Jurnal Obstruksi
Jurnal Obstruksi
Jurnal Obstruksi
To cite this article: 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,
DOI: 10.1080/20786190.2014.977052
a
epartment of Radiology, Nelson R Mandela School of Medicine, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
D
b
Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
*Corresponding author, email: [email protected]
Small bowel obstruction is a common clinical presentation that presents a diagnostic conundrum. Over the last 2 decades, there
has been a paradigm shift in the radiological investigation of small bowel obstruction (SBO) and in the indication for and timing
of surgical intervention. Cross-sectional imaging (predominantly computed tomography) has largely replaced the widespread
use of radiographic small bowel follow-through studies as the imaging modality of choice for SBO. This article illustrates the
current imaging modalities available for diagnosis of small bowel obstruction.
Keywords: computed tomography, enteroclysis, intussusception, radiology of bowel obstruction, small intestinal obstruction
Introduction Clinical
Intestinal obstruction is a common clinical entity presenting Clinically patients present with abdominal pain, distension, nausea,
with signs and symptoms that mimic several acute abdominal and vomiting,3 which may mimic other abdominal emergencies.
disorders and is responsible for approximately 20% of all surgical
admissions for acute abdominal conditions.1,2 Bowel obstruction Over the last 50 years, the aetiology of SBO has changed from
may be mechanical or paralytic in origin and may be subdivided predominantly hernias (Figures 1a and b) to adhesions (Figure 1c),
into large and small intestinal obstruction. The small bowel (SB) Crohn’s disease (Figure1d) and malignancies as the top three causes
is affected in 60–80% of cases.2 of SBO in Western society.3,4 Hernias remain the predominant cause
of SBO in some developing countries,3 with TB and HIV forming a
Over the last 2 decades, there has been a paradigm shift in the significant contributory factor in the developing world.
radiological investigation of small bowel obstruction (SBO) and
in the indication for and timing of surgical intervention. The old Radiological investigations
surgical adage when faced with possible SBO, ‘to never let the Plain radiographs
sun set or rise on an obstructed bowel’,1 has completely changed Despite advances in modern radiology, plain radiographs remain
with the revolutionary advances in abdominal imaging, forming the pivotal starting point in the diagnostic algorithm of SBO. The
the cornerstone in guiding clinical decision-making.3 Diagnostic acute abdominal series encompasses an erect and supine
imaging is charged with the multifaceted task of verifying the abdominal radiograph and an erect chest radiograph.
presence of obstruction and providing relevant information on Conventional radiography is used to triage patients and assist
the site, severity, possible causes, and potential complications of the clinician in formulating an individualized management plan.
the obstruction.4Imaging addresses the pivotal question of Given the non-specific signs and symptoms of SBO, plain
whether to institute a trial of non-surgical treatment or to opt for radiographs are a bedside test that may potentially rule out
emergency surgery due to the risk of strangulation.4 The other causes of an acute abdomen such as renal calculi,
radiological diagnosis of SBO may be made by a variety of pancreatitis, and appendicitis. The literature shows that
imaging techniques including plain radiographs, enteroclysis, abdominal radiography in conjunction with clinical examination
and cross-sectional imaging [Computed Tomography (CT) & is diagnostic in only 50–60% of cases of SBO.3−6 SBO is suggested
Magnetic Resonance Imaging (MRI)]. The literature supports the by the findings of small bowel distension with absent colonic
continued use of plain radiographs for initial screening of gas; however, due to the great interpreter variability and
patients; however, the next step in the imaging pathway depends confusion over diagnostic terms, emphasis has been placed on
on the clinical findings and the particular questions that need to the consistency of the terms used by radiologists to describe
be answered in each individual case. intestinal bowel patterns when reviewing plain abdominal films.3
This article reviews the current imaging modalities available for The following terminology has been advocated to describe SB
diagnosis in order to assist the clinician in making the most gas patterns3–5: as can be seen in Table 1.
appropriate and cost-effective decision for optimum patient
management. Given the escalating costs of healthcare and the The presence of ≥ 2 air fluid levels, differential air fluid levels in
advent of newer more advanced and revolutionary imaging the same loop of bowel more than 2 cm in height and a mean
modalities; the radiologist needs to guide family practitioners in air–fluid level of > 25 mm in width on erect abdominal
requesting the most appropriate available diagnostic study to radiographs is highly suggestive of high grade obstruction.1,4,5
positively influence clinical management, improve patient The cause of SBO is often unidentifiable on plain films.
outcome, lower medical costs, all without compromising a high Rarely pathologies such as gallstone ileus, inguinal hernias,
standard of patient care. gossypibomas, ingested foreign bodies and worm bolus may be
South African Family Practice is co-published by Medpharm Publications, NISC (Pty) Ltd and Cogent, Taylor & Francis Group
147 S Afr Fam Pract 2015; 57(3):146–159
Normal bowel gas pattern ≤4 small bowel loops<2.5 cm in diameter with normal distribution of gas and faeces in a non-distended
colon
Abnormal but non-specific bowel gas pattern At least 1 small bowel loop that is borderline or mildly distended [2.5−3 Cm in diameter] with ≥ 2 air fluid
levels on erect/lateral decubitus films. Colon either normal calibre or borderline distended. May represent
either low grade sbo/adynamic ileus. May require further examination by ct/ba enteroclysis
Probable small bowel obstruction pattern Multiple gas and fluid filled dilated sb loops with moderate amount of large bowel gas. May occur in ear-
ly complete sbo, partial high grade sbo/adynamic ileus. Patient should undergo ct with/out enteroclysis
Definite/unequivocal small bowel obstruction Dilated fluid filled small bowel loops with a gasless colon
(Figure 2)
CT: computed tomography, SBO: small bowel obstruction
diagnosed on plain film6 (Figures 3a and b). Features consistent which necessitate urgent surgical intervention. CT findings
with strangulation such as pneumatosis intestinalis, gas in the modified patient management in 21% either by changing
portal veins and thickened oedematous folds are rarely seen.6 An conservative to surgical management (18%) or vice versa.4
erect chest radiograph/lateral decubitus abdominal film may
show pneumoperitoneum if SBO is complicated by perforation. CT answers the following five specific questions that impact
clinical management.
Significant limitations in the diagnostic accuracy and specificity
of plain film radiography are clearly documented in the literature.1 (a) Is the SB obstructed?
Despite these limitations, the recognition of an unequivocal SBO CT criteria for SBO: Presence of dilated proximal (> 2.5 cm from
pattern, the high sensitivity in detecting high grade obstruction, outer wall to outer wall) (Figure 4) and collapsed or normal caliber
the widespread availability of plain radiographs, and its distal loops1,8.
cost-effectiveness result in conventional radiography forming the
mainstay in the evaluation of suspected SBO.6,7
(b) Where is the transition point (TP)?
Advantages: Cost-effective, easily available. If an unequivocal The transition point (TP) is determined by identifying a caliber
SBO pattern is diagnosed, urgent surgical management may be change between the dilated proximal and collapsed distal SB
commenced. Serial imaging may be performed to assess loops1,8 (Figure 5). A systematic retrograde approach starting from
progression. the rectum and proceeding proximally to the caecum, ileum, and
jejunum is advocated,1,8 to identify whether the small or large bowel
Limitations: Maybe normal in early obstruction. May be non- is involved and to identify the transition zone. The transition point
diagnostic in low grade obstruction. Rarely demonstrates may be described as absent, abrupt [marked prestenotic dilatation
aetiology. and obvious transition] or gradual/discrete [no/minimal prestenotic
dilatation].
Multi-detector computed tomography (MDCT)/
CT enterography/CT enteroclysis (CTE) (c) What is the cause of the obstruction?
Given the significant limitations in the diagnostic accuracy and
The rule of thumb is that the answer to this question is almost
specificity of plain film radiography, cross-sectional imaging like
always at the TP, as can be seen in Table 2.
CT has revolutionized the assessment of SBO. CT has effectively
replaced contrast studies as the imaging modality of choice for
Given the scourge of Human Immunodeficiency Virus (HIV) and
suspected SBO. Advances in MDCT with multiplanar (MPR) and
Mycobacterium Tuberculosis (TB) infection in the developing
3-Dimensional (3D) reformat capabilities allows the demonstration
world, and South Africa specifically, the impact of HIV and TB as a
of pathological processes involving the bowel wall, bowel lumen,
causative agent of SBO requires a special mention.
mesentery, mesenteric vessels, and peritoneal cavity.7 MDCT is
superb in confirming the presence of, determining the site, level,
and cause of SBO, and in demonstrating complications, for Mycobacterium tuberculosis (TB) infection in SBO
example infarction and perforation.5 Thus, CT has become an Tuberculous small bowel infection leading to obstruction is
important tool in the pre-operative assessment of SBO,4,5 reportedly more prevalent in developing countries. TB is rampant
providing an anatomical road-map for surgery, especially for high in our environment, leading to increased mortality and morbidity.9
grade partial and complete SBO.5 Controversy exists regarding Concomitant HIV infection, with the development of multidrug
the use of oral contrast in the CT assessment of SBO; however, and extremely drug resistant strains, significantly compounds
current teaching advocates using IV contrast only in the acute the clinical problem, increasing mortality and the risk of
setting, as the retained intraluminal fluid provides a natural post-operative sepsis. Abdominal TB has a chronic indolent
negative contrast agent allowing for accurate bowel assessment. course and is usually prevalent in poor socio-economic groups
Some authors advocate unenhanced CT for the assessment of with poor healthcare access, which often leads to delays in
SBO, especially when renal impairment or contrast allergies exist; diagnosis, greater morbidity, and a greater healthcare burden.
however, further peer evaluation is required.
It has been well documented that TB is the most common
The speed of helical MDCT and its ability to reveal the cause of infective cause of SBO worldwide.10 In a Tanzanian study
obstruction makes it invaluable in the acute setting.4 CT has performed by Chalya et al.9 22.4% of patients developed SBO due
proven useful in triaging patients into operative versus non- to TB infection. This was comparable to a study performed by Ali
operative treatment groups by differentiating the ileus from et al.11 in Pakistan, which attributed 21.8% of cases of SBO to TB.
mechanical obstruction, and by revealing the more serious
complications of closed loop obstruction and strangulation, Intestinal TB usually presents in one of 3 main forms9:
A review of the radiological imaging modalities of non-traumatic small bowel obstruction 148
Extrinsic Adhesions Diagnosis of exclusion.8 50–75% of SBO cases16Arise from previous CT/MRI: Diagnoses inferred if there is SBO with a narrow
surgery/congenital or secondary to abd/pelvic inflammatory disease/ zone of transition with no identifiable obstructing lesion.
endometriosis. May be single/multiple.10
Hernias External: [95%]. Occur at sites of congenital weakness/previous CT Diagnosis difficult. Key is identification of abnormal
surgery. Indirect inguinal hernias commonest. Femoral hernias position of SB and alteration in course of mesenteric
obvious on CT.16 vessels. Useful in detecting hernias at unsuspected sites
Internal: bowel herniates through the peritoneum/mesentery/peritone- and in the obese. Internal hernias important cause of
um or adhesive band10 and lies trapped intra-abdominally. Substantial closed loop obstruction. On CT the oedematous bowel
risk of strangulation. Commonest type = left paraduodenal.10 Transomen- wall shows mural stratification ‘target sign’ with congestion
tal hernias becoming commoner with complex abdominal surgeries. of the mesentry.
Haematomas Secondary to anticoagulation/trauma/iatrogenic. Duodenum CT: Hyperattenuating clot/active IV contrast extravasation.
(Figure 6a) commonly involved.10 Serosal haematoma may be seen as eccentric hyperdense
bowel wall thickening causing luminal attenuation.10
Endometriosis Presence of functional endometrium outside the uterus. Gastrointes- MRI modality of choice. CT may show hyperattenuating
tinal involvement infrequent cause of SBO. Rectum, sigmoid colon, mass causing bowel obstruction.
terminal ileum usually involved.
Midgut volvulus May occur in congenitally predisposed patients due to malrotation. CT/MRI/US: Abnormality in bowel distribution associated
Can present with obstruction in adulthood. with reversal of superior mesenteric artery and vein
relationship.
Omphalomes- Omphalomesenteric/Vitelline duct embryonic communication between CT: Similar findings to post-operative adhesions except
enteric band yolksac and midgut. Regresses 9th week in utero. Incomplete regression in a virgin abdomen. Diagnosis of exclusion.
results in congenital fibrous bands that cause SBO and volvulus.17
Intraluminal Gallstone Ileus Rare. Common in elderly females. 27% mortality. Terminal ileum Plain film: Rigler’s Triad: SBO, pneumobilia and ectopic
common site of obstruction. Requires urgent surgery.10,17 gallstone. (1/3 of cases). CT superior for diagnosis16,17
Bezoar Unusual cause. Most common foreign body, classified according to CT: mottled intraluminal mass with air retained in the
composition. Common in jejunum/prox ileum. Trichobezoars most interstices. Usually round with encapsulating wall.8
common in children and adolescents, psychiatric patients with Similar to small bowel faeces sign which is uncapsulated
trichotillomania. and tubular.16,17
Gossypibomas Cotton foreign body retained inside the body following surgery. High Most specific imaging findings are radio-opaque markers
risk of fistulization the longer the retention. Usually cannot pass the on plain films.
ileocaecal valve and cause complete SBO.17 CT: Entrapment of air bubbles in a spongiform pattern.
Circumscribed mass with a ‘whirl-like’ gas collection in the
cotton mesh. Intense IV contrast enhancement of surround-
ing soft tissue due to fibrosis and granulation tissue.17
Enteroliths Unusual cause of SBO. Form within SB diverticulae. Can mimic CT/MRI: SB diverticulae with normal gallbladder.16
gallstone ileus.
Distal intestinal Distal SB obstruction by viscous stool. Common in adults with cystic CT: SBO with feculent filling defects in the small bowel.16
obstruction fibrosis. May be complicated by intussusception. Responds to surgical
syndrome management. May be related to pancreatic insufficiency & intestinal
malabsorption.
Intrinsic Inflammatory EG: Crohn’s disease: Acute: mural stratification. Mural enhancement, phlegmon.
(Figure 6b) Abcesses. Strictures. Comb sign: peri-enteric hyperaemia10,16
Chronic: Fibrofatty proliferation. Fistulae, stenosis,
abcesses.10,16
Infectious TB: commonest, esp in developing countries (Figure 6c). Ileocaecal CT/MRI: mural thickening with mesenteric adenopathy.
region commonly affected.10 ± Ascites ± Peritoneal thickening. Chronic TB can cause
retraction and mesenteric fibrosis with mechanical SBO.10
HIV: Increased incidence of opportunistic infection and AIDs defining CT/MRI: findings of lymphoma/intussusception.
neoplasms which may lead to intussusception.
Vascular ISCHAEMIA: secondary to occlusion/stenosis of mesenteric arteries/ CT/MRI: May show thrombi in vessels.10 Ischaemic bowel
veins.10 shows no/delayed enhancement, mural thickening,
mesenteric clouding, air in the portal vein, pnematosis
intestinalis.1,10
RADIATION: adhesive and fibrotic mesenteric changes.10 Abnormal CT: abnormal enhancement and bowel wall thickening
enhancement and bowel wall thickening involving multiple loops in involving multiple loops in the radiation field.10 Angular
the radiation field. bowel wall secondary to adhesions.1
Neoplasms Cause mural thickening/luminal attentuation and SBO. May be primary CT/MRI: enhancing mural thickening/polypoidal masses
(Figures 6d or secondary.16 Benign lesions include lipomas, haemangiomas, with luminal attenuation. May produce focal aneurysmal
and e) neurogenic tumours. Adenocarcinoma: commonest. Most often in SB dilatation.
duodenum.10 Rare in the ileum unless associated with Crohn’s disease.
Carcinoid/lymphoma: occur in distal small bowel/mesentery. Other
primary tumours, e.g. gastrointestinal stromal tumours. Secondary
deposits from melanoma, breast, etc. can cause SBO.
Haematomas Secondary to anticoagulation/trauma/iatrogenic.1 Duodenum CT: Hyperattenuating clot/active IV contrast extravasation.
commonly involved.
Intusssuscep- 5% of adult SBO.1 Secondary to a lead point, e.g. neoplasm.1 CT/MRI: EARLY: Dilated bowel loop containing eccentric
tion (Figure 6f) Common in HIV. Collapsed intussuscepted prox bowel (intussusceptum) fat crescent.
with mesenteric fat and vessels telescopes into the distal bowel lumen ADVANCED: Sausage/reniform mass with alternating
(intussuscepiens).8 layers of low (mesenteric fat) and high
attenuation (bowel wall).1,10
149 S Afr Fam Pract 2015; 57(3):146–159
Figure 1c: Axial CT showing SBO with abrupt transition point (yellow arrow) with no associated mass in keeping with an
adhesive band, confirmed at surgery
Figure 2: Erect abdominal radiograph: Small bowel dilatation with multiple air fluid levels at different heights with string of
beads sign (arrow) in keeping with definite small bowel obstruction
misleading. Motion/streak artefacts/retained residual barium naso-intestinal intubation with controlled continuous
in the gastrointestinal tract can obscure detection of CT administration of positive/neutral enteric contrast in conjunction
features.16 with CT acquisition. By challenging the SB distensibility with
continuous infusion, CTE offers improved sensitivity and
CT Enteroclysis (CTE) is a hybrid technique that encompasses specificity over standard barium EC and CT exams in the
the advantages of CT and enteroclysis (EC) in a single study.5 evaluation of suspected intermittent or low grade SBO.3,5
It offers better control of small bowel distension as it involves 3D acquisition capabilities allow evaluation of enteric and
A review of the radiological imaging modalities of non-traumatic small bowel obstruction 152
Figure 5: Coronal CT abdomen showing an abrupt beak-like transition point in the right iliac fossa with mural hyperenhancement (arrow) secondary to
Crohn’s disease
153 S Afr Fam Pract 2015; 57(3):146–159
Figure 6a: Axial CT in a known haemophiliac showing SBO secondary to Figure 6b: Axial CT showing gross SBO with a target sign in the right
a large hyperdense haematoma (arrow) iliac fossa secondary to active Crohn’s disease
Figure 6c: Coronal CT showing gross small bowel dilatation (yellow arrow) with extensive mesenteric adenopathy (blue arrow)
secondary to tuberculosis
A review of the radiological imaging modalities of non-traumatic small bowel obstruction 154
Figure 6f: Axial post-contrast CT showing a mass in the right iliac fossa (blue arrow) with alternating layers of low (mesenteric
fat) and high attenuation (bowel wall) in keeping with ileocolic intussusception with SBO
Figure 9a: Axial CT enterography using water showing gross SBO with an abrupt transition point (arrow) in the right iliac fossa
secondary to a stricture from tuberculosis
information on extra-enteric structures, have frequent blind spots invaluable clinical weapon in patients who present with
due to overlapping bowel, and may delay subsequent CT due to diagnostic dilemmas.
retained barium.5 This method only provides endoluminal
information, as opposed to CT, which evaluates enteric and Limitations: Requires naso-intestinal intubation, near constant
extra-enteric pathology simultaneously. radiologist involvement.4 High radiation dose. Limited imaging of
luminal pathology only compared to CT.
Intubation methods
Thus, the hybrid technique of CTE is now performed more
Barium EC overcomes the limitations of oral techniques by frequently in the assessment of clinically stable patients with
challenging bowel distensibility and exaggerating the effect of SBO.3
subclinical SBO.3,4 Barium enteroclysis entails naso-intestinal
intubation with the continuous controlled infusion of contrast in Abdominal ultrasound (US)
conjunction with intermittent fluoroscopic screening. This Abdominal sonography has traditionally been regarded as the
method can successfully assess the presence, level, and cause ugly step-sister in the diagnostic pathway for assessment of SBO;
of SBO with an accuracy of 86–100%3,4, 100% sensitivity and 88% however, the literature shows US to demonstrate great potential. At
specificity.3 It detects subtle mucosal abnormalities, small sonography, SBO is diagnosed when SB loops are dilated to more
intraluminal masses, and minimal adhesions, even in the absence than 3 cm; there is hyperperistalsis in the dilated segment and a
of SB dilatation. It is contra-indicated when ischaemia/perforation whirling motion of bowel contents.1 Worsening mechanical
or complete SBO is suspected. obstruction and the need for imminent surgery is suggested by the
presence of free interloop fluid in the absence of other causes for
Advantages: The ability to distinguish normality from low grade ascites.3 Evaluation by an expert sonologist can determine
SBO and to assess multilevel obstruction,4,5 which makes it an the presence, level, and cause of SBO. Adynamic ileus can be
157 S Afr Fam Pract 2015; 57(3):146–159
Conclusion
SBO presents a diagnostic challenge. It is important for clinicians
to understand the advantages and limitations of the various
Figure 10: Reproduced with permission from: Amzallag-Bellenger
imaging modalities to guide clinical management. Ultimately in
E, Oudjit A, Ruiz A, et al. Effectiveness of MR enterography for
the assessment of small-bowel diseases beyond Crohn Disease. the South African context, the local availability of different services
RadioGraphics 2012;32:1423–1444. Adhesive ileal obstruction in a (e.g. on-site CT/MRI scanner) and local clinical expertise will guide
30-year-old woman with a history of appendectomy and recurrent the choice of investigation. From the above review it is apparent
low-grade bowel obstruction. MR enterography was performed after that plain radiographs remain at the forefront of the diagnostic
the administration of 1 litre of an oral contrast agent. Coronal FISP imaging pathway, given their ready availability, cost-effectiveness,
image from MR enterography demonstrates ileal loop dilatation and ability to assess clinical progression on serial radiographs.
(curved arrow), a transition point (straight arrow), and normal distal
caliber (arrowhead). No mass, bowel wall thickening, stricture, or
other specific cause of obstruction was identified. These findings were The documented literature advocates the use of MDCT with IV
suggestive of an obstruction due to bowel adhesion, which was later contrast, as the next step in the imaging pathway for both high
confirmed at laparotomy grade and low grade partial obstruction. CT is highly sensitive
A review of the radiological imaging modalities of non-traumatic small bowel obstruction 158
Figure 12: Diagnostic algorithm providing a guideline for the investigation of SBO. Reproduced with permission of Silva AC, Pimenta M, Guimaraes LS. Small
bowel obstruction: what to look for. Radiographics 2009; 29:423-439.
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Received: 15-04-2014 Accepted: 22-08-2014