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Original Article

Role of computed tomography scoring system in

management of small‑bowel obstruction
Atul Jain, Tanweer Karim, Subhajeet Dey, Meenu Garg1, Shashank Mishra2, Prakash Chand Attri2
Departments of Surgery and 1Microbiology, ESI PGIMSR, New Delhi, 2Department of Surgery, Subharti Medical College,
Meerut, Uttar Pradesh, India

Abstract Context: Patients with a bowel obstruction still represent some of the most difficult and vexing problems that
surgeons face with regard to the correct diagnosis, optimal timing of therapy, and appropriate treatment.
Aims: The aim of this study was to study the role of computed tomography (CT) in determining the etiology
and intervention in intestinal obstruction with specific role of CT scoring system in decision‑making.
Settings and Design: This prospective study was conducted in the Department of General Surgery of a
medical college of North India, for 2 years.
Materials and Methods: In this study, we have selected patients with all age group who attended to
outpatient department and emergency department at CSSH hospital with history and clinical picture
suggestive of intestinal obstruction.
Statistical Analysis Used: Positive predictive value, negative predictive value, and accuracy.
Results: In our study, CT scoring system helped 81% of time in predicting the requirement of surgery. CT
scoring has less sensitivity toward the cases with congenital malformation and those cases should be
managed on basis of clinical and other parameters as conservative management in such cases have high
rate of recurrence of obstruction and other complications.
Conclusions: Clinical sense remains the mainstay of deciding the line of management in cases of intestinal
obstruction. CT in these patients can help surgeon to go for surgery early and prevent complications. It
also helps in preventing unnecessary surgeries in patient who can be managed conservatively. CT scoring
system is less sensitive for congenital malformations and other CT features along with clinical features are
mainstay for decision‑making in these patients.

Keywords: Computed tomography scoring system, intestinal obstruction, small bowel obstruction

Address for correspondence: Dr. Atul Jain, Department of Surgery, ESI PGIMSR, Basaidarapur, New Delhi, India.
E‑mail: docatuljain@gmail.com

INTRODUCTION pathophysiology of bowel obstruction and the use of

isotonic fluid resuscitation, intestinal tube decompression,
The description of patients presenting with small‑bowel and antibiotics have greatly reduced the mortality rate for
obstruction (SBO) dates to the 3rd or 4th century, when patients with mechanical bowel obstruction.[1] However,
praxagoras created an enterocutaneous fistula to relieve patients with a bowel obstruction still represent some of
a bowel obstruction. A better understanding of the the most difficult and vexing problems that surgeons face
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DOI: How to cite this article: Jain A, Karim T, Dey S, Garg M, Mishra S, Attri PC.
10.4103/ssj.ssj_6_17 Role of computed tomography scoring system in management of small-bowel
obstruction. Saudi Surg J 2017;5:65-70.

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Jain, et al.: CT scoring for small bowel obstruction

about the correct diagnosis, optimal timing of therapy, Inclusion criteria

and appropriate treatment. Ultimate clinical decisions a. Patient attending general surger y outpatient
regarding the management of these patients dictate a department/emergency or already admitted patients
thorough history and workup and a heightened awareness b. Patient with diagnosis of subacute SBO referred from
of potential complications. other departments of CSS hospital
c. Patient with distension of abdomen and not passing
Bowel obstruction occurs when the normal propulsion flatus and feces.
and passage of intestinal contents does not occur. This
obstruction can involve only the small intestine (SBO), large Exclusion criteria
intestine (large bowel obstruction), or through systemic a. Patients requiring urgent laparotomy
alterations, involving both the small and large intestine b. Radiological findings suggestive of perforation
(generalized ileus). The days of not letting the sunset c. Radiological findings suggestive of large‑bowel obstruction
twice on a SBO perhaps allowed for less complex surgical d. Patient unfit for CT scan (acute renal failure,
decision‑making algorithms than to watchfully wait and high‑serum creatinine).
wonder about the state of the bowel.[2] This old surgical
adage seems to have lost its reverence with time. The caveat Methods
is that the current diagnostic armamentarium in predicting Informed consent from patient and patient’s attendant
nonoperative failures remains far from foolproof. The was taken for the study. ryle's tube insertion and Foley’s
fundamental clinical shortcoming is the clinicians’ inability catheterization were done in all patients. A detailed history
to definitively predict cases of SBO destined to evolve into was taken under the heading of present medical history
strangulated bowel if left to nonoperative measures. and history with special emphasis on previous surgical
intervention. Patients were fully examined under the heading
The diagnosis of SBO is based on a comprehensive of general physical examination, systemic examination, and
approach that includes clinical background, patient history, local examination. All the patients were taken for a battery
and results of physical examination and laboratory tests. of investigations which included routine investigations
Conventional radiography is the initial method of imaging such as hemogram, liver function test, kidney function
in patients with suspected SBO. test (KFT), serum amylase and lipase, serum electrolytes
and radiological investigations included plain abdominal
Recent studies have demonstrated the superiority of radiographs, ultrasonography (USG), and contrast‑enhanced
computed tomography (CT) in revealing the site, level, and CT (CECT) abdomen. Patients with stable vitals and normal
cause of obstruction and in demonstrating threatening signs KFT were taken for CECT abdomen in which water‑soluble
of bowel viability. CT has proved useful in characterizing oral contrast and intravenous nonionic contrast were given
SBO from extrinsic causes, intrinsic causes, intraluminal to the patient and CT was done. Evaluation was done based
causes, or intestinal malrotation.[3‑5] on the following points in the CT: dilated small bowel,
transition point, ascites, complete obstruction, partial
A clinicoradiological study of intestinal obstruction is obstruction, closed loop, free air, and other factors as and
selected because in routine practice, every surgeon has to when required. The CT score of 7 or more was taken as
come across this surgical emergency and treatment largely criteria for the need of surgery.
depends on early diagnosis and skillful management.
Point values for computed tomography scoring system
MATERIALS AND METHODS
CT Finding Score for finding
This study was conducted at our institution from October Initial CT findings
2012 to August 2014. Initially, 52 cases of intestinal Free air 5
Transition point 3
obstruction were taken for the study, but two cases were Complete obstruction 3
excluded from the study due to patient’s noncompliance. Closed loop 3
A total number of fifty cases have been studied during the Free fluid 3
Partial obstruction 2
period of study. Repeat CT findings
Resolution −5
Materials Improved obstruction −2
Persistent SBO +2
Patients with a diagnosis of SBO, either being admitted in Worsening SBO +3
the Department of General Surgery or referred to surgery Free air +5
from other associated specialties of CSSH Hospital. CT: Computed tomography; SBO: Small‑bowel obstruction

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Jain, et al.: CT scoring for small bowel obstruction

Nonoperative management of SBO included: which 42% cases were operated, this implies that it is less
• Fluid resuscitation  ‑  Isotonic fluid should be given specific indicator for surgery alone [Tables 2 and 3].
intravenously
• Tube decompression  ‑  Stomach continuously Complete obstruction was seen in 6% of cases and all of
evacuated of air and fluid using a nasogastric tube them were taken up for surgery. It has high specificity as an
• Antibiotics indicator for surgery as in cases of complete obstruction
• Foley’s catheterization ‑ To monitor urine output. complication rates are high [Tables 2 and 3]. The less
sensitivity perhaps can be explained by the fact that majority
Patients who had features suggestive of complicated of patients with complete obstruction also develop features
obstruction (strangulation, ischemia) were taken up of strangulation and other complications and surgery is not
for surgery on emergency basis and patients who delayed in those patients. Closed loop was found in 4%
showed improvement on conservative management and of cases and which was seen in patients with hernia and
clinicoradiological features suggestive of simple/partial multiple strictures forming the closed loop. Closed loop has
obstruction were kept on conservative management.
also got high specificity for surgery as complications such
Signs and symptoms suggestive of a complicated as strangulation is high in these patients [Tables 2 and 3].
obstruction include fever, tachycardia, leukocytosis,
Free fluid was seen in 70% (35) of cases and 62% (22) of
localized tenderness, continuous abdominal pain, and
these patients were operated. It has got high sensitivity in
peritonitis. The presence of any three of the following
signs – continuous pain, tachycardia, leukocytosis,
peritoneal signs, and fever has an 82% predictive value for Table 1: Total computed tomography score variation and relation
to surgery done (n=50)
strangulation obstruction. Similarly, the presence of any CT score Number of patients (%) Surgery done (%)
four of the above signs has a near 100% predictive value 0 1 (2) 1 (100)
for strangulation obstruction. 2 1 (2) 1 (100)
3 8 (16) 0
RESULTS 5 9 (18) 0
6 9 (18) 3 (33.3)
8 16 (32) 16 (100)
The study was done in all age groups ranging from 10 1 (2) 1 (100)
5 years to 85 years with a mean age of 39.9 years. The 11 3 (6) 3 (100)
12 1 (2) 1 (100)
occurrence of intestinal obstruction was common in 13 1 (2) 1 (100)
male (58%) with comparison to female (42%). There Total 50 27
were 29 male and 21 females with male to female ratio CT: Computed tomography
1.4: 1. The common symptoms or complaints with which
the patients presented were pain abdomen, vomiting, Table 2: Computed tomography score signs positivity in
distension of abdomen, and constipation. The minimum patients (n=50)
score in our study was 0 and the maximum score was 13 CT signs CT sign positive Surgery done in CT sign
in patients (%) positive patients (%)
[Table 1]. Most common score was 8 (32%) followed by
Free air 8 (16) 8 (100)
5 and 6 (18% each). The results of the points observed in Transition point 36 (72) 20 (55.5)
the study were categorized individually according to the Complete obstruction 3 (6) 3 (100)
Closed loop 2 (4) 2 (100)
positivity and negativity in the patient and management Free fluid 35 (70) 22 (62.85)
done [Tables 2 and 3, [Bar Graphs 1 and 2]]. Partial obstruction 25 (50) 16 (64)
CT: Computed tomography
Free air was seen in 16% of cases and all of them were
taken up for surgery. It implies the specificity of the free Table 3: Computed tomography score signs negativity in
air as an indicator for surgery, it was not seen in 84% of patients (n=50)
cases of which 42% were operated which means it is less CT signs Negative in Surgery done in CT sign
patients (%) negative patients (%)
sensitive in obstruction cases as patients which have free
Free air 42 (84) 19 (45.2)
air apparent in plain X‑ray film are not subjected to CT Transition point 14 (28) 7 (50)
and are taken for surgery without delay [Tables 2 and 3]. Complete obstruction 47 (94) 24 (51)
Closed loop 48 (96) 25 (52)
Transition point was seen in 72% (36) of cases, of which Free fluid 15 (30) 5 (33.3)
55% (20) of cases underwent surgery. It has got high Partial obstruction 25 (50) 11 (44)
sensitivity. Transition point was not seen in 28% cases of CT: Computed tomography

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Jain, et al.: CT scoring for small bowel obstruction
cases of obstruction as free fluid is seen in most of the
cases [Tables 2 and 3]. The free fluid in the peritoneal cavity
indicates complication in cases of obstruction. However,
free fluid can also be seen without complication and in
cases of infectious pathologies.
Partial obstruction was seen in 50% (25) cases, of which
64% (16) were operated. It has got medium sensitivity and
specificity in cases of obstruction as partial obstructions
have good response to conservative management
[Tables 2 and 3]. Clinically, partial obstruction was
diagnosed in 47 patients and 3 with complete; however,
radiologically, only 25 patients had features of partial
obstruction.
In this study, 54% of patients were taken for surgical
management and rest were managed conservatively.
Sixty‑six percent of the patients in our study had simple
obstruction and 34% of the patients had features of
strangulation. The patients who were taken up for surgery
were planned per the clinical and radiological basis.
Figure 1: Obstruction due to band
Bar Graph 1: Computed tomography score sign positivity and surgery
in computed tomography sign positive patients
68 Saudi Surgical Journal | Volume 5 | Issue 2 | May-August 2017
Sixty‑three percent of the patients operated were taken for
emergency surgery and rest 37% were operated in elective
surgery [Table 4].
Adhesions and bands [Figure 1] were the most common
etiology in the study group, i.e., 30%. There were
different etiologies for it (postoperative bowel adhesions,
abdominal tuberculosis). Forty‑six percent of patients
with A and B were subjected to surgery and rest were
managed conservatively [Table 5]. Volvulus was found in
4% cases and they were immediately taken up for surgery
[Table 5]. Eighteen percent of patients had perforations
which were not evident on X‑ray examination and
CT findings with CT score were conclusive in favor
of perforations [Table 5]. All cases were taken up for
emergency surgery and operative findings correlated with
the CT findings. The perforation seen was complications
of abdominal tuberculosis, long‑standing obstruction.
Four percent of cases of malrotation were found in
the studies which were taken up for surgery [Table 5].
Stricture [Figure 2] was found in 8% (4) of cases and
75% (3) of these were operated. The common etiology
was found to be of tuberculosis in these patients
[Table 5]. Paralytic ileus was found in 4% (2) cases which
were managed conservatively by prompt correction of
hypovolemia and serum electrolyte correction [Table 5].
Hernia and intussusception were seen in equal ratio,
i.e., 2% each. These cases were taken up for surgery on
emergency basis [Table 5]. Twenty‑eight percent (14)
Table 4: Distribution of patients according to management
Management Male Female Total Percentage
Conservative 13 10 23 46
Surgical 16 11 27 Elective‑10 54
Emergency‑17
Total 29 21 50 100
Bar Graph 2: Computed tomography score signs negativity in patients
and relation to surgery
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Jain, et al.: CT scoring for small bowel obstruction

of cases had infectious and inflammatory pathology
(abdominal tuberculosis, Crohn’s disease). Most of the
patients (86%, 12) were managed conservatively by
prompt and timely management. Fourteen percent (2)
were taken up for surgery [Table 5].
DISCUSSION
In our hospital during the study period, the incidence of
intestinal obstruction out of all the abdominal surgeries
was about 4.2%.
The involvement of small bowel in obstruction is much
more common than that of large bowel.[7] The delay in the
treatment will lead to high mortality.

Intestinal obstruction is one of the commonly encountered
clinical entities. There is probably not a day that goes by,
in which a clinical surgeon does not at least once, come
across the possible diagnosis of intestinal obstruction.
Intestinal obstruction continues to be a frequent
emergency, which surgeons have to face (1%–4% of
emergency operations).
Richard et  al. analyzed 1000 consecutive abdominal
surgeries in 1976 and reported an incidence of 2.5%.[6]
The mortality has reduced significantly by instituting the
treatment at the earliest period. 1%–4% of mortality in
emergency surgeries is contributed by acute intestinal
obstruction.[8]
Megibow et al.[9] pointed out that CT scans can be useful in
patients who have not had prior surgery but present with
signs of infection, bowel infarction, or palpable abdominal
mass.
Table 6 shows the sensitivity and specificity along
with accuracy of all parameters of CT scoring system.
Free fluid and transition point have highest sensitivity,
respectively. The specificity was highest and same for
free air, complete obstruction, and closed loop. Accuracy
was highest for free fluid followed by partial obstruction
and free air both.

All the patients with score of 8 or above (44%) were taken

up for surgery [Table 1]. Only 10% of cases with score <8
were taken up for surgery on basis of other clinical and CT
features. In these 10% cases, two cases of malrotation were
there and two cases of bowel adhesions with band formation
Figure 2: Stricture at ileum with proximal dilatation
and one case of midgut volvulus were seen. This may imply
that CT scoring has less sensitivity toward the cases with
Table 5: Distribution of patients according to etiology (n=50)
congenital malformation and those cases should be managed
Diagnosis Number of Surgery on basis of clinical and other parameters as conservative
patient (%) done (%) management in such cases has high rate of recurrence of
Adhesions and bands 15 (30) 7 (46.6) obstruction and other complications; hence, these patients
Volvulus 2 (4) 2 (100) should be considered for surgery to prevent further future
Perforation 9 (18) 9 (100)
Malrotation 2 (4) 2 (100) complications.
Strictures 4 (8) 3 (75)
paralytic ileus 2 (4) 0 In this study, 54% of patients were taken for surgical
Hernia 1 (2) 1 (100)
Intussusception 1 (2) 1 (100) management and rest were managed conservatively. Seror
Infectious/inflammatory pathology 14 (28) 2 (14.2) et  al.[10] in a study reported that conservative approach
Total 50 27
resulted in a 73% resolution of obstruction with no

Table 6: Statistics drawn from our study

CT sign Sensitivity (%) Specificity (%) PPV (%) NPV (%) Accuracy (%)
Free air 30 100 100 50 60
Transition point 74 30 55 50 54
Complete obstruction 11 100 100 49 52
Closed loop 7.4 100 100 48 50
Free fluid 81 43 63 66 64
Partial obstruction 59 60 64 56 60
PPV: Positive predictive value; NPV: Negative predictive value; CT: Computed tomography

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Jain, et al.: CT scoring for small bowel obstruction
significant increase in mortality or in rate of strangulation.
In a search done by Maung et  al. [11] concluded that
nonoperative management has success rate of 65%–80% in
cases of partial SBO or cases without clinical or radiological
sign of bowel ischemia.
In a study by Frager et al.,[12] the sensitivity of diagnosing
complete SBO by CT scan was 100% and prevented a
12–72 h delay in surgery. In our study, CT scoring system
helped 81% of time in predicting the requirement of
surgery. Jones et al.[13] in a study concluded that CT scoring
system can successfully help the surgeon decide whether or
not the patient requires surgery 75% of the time.
CONCLUSIONS
X‑ray abdomen and USG of abdomen cannot always
predict the requirement of surgery. CT abdomen along
with CT scoring system can predict the need of surgery
early in majority of patients and prevent the delay in surgery
with reduced morbidity and mortality in those patients. It
also helps in preventing negative laparotomies in patients
when there is dilemma for surgeon to go for conservative
or surgical approach.
Clinical sense still remains the mainstay of deciding the line
of management in cases of intestinal obstruction. CT in
these patients can help surgeon to go for surgery early and
prevent complications. CT scoring system is less sensitive for
congenital malformations and other CT features along with
clinical features are mainstay for decision‑making in these
patients.
Nowadays, CT scan facility is available round‑the‑clock in
almost all hospitals (tertiary centers) and it does not put too
much of financial burden on patient. Hence, it should be
included as a protocol investigation in the patients of intestinal
obstruction for early diagnosis and timely management.
70 Saudi Surgical Journal | Volume 5 | Issue 2 | May-August 2017
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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