International Journal of Surgery 27 (2016) 88e91

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International Journal of Surgery

journal homepage: www.journal-surgery.net

Original research

CT scan findings do not predict outcome of nonoperative management

in small bowel obstruction: Retrospective analysis of 108 consecutive
patients
Victor E. Pricolo*, Filomena Curley
Department of Surgery, Southcoast Health, New Bedford, MA, USA

h i g h l i g h t s

Small bowel obstruction, likely secondary to adhesions from previous abdominal surgery, is a very common occurrence and a relevant acute care
problem.

Computed tomography is routinely used in the diagnostic evaluation of small bowel obstruction.

Certain CT scan findings have been proposed as indicative of need for surgical intervention in adhesive small bowel obstruction.

Our experience does not show that CT scan findings alone can reliably predict failure of nonoperative management in adhesive small bowel obstruction.

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The study purpose was to investigate the ability of Emergency Department CT scan to predict
Received 21 August 2015 the need for operative intervention in patients hospitalized for small bowel obstruction (SBO) likely
Received in revised form secondary to adhesions (ASBO) and initially managed nonoperatively.
13 December 2015
Design: Retrospective case series. Statistical analysis was done with independent-samples t-test and chi-
Accepted 17 January 2016
Available online 22 January 2016
square to identify correlation between variables and outcome of nonoperative management.
Setting: Tertiary care academic medical center.
Patients and Methods: Of 200 consecutive patients hospitalized for SBO, 108 were included in the study
Keywords:
Bowel obstruction
with a diagnosis of ASBO and received initial nonoperative management. Exclusion criteria were need for
Small bowel emergency surgery (e.g. peritonitis) or other diagnoses (e.g. neoplasms, hernias, Crohn's disease). CT
Computed tomography findings such as transition point, small bowel faeces, high grade obstruction, and abnormal vascular
Surgical therapy course were correlated with failure of nonoperative management.
Results: Only 18 patients (16.7%) required operative intervention, while the other 90 (83.3%) were suc-
cessfully discharged after nonoperative care. There was no correlation between CT scan findings and
treatment outcome.
Conclusions: Emergency Department CT scan findings do not significantly alter management decisions in
patients admitted for ASBO and managed initially with nonoperative care.
© 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

1. Introduction [1,2]. A certain percentage of these patients require emergency

Small bowel obstruction (SBO) remains a common clinical entity
that accounts for over 300,000 hospital admissions and approxi-
mately $3 billion in health care costs per year in the United States
Abbreviations and Acronyms: ASBO, adhesive small bowel obstruction; CT,
computerized tomography; ED, emergency department; NOM, non-operative
management; OM, operative management; SBO, small bowel obstruction; WBC,
white blood cell.
* Corresponding author.
E-mail addresses: vepricolo@gmail.com, pricolov@southcoast.org (V.E. Pricolo).
surgical intervention for findings indicative of peritonitis from
perforation or bowel ischemia. The majority of patients with SBO
likely secondary to peritoneal adhesions from previous abdominal
surgery (adhesive small bowel obstruction e ASBO) are initially
managed non-operatively with hospitalization, intravenous hy-
dration, fasting, nasogastric tube drainage and observation. How-
ever, some of these patients develop worsening signs or symptoms,
or simply fail to improve after a few days in the hospital, thus
requiring operative intervention.
Over the last 10e15 years, computed tomography (CT) has

http://dx.doi.org/10.1016/j.ijsu.2016.01.033
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 V.E. Pricolo, F. Curley / International Journal of Surgery 27 (2016) 88e91 89

become the standard of care in the initial diagnostic assessment of
SBO, and for virtually every patient presenting to an Emergency
Department with abdominal pain [3]. While there are several
informative elements associated with SBO on CT, radiologists tend
to emphasize in their reports certain findings such as “a transition
point”, the “small bowel faeces” sign, a “high-grade obstruction”
and an “abnormal vascular course”. The implication of such “high-
risk” findings is that they may correlate with a higher likelihood
that the SBO will fail to improve with nonoperative management
and may warrant early surgical intervention [4]. However, from a
therapeutic decision making standpoint, whether or not such CT
findings actually help risk stratify this group of patients remains a
matter of controversy [5].
The purpose of our study was to determine whether or not
“high-risk” radiologic findings were in fact associated with a
greater need for operative management in patients hospitalized for
observation with a presumptive diagnosis of ASBO at a tertiary care
institution.
2. Materials and methods
The Hospital Institutional Review Board approved this study.
The Department of Surgery billing database for a 12 month-period
was used to generate a list of consecutive patients who were
admitted with a diagnosis of SBO. Variables entered into the anal-
ysis were demographic data including age and gender, admission
history and physical exam, admission laboratory data, radiology
reports, operative notes if applicable, and discharge summaries.
Additional historical data including past surgical history and pre-
senting signs and symptoms were considered as well. In the review
of radiology reports, attention was devoted to entering whether or
not key words such as “transition point”, “small bowel feces sign”,
“high grade obstruction”, and “abnormal vascular course” were
used. Discharge summaries and, if present, operative reports were
reviewed to determine if non-operative management of small
bowel obstruction was successful. Patients who underwent surgical
intervention within 24 h of admission were excluded from the
study, as they did not represent patients who were admitted for the
purposes of conservative management of small bowel obstruction.
Statistical analysis was done with independent samples t-test
and chi-square to identify a correlation between patient charac-
teristics, management groups, radiologic variables, and need for
operative management (OM) versus success of nonoperative
management (NOM).
3. Results
A total of 200 patients were admitted from the Emergency
Department with a diagnosis of small bowel obstruction during the
one-year period. Their management allocation is reported in Fig. 1.
Ninety-two patients were excluded from the study for a variety of
reasons: 43 patients required prompt operative intervention (e.g
peritonitis, free intra-abdominal air or lack of history or previous
abdominal surgery), 33 were found to have causes for SBO other
than adhesions (e.g. hernia, Crohn's, diverticulitis, appendicitis,
neoplasm) and 16 patients had other diagnoses upon review of the
admission history and physical (e.g. large bowel obstruction,
paralytic ileus).
The 108 patients that qualified for this study were 53 males and
55 females, ranging in age between 23 and 96 years. They all had a
confirmed admitting diagnosis of ASBO and were initially treated
nonoperatively. No patient in this group had findings of ascites by
CT scan. The initial diagnosis of SBO was made by CT scan of the
abdomen and pelvis, with intravenous contrast, obtained in the
Emergency Department. No oral contrast was administered, in
consideration of the risk of vomiting and aspiration pneumonia. Of
this group, 18 patients (16.7%) underwent an operation during the
same admission for small bowel obstruction that failed to improve
with nonoperative management (operative management
group ¼ OM). Only 3 of these patients underwent a follow-up CT
scan during the same hospitalization, showing persistent SBO. All
these patients had intraoperative findings of peritoneal adhesions
as the cause of SBO and were successfully treated without mor-
tality. The remaining 90 patients (83.3%) were successfully
managed conservatively and were discharged from the hospital
without undergoing an operation (nonoperative management
group ¼ NOM). None of these patients required a follow-up CT scan
during the same hospitalization. No patient in the NOM group was
readmitted within 30 days for recurrent SBO after discharge. Pa-
tient characteristics between the operative and nonoperative
groups were similar, as shown in Table 1.
The frequency of the four mentioned radiologic signs in the OM
group and in the NOM group was compared and is reported in
Table 2.
None of the above mentioned radiologic findings on admission
CT scan had a statistically significant association with the success or
failure of non-operative management in our study. No patient was
managed differently, or had a different outcome, on the basis of the
described “high-risk” radiographic findings.
4. Discussion
The goal of this study was to provide additional data to assess
the value of the information obtained from a CT scan of the
abdomen and pelvis in patients who present to an Emergency
Table 1
Patient demographics and characteristics.

OM group NOM group p value

Age, years (mean) 58.35 60.23 0.49

Male gender, n (%) 11 (61.1) 42 (46.7) 0.10
Hx abdominal surgery, n (%) 18 (100) 90 (100)
Race, n (%)
White 13 (72.2) 68 (75.6) 0.84
Non-white 5 (27.8) 22 (24.4) 0.69
Ethnicity, n (%)
Hispanic 4 (22.2) 25 (27.8) 0.53
Non-hispanic 14 (77.8) 65 (72.2) 0.082
Diabetes Mellitus, n (%) 3 (16.7) 14 (15.6) 0.58
COPD, n (%) 2 (11.1) 8 (8.9) 0.44
History of CHF, n (%) 1 (5.6) 4 (4.4) 0.34
Obesity, n (%) 3 (16.7) 12 (13.3) 0.52
Renal failure, n (%) 2 (11.1) 7 (7.8) 0.45
WBC count (cells/mcL), mean 9.5 8.9 0.91
Fig. 1. Management allocation for patients admitted for ASBO.

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90 V.E. Pricolo, F. Curley / International Journal of Surgery 27 (2016) 88e91
Table 2
Incidence and correlation of “high risk” CT scan findings with operative manage-
ment (OM) and nonoperative management (NOM) of ASBO.
CT finding N pts OM group NOM group p value
Transition point 78 13 (16.7%) 65 (83.3%) 0.68
Small bowel feces 35 3 (8.6%) 32 (91.4%) 0.19
High grade obstruction 14 2 (14.3%) 12 (85.7%) 0.81
Abnormal vascular course 3 0 3 0.44
Department with SBO. While such imaging is considered the gold
standard from a diagnostic point of view, some of the CT findings
may have a more limited role in affecting substantial changes in
patient management.
There is general agreement that patients who have a SBO with
signs of peritonitis or evidence of clinical deterioration should
undergo timely surgical exploration, rather than imaging studies
that would not obviate, but only unnecessarily delay, the need for
surgical intervention [6]. In most patients who have a SBO, the most
likely cause is adhesive disease from previous surgery. Such infor-
mation can be obtained from the patient's history. Additional sur-
gery will cause additional adhesions and will not reliably prevent
additional episodes of SBO. Consequently, surgical intervention is
reserved for cases that fail to improve or worsen after a few days of
NOM. Patients without history of previous surgery or in whom a
tumor or an inflammatory process is suspected may warrant sur-
gical exploration after initial stabilization and rehydration.
Plain abdominal radiographs, or plain films have long been a
useful initial diagnostic test for detecting SBO, as they are cost
effective and almost universally available [7]. They demonstrate
features such as air-fluid levels, bowel dilatation and paucity of
colonic air, suggestive of a small bowel obstruction. Plain films have
been found to be very accurate with 60e93% sensitivity in the
diagnosis of SBO, especially if reviewed by experienced radiologists
or surgeons [8].
CT for SBO has a reported sensitivity of 80e94% [9]. When
compared to plain radiographs, CT may offer the advantage of
better localizing the site of obstruction, the cause of it (e.g.
inflammation, neoplasm), and possibly ischemic changes, if intra-
venous contrast is used [10,11]. In addition, certain signs have been
suggested as relevant in their potentially predictive value in guid-
ing management decisions. The “transition point” is an abrupt
change from dilated to collapsed bowel loops and is indicative of
the site of obstruction. The “small bowel faeces” sign arises from
the mixing of air and enteric contents in stasis suggesting chro-
nicity of the obstruction [12]. A “high grade“ obstruction is defined
on CT when little or no gas is present in the distal small bowel or
ascending colon [13,14]. An “abnormal vascular course”, or “whirl
sign” may be indicative of a small bowel volvulus [15,16].
The transition point or transition zone is a frequently empha-
sized finding on CT scan report for a SBO, described in up to 75% of
cases [17]. Our study did not demonstrate a statistically significant
correlation between presence of a transition point and failure of
NOM. There is no evidence that such finding is a reliable predictor
of need for operative intervention [13,14,17,18]. The described
location of the site of obstruction by CT scan may, at times, provide
some guidance in the choice of incision or laparoscopic port
placement at the time of surgery.
The small bowel faeces sign is a less frequently emphasized
finding on CT scan that, in our analysis, was not found to be pre-
dictive of need for operative intervention. This radiographic sign is
likely related to stasis of small bowel content, fluid reabsorption
and/or bacterial overgrowth [3,12]. It is a finding non-specific for
SBO and, in some publications, it has been found to inversely
correlate with failure of NOM [14,19,20].
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With respect to the degree or grade of obstruction, our review
did not identify any correlation between the high grade obstruction
and the likelihood of eventual surgical management. An additional
complicating factor is the variable definition of high-grade
obstruction in the literature. Although some studies have re-
ported an increased likelihood of OM in patients with this CT
finding, other have not confirmed such correlation [13,18,21].
In our series, an abnormal vascular course was rarely described
and all such patients improved with NOM. Even in the presence of
such finding, clinical factors are being taken into account and sur-
gical intervention is not always warranted [15,16].
Our study had some limitations in that it was retrospective,
observational, and consequently it did not set precise triggers to
declare failure of NOM and proceed with OM. Nonetheless, it ap-
pears that both available literature data and our institutional
experience do not support reliance on certain CT findings to decide
on OM versus NOM in most patients with ASBO that are initially
admitted without need for an emergent operation. Recent practice
guidelines supported by level 1 evidence recommend NOM,
regardless of radiologic findings, in patients with SBO (partial or
complete) without evidence of peritoneal signs or clinical and
laboratory evidence of deterioration [6,22,23].
In our series, in patients with ASBO who had been selected for a
trial of nonoperative management,“high-risk” findings at the initial
CT scan did not provide additional information that significantly
affected management. High quality abdomino-pelvic CT scan re-
mains most valuable as an initial diagnostic tool, especially with
appropriate contrast enhancement, in order to determine ischemic,
inflammatory or neoplastic changes associated with SBO at the
time of hospital admission that may require early operative inter-
vention. In patients with ASBO that are initially treated non-
operatively, clinical course after hospital admission, with return of
bowel function or failure to improve, remains the most relevant
factor affecting management decisions to proceed with surgical
intervention.
Ethical approval
Yes, ethical approval was given.
It was given by Patricia Houser, Director, Research Protection
Office at Lifespan (Rhode Island Hospital).
IRB registration # 0000396, 00004624.
Sources of funding
None.
Author contribution
Authors: Victor E. Pricolo for design, data management and
writing.
Filomena Curley for data collection, supervision and analysis.
Contributors: Kyrellos Zamary, Jennifer Foster (assistance in
data collection).
Steven Reinert, (data analysis).
Conflicts of interest
None.
Trial registry number
N/A.
 V.E. Pricolo, F. Curley / International Journal of Surgery 27 (2016) 88e91
Guarantor
Victor E. Pricolo.
Research registration unique identifying number (UIN)
Lifespan IRB CMTT/PROJ: 003012.
TITLE: (291636-1) Value of CT in predicting non-operative
management of SBO.
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