateresa Martino, Roberto Ronza, Roberto Rizzati, Mariano Scaglione. Imaging in Emergency Surgery 203-230.
[Crossref]
6. Richard M. Gore, Robert I. Silvers, Kiran H. Thakrar, Daniel R. Wenzke, Uday K. Mehta, Geraldine M. Newmark, Jonathan
W. Berlin. 2015. Bowel Obstruction. Radiologic Clinics of North America 53:6, 1225-1240. [Crossref]
7. Kevin P. Murphy, Maria Twomey, Patrick D. McLaughlin, Owen J. O’Connor, Michael M. Maher. 2015. Imaging of Ischemia,
Obstruction and Infection in the Abdomen. Radiologic Clinics of North America 53:4, 847-869. [Crossref]
8. Narisha Maharaj, Bhugwan Singh. 2015. A review of the radiological imaging modalities of non-traumatic small bowel obstruction.
South African Family Practice 57:3, 146-159. [Crossref]
9. Erik K. Paulson, William M. Thompson. 2015. Review of Small-Bowel Obstruction: The Diagnosis and When to Worry.
American Journal of Roentgenology 2005.185:1036-1044.

Radiology 275:2, 332-342. [Crossref]


10. Tunc Eren, Salih Boluk, Baris Bayraktar, Ibrahim Ali Ozemir, Sumeyra Yildirim Boluk, Ercument Tombalak, Orhan Alimoglu.
2015. Surgical indicators for the operative treatment of acute mechanical intestinal obstruction due to adhesions. Annals of Surgical
Treatment and Research 88:6, 325. [Crossref]
11. Kazuaki Nakashima, Hideki Ishimaru, Toshifumi Fujimoto, Takashi Mizowaki, Kazunori Mitarai, Kei Nakashima, Yohjiro
Matsuoka, Masataka Uetani. 2014. Diagnostic performance of CT findings for bowel ischemia and necrosis in closed-loop small-
bowel obstruction. Abdominal Imaging . [Crossref]
12. Arvind Srinath, Erin Young, Eva Szigethy. 2014. Pain Management in Patients with Inflammatory Bowel Disease. Inflammatory
Bowel Diseases 20:12, 2433-2449. [Crossref]
13. Francesca Iacobellis, Daniela Berritto, Maria Paola Belfiore, Imma Di Lanno, Manuela Maiorino, Luca Saba, Roberto Grassi. 2014.
Meaning of Free Intraperitoneal Fluid in Small-Bowel Obstruction. Journal of Ultrasound in Medicine 33:5, 887-893. [Crossref]
14. Lorene E. Romine, Randy Fanous, Michael J. Gabe, Richard C. Semelka, Michele A. Brown. Imaging Maternal Conditions in
Pregnancy 131-179. [Crossref]
15. Katsumi Hayakawa, Masato Tanikake, Shoko Yoshida, Akira Yamamoto, Eiji Yamamoto, Taisuke Morimoto. 2013. CT findings
of small bowel strangulation: the importance of contrast enhancement. Emergency Radiology 20:1, 3-9. [Crossref]
16. Muhammad Idris, Nazia Kashif, Sidra Idris, Wasim Ahmad Memon, Ul-Haq Tanveer, Zishan Haider. 2012. Accuracy of 64-slice
multidetector computed tomography scan in detection of the point of transition of small bowel obstruction. Japanese Journal of
Radiology 30:3, 235-241. [Crossref]
17. Taro Takahara, Thomas C. Kwee, Sotaro Sadahiro, Tomohiro Yamashita, Yuki Toyoguchi, Takeshi Yoshizako, Tomohiro Horie,
Peter R. Luijten, Yutaka Imai. 2011. Low b-value diffusion-weighted imaging for diagnosing strangulated small bowel obstruction:
A feasibility study. Journal of Magnetic Resonance Imaging 34:5, 1117-1124. [Crossref]
18. AJAY SHARMA, MARGRET S. THOMPSON, PETER V. SCRIVANI, NATHAN L. DYKES, AMY E. YEAGER, SEAN R.
FREER, HOLLIS N. ERB. 2011. COMPARISON OF RADIOGRAPHY AND ULTRASONOGRAPHY FOR DIAGNOSING
SMALL-INTESTINAL MECHANICAL OBSTRUCTION IN VOMITING DOGS. Veterinary Radiology & Ultrasound 52:3,
248-255. [Crossref]
19. Geoffrey E. Hayden, Kevin L. Sprouse. 2011. Bowel Obstruction and Hernia. Emergency Medicine Clinics of North America 29:2,
319-345. [Crossref]
20. Benjamin T. Jarman. 2011. Small Bowel Imaging. Surgical Clinics of North America 91:1, 109-125. [Crossref]
21. Maryam Rezvani, Vahid Yaghmai. CT of the Small Bowel 290-295. [Crossref]
22. Taro Takahara, Thomas C. Kwee, Hiroki Haradome, Kei Aoki, Hiroyoshi Matsuoka, Akihisa Nakamura, Keita Honya, Mitsuyuki
Takahashi, Tomohiro Yamashita, Peter R. Luijten, Yutaka Imai. 2011. Peristalsis gap sign at cine magnetic resonance imaging
for diagnosing strangulated small bowel obstruction: feasibility study. Japanese Journal of Radiology 29:1, 11-18. [Crossref]
23. Joshua Broder. Imaging of Nontraumatic Abdominal Conditions 445-577. [Crossref]
24. Kyung Mi Jang, Kwangseon Min, Min Jeong Kim, Sung Hye Koh, Eui Yong Jeon, In-Gyu Kim, Dongil Choi. 2010. Diagnostic
Performance of CT in the Detection of Intestinal Ischemia Associated With Small-Bowel Obstruction Using Maximal Attenuation
of Region of Interest. American Journal of Roentgenology 194:4, 957-963. [Abstract] [Full Text] [PDF] [PDF Plus]
25. Colleen Trevino. 2010. Small Bowel Obstruction. AACN Advanced Critical Care 21:2, 187-194. [Crossref]
26. . Bowel Obstruction 956-958. [Crossref]
27. Susan P. Torrey, Philip L. Henneman. Disorders of the Small Intestine 1184-1192. [Crossref]
28. Karis Tekwani, Rishi Sikka. 2009. High-Risk Chief Complaints III: Abdomen and Extremities. Emergency Medicine Clinics of
North America 27:4, 747-765. [Crossref]
29. Gopal Vijayaraghavan, Divya Kurup, Ajay Singh. 2009. Imaging of Acute Abdomen and Pelvis: Common Acute Pathologies.
Seminars in Roentgenology 44:4, 221-227. [Crossref]
30. Ana Catarina Silva, Madalena Pimenta, Luis S Guimaraes. 2009. Small Bowel Obstruction: What to Look For. RadioGraphics
29:2, 423-439. [Crossref]
31. OG Gümüştaş, A Gümüştaş, R Yalçın, G Savcı, RA Soylu. 2008. Unusual causes of small bowel obstruction and contemporary
diagnostic algorithm. Journal of Medical Imaging and Radiation Oncology 52:3, 208-215. [Crossref]
32. Cheng-Jui Lin, Chyou-Shen Lee, Hsiang-Kuang Tseng, Yuan-ching Chang. 2008. Mechanical Bowel Strangulation Mimicking
Mesenteric Vasculitis in a Systemic Lupus Erythematosus Patient. Southern Medical Journal 101:4, 436-438. [Crossref]
33. Nancy A. Hammond, Frank H. Miller, Vahid Yaghmai, Dava Grundhoefer, Paul Nikolaidis. 2008. MR imaging of acute bowel
pathology: a pictorial review. Emergency Radiology 15:2, 99-104. [Crossref]
American Journal of Roentgenology 2005.185:1036-1044.

34. R. Hyland, A. Chalmers. 2007. CT features of jejunal pathology. Clinical Radiology 62:12, 1154-1162. [Crossref]
35. A J Crowther, J M McMaster, J Abercrombie, D M Hahn. 2006. Sacral Fracture Associated with Small Bowel Entrapment: A
Case Report. Journal of Orthopaedic Trauma 20:8, 580-583. [Crossref]