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Sandrasegaran et al.

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
Small-Bowel Complications
of Gastrointestinal Surgery

Small-Bowel Complications
of Major Gastrointestinal
Tract Surgery
Kumaresan Sandrasegaran1 OBJECTIVE. Gastrointestinal complications of major abdominal surgery often require ra-
Dean D. Maglinte1 diologic assessment. The purpose of this article is to review the expected imaging findings and
John C. Lappas1 complications after commonly performed gastric and pancreatic surgery.
Thomas J. Howard2 CONCLUSION. It is important to understand the postsurgical anatomy to avoid misin-
terpreting an expected postoperative finding as a complication. Postoperative complications
Sandrasegaran K, Maglinte DD, Lappas JC, can be categorized as being related to adhesions, anastomosis, an enteric connection, and ab-
Howard TJ normal bowel position.

bdominal, pancreatic, and gastric finding should not be mistaken for an is-

A surgeons perform increasingly


complex procedures. The radiol-
ogist is faced with CT or upper
chemic or inflamed bowel or for fluid collec-
tion (Fig. 1). Another finding is reactive lym-
phadenopathy of up to 1.5 cm, which might
gastrointestinal contrast studies in which the be mistaken for a recurrent tumor [2]. This
anatomy is difficult to discern and there is occurs in the first month after Whipple and
uncertainty whether a finding is an expected other pancreatic surgery. Third is perivascu-
postoperative change or relates to a compli- lar cuffing, which is commonly seen 1–2
cation. We retrospectively reviewed 377 months after surgery and should not be mis-
cases of complex abdominal surgery per- taken for recurrent tumor if preoperative
formed by gastric and pancreatic surgeons at scans did not show this finding. The celiac
our affiliated institutions between January and superior mesenteric arteries are most af-
2002 and August 2003. This pictorial essay fected and the common hepatic artery, less af-
shows the expected anatomy after com- fected. Fluid collection in the duodenal bed in
monly performed procedures and the range the first 3 weeks after surgery is an expected
of complications that might be seen on im- finding. Unless there are clinical signs of in-
aging studies. For ease of categorization, fection, these collections need not be drained;
postoperative small-bowel complications they tend to be transient. Pneumobilia is a
are classified as related to anastomosis, an permanent feature after hepaticojejunostomy.
enteric connection, abnormal bowel posi- Periportal edema is seen in the first 2 postop-
tion, or adhesions. erative weeks.

Whipple Procedure Puestow Procedure


Received June 4, 2004; accepted after revision Whipple surgery is the only curative proce- In cases of severe chronic pancreatitis,
December 8, 2004. dure for carcinoma of the head of pancreas end-to-end pancreaticojejunal anastomosis,
(Fig. 1). The survival rate is approximately such as in the Whipple procedure, is insuffi-
1Department of Radiology, Indiana University Medical 30% 5 years after resection [1] and less than cient to drain the pancreas. The Puestow pro-
Center, UH Suite 0279, 550 N. University Boulevard, 1% for those who do not qualify for the pro- cedure (Fig. 2), a side-to-side longitudinal
Indianapolis, IN 46202. Address correspondence to
K. Sandrasegaran (ksandras@iupui.edu).
cedure. It is important to appreciate postoper- pancreaticojejunostomy, drains the pancre-
ative anatomy to prevent overdiagnosing atic duct directly into a jejunum loop [3]. In
2Department of Surgery, Indiana University complications. Puestow’s original description of the tech-
Medical Center, Indianapolis, IN. There are several normally expected CT nique, the spleen and distal pancreas were re-
AJR 2005; 185:671–681
findings after the Whipple procedure. One is moved. The Roux loop in the Puestow proce-
an afferent loop that is fluid filled and edem- dure may be mistaken for a peripancreatic
0361–803X/05/1853–671
atous and shows bright contrast enhancement fluid collection if the nature of surgery is not
© American Roentgen Ray Society in the first two postoperative weeks. This appreciated.

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Sandrasegaran et al.

A B
Fig. 1—Whipple procedure.
A, Diagram of anatomy after pylorus-preserving Whipple procedure in which cuff of duodenum is spared. Insert shows original Whipple procedure. The procedure entails
radical dissection of pancreatic head, adjacent nodes, right half of omentum, gallbladder, common bile duct, and most or all of duodenum, followed by gastrojejunos-
tomy/duodenojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy. (Used with permission of Visual Media, Indianapolis, IN)
B, Coronal reformat of isotropic source images in 64-year-old man 5 weeks after Whipple procedure shows edematous jejunal Roux loop (straight arrow). Compare with nor-
mal distal small bowel (curved arrow). Note normal-sized mesenteric nodes and stent at site of pancreaticojejunostomy (arrowhead).

Bariatric Roux-en-Y Gastric Bypass en-Y procedures. Anastomotic leak is found in may show these ulcers; however, the method is
Procedure up to 27% of patients having laparoscopic reported to have a sensitivity of only 50% com-
In the United States, more than 30% of Roux-en-Y gastric bypass and, in our experi- pared with endoscopy [11]. In our experience,
adults are obese; 2–3% of men and 6–7% of ence, it is the most common postoperative most stomal ulcers are visualized with modern
women are morbidly obese [4, 5]. The Roux- complication of the Puestow procedure. fluoroscopic units and an adequate volume
en-Y gastric bypass procedure is the gold Stenosis—Symptomatic anastomotic steno- (100–200 mL) of barium for oral contrast.
standard for bariatric surgery (Fig. 3). Open sis at the gastrojejunostomy site is found in Leak and perforation—Anastomotic leak
and laparoscopic Roux-en-Y bypass proce- approximately 3–5% of patients having Roux- or perforation is the most serious complica-
dures are associated with a 5–20% incidence en-Y gastric bypass surgery [7, 8]. The inci- tion of Roux-en-Y gastric bypass surgery. It
of complications [6]. An upper gastrointesti- dence is higher in patients having a laparo- occurs in 3–5% of patients and is usually
nal contrast series is usually performed on the scopic Roux-en-Y bypass than in those having caused by staple gun failure. The incidence
first postoperative day to detect gastrojejunal an open procedure. Upper gastrointestinal con- of leakage can be reduced by manually sew-
leak or obstruction. Understanding the post- trast series show delayed passage of contrast ing the gastrojejunostomy [12, 13]. The
operative anatomy is important to prevent material. On CT, a spherical pouch or air–con- complication is evident in the first postoper-
overdiagnosis of complications (Fig. 4). trast level is suggestive of this diagnosis. An- ative week. Although upper gastrointestinal
other type of obstruction to gastric emptying is studies may show this leak (Fig. 5), the im-
Complications stenosis of the Roux limb at the site of meso- ages may be of poor quality because of the
Anastomotic Complications colonic tunneling in the Roux-en-Y bypass patient’s size. It is our practice to obtain a
Anastomotic complications are the most procedure. This is usually caused by excessive CT scan with IV and positive oral (dilute wa-
significant bowel-related complications. They stapling at the site of the mesenteric defect. ter-soluble) contrast in any patient who has
occur as a result of ischemia or suboptimal sur- Ulcers—Anastomotic ulcers after gastric unexplained fever, pain, or persistent nau-
gical technique, including staple gun failure, bypass procedures are common, with an inci- sea. Some anastomotic leaks are compli-
and account for most of the morbidity and mor- dence of 12–16% [9, 10]. An upper gas- cated by an enteroenteric, enterovesical, or
tality from the Whipple, Puestow, and Roux- trointestinal double-contrast barium series enterocutaneous fistula (Fig. 5).

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Small-Bowel Complications of Gastrointestinal Surgery

A B
Fig. 2—Puestow procedure.
A, Diagram of anatomy after modified Puestow procedure. The pancreas is filleted to expose main duct from neck to tail, and ductal calculi are removed. Roux loop of jejunum
is anastomosed to “capsule” of pancreas with direct drainage of main and secondary pancreatic ducts into lumen of jejunum over 8–10 cm segment. This procedure is best
performed if main pancreatic duct is significantly (>6 mm) dilated. (Used with permission of Visual Media, Indianapolis, IN)
B, Magnified view of axial CT image at level of upper abdomen in 67-year-old woman shows drainage jejunostomy Roux loop (black arrowheads) containing gas bubbles
closely applied to anterior aspect of atrophic calcified pancreatic body (white arrow).

A B
Fig. 3—Roux-en-Y gastric bypass procedure.
A, Line diagram showing anatomy after Roux-en-Y gastric bypass procedure. In this procedure, 90% of stomach, entire duodenum, and proximal 30 cm of jejunum are excluded
from digestion. Retrocolic version is demonstrated. Note short afferent loop at gastrojejunostomy, shown by circular staples. Duodenum is part of afferent loop at jejunoje-
junostomy, shown by linear sutures. (Used with permission of Visual Media, Indianapolis, IN)
B, Upper gastrointestinal contrast image following Roux-en-Y gastric bypass procedure in 32-year-old woman shows esophagus (thin white arrow), gastric pouch (thick black
arrow), short afferent loop (curved black arrow), and efferent loop (thick white arrows). Gastric remnant shows dilute contrast (curved white arrow) that has refluxed via
duodenum from previous contrast study.
(Fig. 3 continues on next page)

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Sandrasegaran et al.

C
Fig. 3 (continued)—Roux-en-Y gastric bypass procedure. Fig. 4—Roux-en-Y gastric bypass procedure anatomy. Axial CT after the procedure
C, Axial CT image of upper abdomen performed without IV contrast after Roux-en-Y in 48-year-old woman shows small pouch (straight white arrow) separated surgically
gastric bypass procedure in 36-year-old woman shows small gastric pouch filled with from remnant (black arrow). Remnant was mistaken for abscess, and drainage
dense, orally introduced contrast (black arrow). Adjacent, but surgically separated, is catheter (curved arrow) was placed .
most of stomach, gastric remnant (white arrow). Surgical staples separating the two
are seen (arrowhead). Dilute oral contrast in remnant has refluxed via duodenum. This
should not be mistaken for direct leak from pouch (gastrogastric fistula), which will
manifest with dense oral contrast in remnant without any in distal duodenum.

A B
Fig. 5—Anastomotic leak in 29-year-old woman.
A, Upper gastrointestinal contrast series after Roux-en-Y gastric bypass procedure shows edematous gastric pouch with leakage of contrast from gastrojejunal anastomotic
site (black arrow) extending into left upper quadrant. There is also dense orally introduced contrast in gastric remnant (arrowhead) without contrast in the duodenum,
indicating gastrogastric leak rather than retrograde reflux. Contrast is seen in transverse colon (white arrow) from previous upper gastrointestinal study.
B, Axial CT of upper abdomen after Roux-en-Y gastric bypass procedure shows leak at gastrojejunostomy site complicated by abscess (black arrow). An enterocutaneous
fistula is shown by a track of gas bubbles (arrowheads). Adjacent images (not shown) indicate gas bubbles are in a fistula and not small bowel. Leaked oral contrast is seen
in open abdominal wound (white arrow).

Afferent loop obstruction—Afferent loop surgery, the afferent limb is the duodenum; in tomotic stenosis, stomal ulcer, recurrent tu-
obstruction occurs in 0.3% cases after gastro- pancreatic surgery, the Roux segment is the mor, and obturation from bezoar. Chronic
enterostomy [14], including Billroth II sur- afferent limb (Fig. 1). Possible causes of ob- partial afferent-loop obstruction is termed
gery and the Whipple procedure. In Billroth II struction are adhesions, internal hernia, anas- “afferent loop syndrome.” Diagnosis is possi-

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Small-Bowel Complications of Gastrointestinal Surgery

A B
Fig. 6—Afferent loop obstruction in 50-year-old man.
A, Upper gastrointestinal contrast series after Whipple procedure shows dilation of
afferent loop (white arrow) but not efferent loop (black arrow) or stomach (S). At
surgery, the cause of the afferent-loop obstruction was found to be adhesions.
B, Axial CT image after Whipple procedure shows valvulae conniventes in uniformly
dilated afferent loop (black arrows) confirming diagnosis of afferent-loop obstruction
rather than pseudocyst. Back pressure from afferent-loop obstruction can cause
biliary or main pancreatic duct dilation (not shown).
C, Coronal multiplanar reconstruction shows distended afferent loop (black arrows)
well. Presence of dilated fluid-filled structure with caliber of more than 3.5 cm in
periportal region extending transversely anterior to spine is highly diagnostic.

ble but difficult to make with an upper gas- not form until approximately 4 months after plantation is estimated to be 100 cm. Patients
trointestinal series (Fig. 6). CT is the most surgery. These structures do not usually in- with a longer small bowel may also have di-
useful imaging technique for diagnosis. crease significantly in size after 12 months. gestive problems if the integrity of residual
Although often an incidental finding, blind mucosa is impaired or the distal ileum has
Enteric Connection pouch can lead to malabsorption, gastrointes- been resected. Short gut syndrome can be
Enteric-related complications are rare and tinal bleeding, and bowel perforation [15]. If simulated by inadvertent surgery when the
result from improper anatomic connection of symptoms are ascribed to the pouch, the ileum is mistaken for the jejunum and a gas-
bowel loops. They are distinct from anasto- pouch can be laparoscopically removed. troileostomy rather than a gastrojejunos-
mosis-related complications. Short gut syndrome—Malabsorption can tomy is created (Fig. 8). This complication is
Blind pouch syndrome— Side-to-side be caused by inadequate length of function- easily depicted by an upper gastrointestinal
anastomosis performed in Roux-en-Y gastric ing small bowel after widespread small- contrast series. CT examination may show
bypass surgery and after intestinal resection bowel resection, such as in Crohn’s disease. multiple loops of nondistended jejunum that
can result in an enlarged aperistaltic loop of The minimal length of small bowel (exclud- are not opacified with oral contrast, while
the small bowel (Fig. 7). This enlarged loop is ing the duodenum) required to cope without there is oral contrast in the stomach, ileum,
termed “blind pouch.” The blind pouches do parenteral nutrition or small-bowel trans- and right colon.

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Sandrasegaran et al.

Fig. 7—Blind pouch.


A, Diagram of formation of blind pouch after side-to-side enteroenterostomy. Dotted
black line shows anatomy before development of blind pouch. Arrows show direc-
tion of peristalsis. The blind pouch is filled rather than emptied by peristalsis. (Used
with permission of Visual Media, Indianapolis, IN)
B and C, Axial CT images of mid abdomen 10 months after multiple enteric resections
for gastrointestinal stromal tumor in 51-year-old woman show right (white arrows)
and left (black straight arrow, C) blind pouches. These are adjacent to surgical clips
(arrowheads). There is no obstruction of proximal or intervening small bowel (curved
arrows). CT findings are fairly characteristic and should not be mistaken for abscess
or small-bowel obstruction. S = stomach.

B C

Altered Bowel Position during a retrocolic anastomosis (Fig. 9). The at the jejunojejunostomy, or adhesion-related
Bowel position is usually altered as a con- reported incidence of internal hernia is about simple bowel obstruction. Appendix 1 shows
sequence of major abdominal surgery. How- 2.5% [7, 16], and it generally involves the findings that indicate transmesenteric hernia.
ever, small bowel may become trapped in Roux loop. Antecolic placement of the Roux There are no reports of a high frequency of
undesirable positions postoperatively. This loop does not lead to transmesenteric hernia other types of internal hernia after abdominal
type of complication includes hernia and but is complicated by a Petersen-type internal surgery. During diagnosis, it is important to
intussusceptions. hernia in rare cases. distinguish an internal hernia from adhesive
Transmesenteric internal hernia—Trans- An upper gastrointestinal barium series small-bowel obstruction. The former gener-
mesenteric hernia can occur in any proce- could show the degree and location of small- ally requires emergency surgery [17].
dure, including liver transplantation and gas- bowel obstruction (Fig. 9) but is less useful in External hernia—External hernias are an-
tric bariatric surgery, in which a Roux loop is determining the cause of obstruction. The other complication of gastrointestinal surgery.
fashioned. Transmesenteric hernias are more finding of dilated proximal jejunum that re- Ventral hernia is a major source of morbidity
common after laparoscopic bariatric surgery mains fixed in a high position on erect views after any major abdominal procedure. It is
than after open surgery [16]. Transmesenteric suggests internal hernia. CT is more helpful more common after open Roux-en-Y gastric
hernias occur through the tear in the mesoco- in differentiating transmesenteric hernia (Fig. bypass surgery (incidence of up to 17%) than
lon through which the Roux loop is brought 10) from mesocolic tunnel stenosis, stenosis after a laparoscopic Roux-en-Y procedure. A

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Small-Bowel Complications of Gastrointestinal Surgery

Fig. 8—Short gut syndrome in 64-year-old man. Upper gastrointestinal contrast


image shows only a few loops of small bowel between nasoenteric tube (white
arrow) and ileocecal junction (black arrow). Patient had inadvertent gastroileostomy
instead of gastrojejunostomy during Billroth II surgery. AC = ascending colon,
DC = descending colon.

A B
Fig. 9—Transmesenteric hernia.
A, Diagram of sagittal anatomy after Roux-en-Y gastric bypass procedure and potential site of transmesenteric hernia. (Used with permission of Visual Media, Indianapolis, IN)
B, Upper gastrointestinal contrast image after Roux-en-Y gastric bypass procedure in 43-year-old woman shows distention of afferent (white arrow) and efferent (black
arrow) with abrupt cutoff in mid efferent loop. Appearance is similar to mesocolic tunnel stenosis but more loops of distended efferent loops are seen, suggesting
transmesenteric hernia, which was found at surgery.

Richter hernia can occur at the site of the trocar Intussusception—Intussusception accounts foreign material, such as sutures and feeding
after laparoscopic procedures [18]. Parastomal for 5% of small-bowel obstruction in adults tubes, and hyperperistalsis of bowel that has
and lumbar are other external hernias com- [19] and is more common in postoperative pa- been extensively handled [20]. CT appear-
monly associated with abdominal surgery. tients. Possible causes include the presence of ances of these have been described [21].

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Adhesions hesive obstructions are usually treated con- 12. Higa KD, Boone KB, Ho T. Complications of the
Adhesions are the most common cause of servatively, while obstructions with an inter- laparoscopic Roux-en-Y gastric bypass: 1,040 pa-
bowel obstruction after surgery. The adhesions nal hernia or closed loop require surgery. tients—what have we learned? Obes Surg 2000;
can be symptomatic and nonobstructive. Ad- 10:509–513
hesive small-bowel obstruction is classified as 13. Schauer PR, Ikramuddin S, Gourash W, Ra-
simple, closed loop, or strangulating. References manathan R, Luketich J. Outcomes after laparo-
1. Sohn TA, Yeo CJ, Cameron JL, Koniaris L, Kaushal scopic Roux-en-Y gastric bypass for morbid obe-
Symptomatic, Without Overt Obstruction S, Abrams RA. Resected adenocarcinoma of the pan- sity. Ann Surg 2000; 232:515–529
More than 90% of patients who have had creas—616 patients: results, outcomes, and prognos- 14. Jordan GL Jr. Surgical management of postgastrec-
abdominal surgery have enteric adhesions, tic indicators. J Gastrointest Surg 2000; 4:567–579 tomy problems. Arch Surg 1971; 102:251–259
even if there is no clinical obstruction [22]. We 2. Mortele KJ, Lemmerling M, de Hemptinne B, De 15. Maglinte DD. “Blind pouch” syndrome: a cause of
routinely find CT features that suggest adhe- Vos M, De Bock G, Kunnen M. Postoperative find- gastrointestinal bleeding. Radiology 1979; 132:314
sions in postoperative patients who report ab- ings following the Whipple procedure: determina- 16. Higa KD, Ho T, Boone KB. Internal hernias after
dominal bloating or pain (Fig. 11) (Appendix tion of prevalence and morphologic abdominal CT laparoscopic Roux-en-Y gastric bypass: incidence,
2). These patients do not have high-grade features. Eur Radiol 2000; 10:123–128 treatment and prevention. Obes Surg 2003;
small-bowel obstruction but may have inter- 3. Puestow CB, Gillesby WJ. Retrograde surgical 13:350–354
mittent or low-grade small-bowel obstruction, drainage of pancreas for chronic relapsing pancre- 17. Sandrasegaran K, Maglinte DD, Howard TJ, Kelvin
for which CT has poor sensitivity [23]. atitis. AMA Arch Surg 1958; 76:898–907 FM, Lappas JC. The multifaceted role of radiology
4. Brolin RE. Bariatric surgery and long-term control in small bowel obstruction. Semin Ultrasound CT
Adhesive Small-Bowel Obstruction of morbid obesity. JAMA 2002; 288:2793–2796 MR 2003; 24:319–335
The diagnosis of adhesion-related small- 5. Martin LF, Hunter SM, Lauve RM, O’Leary JP. Se- 18. Matthews BD, Heniford BT, Sing RF. Preperito-
bowel obstruction is presumed on CT if vere obesity: expensive to society, frustrating to neal Richter hernia after a laparoscopic gastric by-
there is a narrow zone of transition without treat, but important to confront. South Med J 1995; pass. Surg Laparosc Endosc Percutan Tech 2001;
an identifiable obstructive lesion. At our in- 88:895–902 11:47–49
stitution, low-grade and partial high-grade 6. Cottam DR, Mattar SG, Schauer PR. Laparoscopic 19. Reijnen HA, Joosten HJ, de Boer HH. Diagnosis
obstructions are treated by enteric decom- era of operations for morbid obesity. Arch Surg and treatment of adult intussusception. Am J Surg
pression in which a long tube is placed under 2003; 138:367–375 1989; 158:25–28
fluoroscopic guidance. Although these pa- 7. Blachar A, Federle MP, Pealer KM, Ikramuddin S, 20. Allbery SM, Swischuk LE, John SD, Angel C. Post-
tients rarely require surgery, those with com- Schauer PR. Gastrointestinal complications of lap- operative intussusception: often an elusive diagno-
plete, closed-loop, or strangulating obstruc- aroscopic Roux-en-Y gastric bypass surgery: clin- sis. (letter) Pediatr Radiol 1998; 28:271
tion require emergent surgery. CT findings ical and imaging findings. Radiology 2002; 21. Merine D, Fishman EK, Jones B, Siegelman SS.
of closed-loop (Appendix 3) and strangulat- 223:625–632 Enteroenteric intussusception: CT findings in nine
ing obstruction (Appendix 4) are shown in 8. Higa KD, Boone KB, Ho T, Davies OG. Laparo- patients. AJR 1987; 148:1129–1132
Figures 12 and 13, respectively [24, 25]. scopic Roux-en-Y gastric bypass for morbid obe- 22. Menzies D, Ellis H. Intestinal obstruction from ad-
sity: technique and preliminary results of our first hesions—how big is the problem? Ann R Coll Surg
Summary 400 patients. Arch Surg 2000; 135:1029–1033; dis- Engl 1990; 72:60–63
In conclusion, knowledge of complex ab- cussion, 1033–1034 23. Maglinte DD, Kelvin FM, Rowe MG, Bender GN,
dominal surgery is useful in differentiating 9. MacLean LD, Rhode BM, Nohr C, Katz S, McLean Rouch DM. Small-bowel obstruction: optimizing
postoperative anatomy from complications. AP. Stomal ulcer after gastric bypass. J Am Coll radiologic investigation and nonsurgical manage-
When dealing with postoperative small- Surg 1997; 185:1–7; comment, 87–88 ment. Radiology 2001; 218:39–46
bowel obstruction, the radiologist should be 10. Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, 24. Balthazar EJ, Bauman JS, Megibow AJ. CT diag-
able to diagnose less common types of ob- Wolfe L. Stomal complications of gastric bypass: nosis of closed loop obstruction. J Comput Assist
struction, such as afferent-loop, closed-loop, incidence and outcome of therapy. Am J Gastroen- Tomogr 1985; 9:953–955
and strangulating obstruction, as well as un- terol 1992; 87:1165–1169 25. Balthazar EJ, Birnbaum BA, Megibow AJ, Gordon
usual causes such as internal hernia. This dis- 11. Ott DJ, Munitz HA, Gelfand DW, Lane TG, Wu RB, Whelan CA, Hulnick DH. Closed-loop and
crimination may be important in planning WC. The sensitivity of radiography of the postop- strangulating intestinal obstruction: CT signs. Ra-
therapy because even high-grade partial ad- erative stomach. Radiology 1982; 144:741–743 diology 1992; 185:769–775

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APPENDIX 1: CT Findings of Transmesenteric Hernia (Fig. 10)

• Cluster of dilated loops of bowel anterior to stomach or transverse


colon
• Deviation, crowding, or engorgement of mesenteric vessels as they
pass between stomach and transverse colon
• Downward displacement of transverse colon or hepatic flexure
• Close proximity of distal obstructed loop to site of mesenteric ves-
sel abnormalities
• Fluid distention of obstructed loop with paucity of air

B C
Fig. 10—Transmesenteric hernia in 47-year-old woman.
A and B, Axial CT images show dilated jejunal loops anteriorly (large white arrows). Mesenteric vessels supplying these loops curve (small black arrows, A) through trans-
verse mesocolon (small white arrows). Transition is abrupt (arrowhead), in line with slightly thickened mesocolon and proximal to site of jejunojejunostomy, shown by surgical
clips (large black arrow).
C, Coronal reconstruction in same patient shows distended efferent loops (black arrow) lying above and depressing transverse colon (white arrow).

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APPENDIX 2: CT Findings Suggesting Presence of Adhesions (Fig. 11)

• Acute angulation of small-bowel loops


• Traction deformities
• Stretching of loops; air trapped in valvulae conniventes
• Asymmetric thickening of small-bowel wall
• Small-bowel loops closely applied to anterior peritoneum
• Thickening of anterior peritoneum

Fig. 11—Nonobstructive symptomatic adhesions. Axial CT image in 59-year-old man


with abdominal pain after renal transplant shows small bowel adherent to anterior
peritoneum (white arrows) and kinking of bowel loop (arrowhead). There were no
overt CT features of small-bowel obstruction. Patient subsequently underwent adhe-
sion lysis with improvement of symptoms. K = superior pole of transplanted kidney.

APPENDIX 3: CT Findings of Closed-Loop Obstruction (Fig. 12)

• Distended fluid-filled loops • Proximal bowel less distended than closed loop
• C or U segment if axial CLO • Distal bowel nondistended
• Radial distribution of loops in more oblique CLO Note—CLO = closed-loop obstruction.
• Two ends of distended loop come together

A B
Fig. 12—Closed-loop obstruction in 50-year-old man.
A and B, Axial CT images show beaked appearance of distal and proximal ends of closed loop (arrowheads) as well as bowel wall thickening and increased enhancement,
indicating impaired mesenteric venous return. Fluid-filled, distended small-bowel loops (white arrows, A) show radial distribution. Black arrow (A) = jejunum.
(Fig. 12 continues on next page)

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Fig. 12 (continued)—
Closed loop obstruction
in 50-year-old man.
C, Sagittal reconstruc-
tion allows better appre-
ciation of proximity of
ends of closed loop
(arrowheads).
D, Coronal reconstruc-
tion shows radial pattern
of closed loop (white
arrows). Distended
bowel in left flank con-
taining oral contrast on
images A and D (black
arrows) is jejunum,
which lies proximal to
closed loop. There is
moderate ascites.

C D

APPENDIX 4: CT Findings in Strangulated Obstruction of Small Bowel (Fig. 13)

• Early Signs • Advanced Ischemia


Wall thickening Mesenteric vessel blurring
Ascites Hemorrhagic ascites
Mesenteric vessel engorgement Mesenteric or portal venous gas
Target or halo appearance due to submucosal edema Pneumatosis
Enhancement of bowel wall on venous phase of IV contrast
Reduced enhancement of bowel wall on arterial phase of
IV contrast

A B
Fig. 13—Strangulating obstruction.
A, Axial CT after Whipple procedure in 68-year-old woman shows enhancing loop of jejunum in left flank (white arrows). Patient was found to have necrotic jejunum with
closed-loop obstruction at surgery, which was performed 8 hours later.
B, Axial CT in 63-year-old man 10 days after sigmoid colectomy shows mesenteric venous air (arrowheads). Patient died during emergency laparotomy and was found to
have strangulating obstruction.

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