Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

Closed Loop in Small bowel obstruction
by Jay P. Heiken and Robin Smithuis
Mallinckrodt Institute of Radiology of the Washington University School of Medicine, St. Louis, Missouri and the Rijnland
Hospital, Leiderdorp, the Netherlands

Small Bowel Closed Loop Obstruction

Imaging technique in SBO Publicationdate 2012-11-01
Small Bowel Feces Sign
Case of small bowel strangulation This article is based on a presentation given by Jay
Paraduodenal herniation
Heiken in 2006 and adapted for the Radiology Assist‐
Volvulus of Large Bowel.
Cecal Volvulus ant by Robin Smithuis.
Sigmoid Volvulus In 2012 an updated version was presented.
Jay Heiken is professor of radiology at the Mallinck‐
rodt Institute of Radiology of the Washington Univer‐
sity School of Medicine in St. Louis.
He has a special interest in abdominal imaging and is
co-author of the well known book 'Computed Body
Tomography With MRI Correlation'.

Small Bowel Closed Loop

Obstruction

Closed Loop Obstruction

Closed loop obstruction is a specific type of obstruc‐

tion in which two points along the course of a bowel
are obstructed at a single location thus forming a
closed loop.
Usually this is due to adhesions, a twist of the mesen‐
tery or internal herniation.
In the large bowel it is known as a volvulus.
In the small bowel it is simply known as small bowel
closed loop obstruction.
Especially in the small bowel the risk of strangulation
and bowel infarction is high with a mortality rate of
10-35%.

Case of small bowel obstruction

Enable Scroll
Let first start with a rather difficult case and then con‐
tinue with some basic knowledge about closed loop
obstruction.

Here we have a patient with a small bowel

obstruction.
 So the most important question for you to answer is:
Abdomen Breast IsCardiovascular
there a closed loop
Chestobstruction?
Head/Neck Musculoskeletal
Because if there is, this patient is at risk for bowel in‐
farction and surgery is the best option.
Neuroradiology Pediatrics More
Scroll through the images.
Can you find the closed loop and what is the cause?

Scroll through the images

When we have a patient in the ER with what appears

to be a small bowel obstruction (SBO), the most im‐
portant thing we can do, besides making the dia‐
gnosis, is to identify the presence or absence of stran‐
gulation.
Strangulation is defined as obstruction associated
with vascular compromise.
The morbidity and mortality rate in the SBO-group is
mainly due to bowel infarction and subsequent nec‐
rosis.
This is most commonly caused by a closed loop ob‐
struction.
CT is the imaging procedure of choice in the evalu‐
ation of patients suspected of SBO.

The CT-presentation of a closed loop obstruction in

the small bowel depends on two things:
length of the bowel segment that forms the
closed loop
orientation of the loop in relation to the imaging
plane

If we have a short closed loop oriented within the

'U' or 'C' shaped loops of bowel. Point of obstruction has a beak- plane of imaging, we will see a U- or C-shaped loop of
like appearance bowel.

Another important appearance of a closed loop ob‐

struction is that of a radial array of dilated small
bowel loops with the mesenteric vessels converging
 to a central point.
Abdomen Breast This is almost always
Cardiovascular Chestdue to a smallMusculoskeletal
Head/Neck bowel volvulus.

The findings of ischemia in closed loop obstruction

are the same
Neuroradiology Pediatrics as in patients with other causes of mes‐
More
enteric ischemia:
bowel wall thickening
mesenteric edema
ascites
enhancement of the bowel in ischemia can be
normal, increased or there can be lack of
enhancement.

Closed loop obstruction with radial array of dilated loops. There is

bowel wall thickening and mesenteric edema indicating ischemia

The case on the left shows another patient with

closed loop obstruction.
Although there is good enhancement of the vessels
there seems to be a lack of enhancement of the
bowel wall.

Other signs of ischemia in this case are mesenteric

edema and bowel wall thickening.
Infarcted bowel was found at operation.

Closed loop obstruction with bowel ischemia

If the closed loop is longer and is oriented perpendic‐

ular to the plane of section, we will see a clump of
bowel loops as shown in the case on the left.
Sometimes this is difficult to appreciate on just the
axial images and coronal or sagittal reconstructions
can be helpful.
In this case there is also mesenteric edema and local‐
ised ascites in combination with dilated loops with
wall thickening indicating strangulation and risk of
infarction.
Closed loop obstruction presenting as a clump of bowel loops

Imaging technique in SBO

CT is the imaging procedure of choise in patients who
are suspected for bowel obstruction.
When we examine these patients, we should not give
oral contrast for following reasons:
There is already bowel distension and
administering oral contrast material will make
the patient even more uncomfortable and likely
will cause emesis
The bowel content serves as a neutral contrast
agent and i.v. contrast is given to see if there is
abnormal enhancement of the bowel wall.

Abdomen Breast Cardiovascular
Neuroradiology Pediatrics More
Closed loop obstruction and small bowel feces sign in a patient
with non-dilated proximal bowel
If positive contrast is given this will hamper our
ability to assess the enhancement of the bowel
wall. Chest Head/Neck Musculoskeletal
In some of the patients with a closed loop obstruction
a bowel obstruction is not suspected.
In the case on the left positive oral contrast was
given.
Notice the constriction in the small bowel in figure B.
Distal to the constriction in figure C we see a cluster
of dilated small bowel loops not filled with oral con‐
trast, indicating the closed loop.
Only rarely contrast will pass the point of obstruction
and enter the area of the closed loop.
If we go back to figure B, you may already have no‐
ticed that there are two points of narrowing in the
small bowel (arrows).
Therefore we have two adjacent collapsed small
bowel segments representing the point of the closed
loop obstruction.
The bowel wall thickening, ascites and mesenteric ed‐
ema indicate the presence of bowel ischemia.
Notice that you cannot appreciate the degree of
bowel wall enhancement in the loops that are filled
with oral contrast.
Small Bowel Feces Sign
In some of these patients with SBO the proximal
small bowel proximal to the point of obstruction may
not be dilated.
On the left we see images of a patient in whom ob‐
struction was not suspected.
This patient also received positive oral contrast.
Look for the major findings and then continue.
First you will notice that the small bowel is not
dilated.
When you go down to the pelvis you see a dilated
loop of bowel with inhomogeneous content and fi‐
nally deep down in the pelvis there is a C-shaped
dilated bowel indicating a closed loop obstruction.
The other important finding in this patient is the
'Small Bowel Feces Sign' (SBFS: arrow).
The SBFS is a very useful sign as it is seen at the
zone of transition from normal to obstructed bowel
and thus facilitating identification of the point and the
cause of the bowel obstruction.
The SBFS has been defined as gas and solid material
within a dilated small-bowel loop that simulates the
appearance of feces.
 Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
Case of small bowel strangulation
Enable Scroll
The CT images
Neuroradiology Pediatrics More are of a patient with mild left flank
pain.
At presentation the lab findings were normal.
Based on this CT it was thought that this patient had
a diverticulitis (red arrow).
The mild dilatation of the small bowel adjacent to the
descending colon was thought to be a reactive sen‐
tinel loop.

Scroll through the axial images.

Notice the locally dilated small bowel with the radiat‐
Click to enlarge and then scroll through the images ing pattern of the mesentery (image 7/11).

Three days later the CT was repeated with i.v. con‐

Enable Scroll trast to get a better impression of the small bowel.
There is a progressive dilatation of the small bowel.
First study the images, then continue with the next
series.

Click to enlarge and then scroll through the images

Notice the radial array of dilated small bowel loops on

Enable Scroll the left with the mesenteric vessels converging to a
central point.
These bowel loops are wider than other loops and
show less enhancement.
There are dilated mesenteric veins (yellow arrow).
At the point of strangulation the afferent loop is
dilated (blue arrow) and efferent loop is collapsed
(red arrow).
The distal small bowel is collapsed (red arrows).
The proximal small bowel is dilated (blue arrow).
There is a large amount of ascites in Douglas cave,
which also indicates the possibility of ischemia (blue
Click to enlarge and then scroll through the images arrow).

Sometimes multiplanar reconstructions can be help‐

Enable Scroll ful in making the diagnosis of closed loop obstruc‐
tion.
Scroll through the sagittal images.
Notice how the afferent loop enters the strangulated
bowel and mesentery (image 8-10/13).
 Notice reactive changes in the mesocolon simulating
Abdomen Breast diverticulitis.
Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

Click to enlarge and then scroll through the images

The coronal reconstruction demonstrates the point of

Enable Scroll strangulation with the dilated afferent loop, the stran‐
gulated loop and the collapsed efferent loop.
The yellow arrow marks the dilated veins.

Coronal reconstructions. Click to enlarge and then scroll through

the images

At operation an ischemic strangulated small bowel

was found, which was herniated through a hole in the
mesocolon.
Here we see the resected part of the small bowel.
Notice the areas of necrosis and the dilated veins,
which were also seen on the CT-images.

Coronal reconstructions of another patient with a

Enable Scroll closed loop obstruction.
The obstructed afferent loops are indicated in red ar‐
rowheads.
The collapsed efferent loop is indicated by a red ar‐
row.
Notice the closed loop cranially to the area of ob‐
struction.
At surgery the bowell was not ischemic.

Go to the axial images of this case

Click to enlarge and then scroll through the images
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
Paraduodenal herniation
Neuroradiology Pediatrics
There are More
various types of internal herniation.
The illustrations shows a left paraduodenal hernia.
This is an uncommon form of internal herniation.

The CT-images show a left paraduodenal hernia.

Enable Scroll Notice the engorged veins (blue arrow).
The duodenum is dilated (red arrow) and there is re‐
tention of fluid in the stomach.
At operation the herniated small bowel was not
ischemic.

Click to enlarge and then scroll through the images

Volvulus of Large Bowel.

On the left a plain abdominal film is shown of a 57

year old man with a two day history of increasing ab‐
dominal pain and distension.
First look at the image and then continue.

Besides diffuse dilatation of the bowel, the major find‐

ing on this film is a large air containing structure in
the pelvis.
An important diagnosis to consider would be a volvu‐
lus of the colon and many would diagnose this as a
sigmoid volvulus because it is located in the pelvis.
However this actually is a cecal volvulus as will be ex‐
plained below.

Cecal Volvulus
A volvulus always extends away from the area of
bowel twist.
 So a sigmoid volvulus can only move upwards and
Abdomen Breast usually goes to the
Cardiovascular rightHead/Neck
Chest upper quadrant.
Musculoskeletal
Cecal volvulus however can go almost anywhere and
can even be located in the pelvis (figure).
Neuroradiology Pediatrics More

Cecal volvulus can go almost anywhere

On the left there are additional CT-images of the same

patient as above.
First look at these images and look for the major find‐
ings and then continue.

First we see a collapsed descending colon and a non-

dilated ascending colon, so this cannot be a sigmoid
volvulus.
Secondly, we see a beak-like structure in the right
lower quadrant which is where the bowel is twisted. In
the left lower quadrant we see the dilated cecum.

Coronal recontructions can be very helpfull in demon‐

strating what is going on.
On the left we see the non-dilated ascending and des‐
cending colon (straight arrows) and the transition
point of the volvulus (curved arrow).

Cecal volvulus is due to the cecum twisting around

the ascending colon thus leading to small bowel ob‐
struction.
A long narrow based mesentery predisposes to volvu‐
lus.
An incomplete midgut rotation is a predisposing
factor.
Infarction is usually the result of venous congestion,
while the arterial supply is rarely compromised.

Cecal volvulus accounts for about 25% of cases of

colonic volvulus.

On the left a typical cecal volvulus is seen.

We can see the beak-like transition zone located in
 the right lower quadrant indicating that this is a cecal
Abdomen Breast volvulus.
Cardiovascular Chest Head/Neck Musculoskeletal
The dilated cecum is located in the left upper quad‐
rant.
Also notice
Neuroradiology Pediatrics the collapsed descending colon posterior
More
to the dilated cecum (curved arrow).

Dilated cecal volvulus (C) shifting away from the area of bowel
twist (arrow)

The x-rays show a typical cecal volvulus.

Notice that the dilated bowel points toward the area
of twist, which is the area where you expect the
cecum to be located.
Continue with the CT-images.

Scroll through the images.

Enable Scroll The areas of twist and obstruction are marked.

Cecal volvulus. Click to enlarge and then scroll through the

images

Sigmoid Volvulus
On the left a patient with a sigmoid volvulus.
We can see the distended sigmoid extending from the
pelvis way up into the right upper quadrant.
Look at the image and decide for yourself why this
cannot be a cecal volvulus.
Then continue.

The key finding is the dilatation of the proximal colon.

The dilated loop seen on the left side is the dilated
transverse colon.
 At CT we can nicely appreciate the area of the twist
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
with the sigmoid extending up to the diafragm.

The sigmoid
Neuroradiology Pediatrics is the commonest site of colonic volvu‐
More
lus.
It accounts for 75% of large bowel obstruction.

AP supine and erect radiograph of the abdomen

demonstrates the characteristic coffee bean sign in
sigmoid volvulus.
Notice that the dilated loops point towards the sig‐
moid area.
Continue with the CT-images.

Sigmoid volvulus

Scroll through the images.

Enable Scroll Notice the transition point (red arrows).

Sigmoid volvulus. Click to enlarge and then scroll through the

images

Here another sigmoid volvulus.

On the abdominal x-rays it is difficult to recognize
what is going on, since so many bowel loops are
dilated.
Continue with the CT-images.

Sigmoid volvulus

CT is very helpful in this case and demonstrates the

Enable Scroll twist at the transition point (arrow).
The last image shows the collapsed rectum posterior
to the dilated small bowel loops.
 Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

Sigmoid volvulus. Click to enlarge and then scroll through the

images

In the pelvis dilated small bowel loops were seen and

a collapsed distal sigmoid (arrow).

1. CT of Small-Bowel Obstruction
by Emil J. Balthazar
Department of Radiology, New York University-Tisch-Bellevue Medical Center, 550 First Ave., New York, NY 10016.
AJR 1994;162:255-261
2. CT of Cecal Volvulus, Unraveling the Image
by Carolyn J. Moore, Frank M. Corl and Elliot K. Fishman
Department of Radiology, Johns Hopkins Hospital, 601 N. Caroline St., Baltimore, MD 21287.
AJR 2001; 177:95-98

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