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al.
Imaging of
Acute Small-
Bowel
Obstruction
Imaging of Acute
Small-Bowel Obstruction
Savvas Nicolaou1 OBJECTIVE. The objective of this pictorial essay is to review the different imaging tech-
Brian Kai2 niques used for diagnosing small-bowel obstruction.
Stephen Ho3 CONCLUSION. Small-bowel obstruction is a common presentation, for which safe and
Jenny Su4 effective management depends on a rapid and accurate diagnosis. Conventional radiographs re-
Karim Ahamed5 main the first line of imaging. CT is used increasingly more because it provides essential
diagnostic information not apparent from radiographs. MRI may play a role in the future as
Nicolaou S, Kai B, Ho S, Su J, Ahamed K technology improves and it becomes more readily available.
A B
B C
Fig. 3—Strangulation.
A, Supine abdominal radiograph in 46-year-old woman
with ischemic colitis shows linear radiolucency
(arrows) along wall of bowel, which is consistent with
pneumatosis intestinalis. Dilated loops of small bowel
are also present.
B, Right-side-up decubitus abdominal radiograph in 69-
year-old woman shows multiple branching
radiolucencies (arrows) in periphery of liver shadow,
which is indicative of portal venous gas. Dilated loops
of small bowel are also present, which is consistent
with small-bowel obstruction.
A B
subacute setting, enteroclysis is very accurate ening supports infarction in the appropriate CT
in diagnosing low-grade and intermittent ob- clinical context [5]. Bowel wall perfusion can If an acute obstruction is suspected, CT is
structions [4] and can serve as an adjunct to also be assessed by Doppler sonography. the technique of choice for several reasons.
CT if more information, such as how much Sonography has been reported to have a First, it does not require oral contrast mate-
contrast material is making its way through sensitivity of 89% compared with 71% for rial because the retained intraluminal fluid
the obstruction, is required [4] (Fig. 4). conventional abdominal radiography in diag- serves as a natural negative contrast agent.
nosing small-bowel obstruction and is supe- Second, when compared with enteroclysis,
Sonography rior in its ability to identify features of stran- CT is rapid, noninvasive, and readily avail-
On sonography, small-bowel obstruction is gulation and to predict the location and cause able [3]. Finally, it also allows extramural ar-
suspected if multiple dilated (> 3 cm), fluid- of obstruction [5]. Although not routinely eas that would not be visible on contrast stud-
filled loops are seen (Fig. 5). The obstructing used, sonography may be indicated in criti- ies to be assessed.
cause can occasionally be visualized if it is a cally ill patients because transfer of the pa- The diagnosis of small-bowel obstruction
tumor or hernia. The presence of aperistalsis, tient to the examination table may be time- on CT involves identifying dilated loops of
fluid-filled bowel distention, and wall thick- consuming and difficult [5]. bowel proximally with normal-caliber or
A B
Fig. 5—Sonography features of small-bowel obstruction. Both cases are due to postoperative adhesions.
A, Abdominal sonogram in 40-year-old woman shows dilated, fluid-filled loop of small bowel with prominent valvulae conniventes (arrows).
B, Abdominal sonogram in 62-year-old man shows thickened small-bowel wall (arrows). Real-time scanning showed small bowel to be hyperperistaltic.
A B
A B
Fig. 7—Small-bowel obstruction secondary to Crohn’s disease.
A, Axial CT scan through lower abdomen of 44-year-old woman with small-bowel obstruction secondary to Crohn’s disease shows multiple fluid-filled loops of small bowel
(arrows) and CT equivalent of string-of-pearls sign on radiography.
B, Axial CT scan through lower abdomen in 28-year-old woman with Crohn’s disease shows partially solid material intermixed with air within distal small bowel (arrows),
similar in appearance to feces in colon; this finding is called the “small-bowel feces” sign.
A B
Fig. 8—58-year-old woman with small-bowel obstruction secondary to adhesions.
A, Axial CT scan through lower abdomen shows dilated proximal loop (arrow) and collapsed distal loop (arrowhead).
B, CT scan obtained inferior to A shows narrowing of involved loop of bowel (arrows). Adhesion is inferred to be causing narrowing given history of previous abdominal
surgery and given neither masses nor extrinsic processes are seen to result in narrowing. Multiple dilated loops of small bowel are also seen.
A B
Fig. 10—66-year-old woman with diagnosis of ischemic bowel.
A, Axial contrast-enhanced CT scan through mid abdomen shows multiple dilated
air- and fluid-filled loops of small bowel. There is evidence of pneumatosis
intestinalis and lack of bowel wall enhancement (thin arrow) as compared with
normally enhancing loop (thick arrow). Also seen is intraperitoneal free fluid
(arrowhead). Round radiodensity seen in one loop of small bowel is surgical drain.
B, CT scan obtained inferior to A shows air in mesentery (arrowhead), and lack of
bowel wall enhancement (arrows) is again seen.
C, CT scan obtained superior to A shows air in intrahepatic portal venous vasculature
(arrow).
Fig. 11—57-year-old woman with small-bowel volvulus. Axial CT scan through upper
pelvis shows whirl sign (arrow) signifying volvulus. Volvulus can result if loop of
bowel is able to rotate around its mesentery. If loop sits in axial plane, it will appear
as ⊂ or ∪ shape. If orientation of loop is at right angle to axial plane, appearance will
vary depending on slice.
collapsed loops distally. A small-bowel cali- diagnosis is more certain [6]. The transition been shown to be present in 60% of simple
ber of greater than 2.5 cm is considered di- point often resembles a beak and is described small-bowel obstruction cases [7]. Other reli-
lated [6]. If a transition point is detected, the as the beak sign (Fig. 6). This finding has able features include the string-of-pearls sign
A B
Fig. 12—64-year-old man with small-bowel obstruction secondary to incarcerated right inguinal hernia.
A, CT scan shows incarcerated right inguinal hernia resulting in small-bowel obstruction. Left and right arrows point to dilated loop of small bowel with engorged mesentery
(middle arrow).
B, Inferior transverse CT image obtained at level of symphysis pubis reveals incarcerated thick wall loop of small bowel within right inguinal canal (arrow).
structions [2]. However, when all grades of struction from ileus and determining the
small-bowel obstructions are taken into ac- cause of obstruction (Figs. 11 and 12).
count, the reliability of CT decreases dramat- Multiplanar reformations are now being
ically (sensitivity of 64% and specificity of used in difficult cases. Multiplanar views may
79%) [2]. Therefore, CT is not the ideal tech- help identify the site, level, and cause of ob-
nique for diagnosis of low-grade or subacute struction when axial findings are indetermi-
obstructions and should be complemented by nate [7] (Figs. 13 and 14). CT enteroclysis, a
a contrast study, ideally enteroclysis [6]. relatively new investigational tool for diag-
The most important information that CT nosing small-bowel obstruction, can also be
can provide the surgeon is whether there is an used with multiplanar reconstructions to
associated strangulation. The sensitivity of overcome the unreliability of CT for diagnos-
contrast-enhanced CT for intestinal ischemia ing low-grade obstructions. CT enteroclysis
has been reported to be as high as 90% [1]. has a greater sensitivity and specificity (89%
There are various signs that have been associ- and 100%, respectively) than CT alone (50%
ated with ischemia [3, 7], although their use- and 94%, respectively) [1]. At the same time,
fulness is debatable. These include, first, the 3D imaging provides precise localization
thickened bowel wall (Fig. 9); second, ascites of the pathology [1].
(Fig. 9); third, the target sign, a trilaminar ap-
Fig. 13—80-year-old man with small-bowel obstruction pearance of the bowel wall resulting from IV MRI
secondary to adenocarcinoma of large bowel. Coronal
reformatted 2-mm-thick CT view of abdomen reveals contrast enhancement of the mucosal and MRI provides rapid, accurate identification
small-bowel obstruction is caused by thick annular muscularis layers, plus submucosal edema of small-bowel obstruction [8] and assists in
constricting mass lesion involving hepatic flexure of (Fig. 9); fourth, poor or absent enhancement the determination of cause without exposing
large colon (thin arrows) resulting in proximal dilata-
tion of cecum (thick arrow) and small bowel (arrow- of bowel wall on IV contrast-enhanced scans the patient to radiation. MRI also utilizes in-
heads). Pathology revealed colonic adenocarcinoma. (Figs. 10A and 10B); fifth, pneumatosis in- traluminal air as a natural contrast agent and is
testinalis and gas in mesenteric or portal veins not limited by previous administration of bar-
(Fig. 10C); sixth, the whirl sign, a twisting of ium. The diagnosis of small-bowel obstruction
(Fig. 7A) and the “small-bowel feces” sign the mesenteric vasculature signifying a vol- on MRI is similar to CT and involves identify-
(Fig. 7B). The small-bowel feces sign is a re- vulus (Fig. 11); seventh, tortuous engorged ing dilated loops of bowel proximal to the ob-
sult of stasis and mixing of small-bowel con- mesenteric vessels (Fig. 12A); eighth, mesen- struction, a distinct transition point, and nor-
tents and is present in 82% of cases of small- teric hemorrhage; and, finally, increased at- mal-caliber or collapsed bowel distally.
bowel obstruction [2, 3]. Occasionally, visu- tenuation of bowel wall on noncontrast scans. Multiplanar capabilities of MRI allow visual-
alization of an adhesional band is possible, al- Although these signs are individually in- ization of the cause of small-bowel obstruction
though it is rare to be able to do so (Fig. 8). sufficiently sensitive, they are quite sugges- (Fig. 15). Rapid scanning with MRI using the
CT has a sensitivity of 81–94% and a spec- tive of ischemia when used together [7]. CT is HASTE sequence can, within seconds, evalu-
ificity of 96% for diagnosing high-grade ob- also useful in differentiating small-bowel ob- ate small-bowel obstruction with a high degree
of accuracy [8]. Furthermore, it avoids artifacts cause it is readily available, is cheap, and can small bowel obstruction. Semin Roentgenol 2001;
related to peristalsis and breathing that have be done serially to follow clinical progression. 36:108–117
limited the diagnostic yield of MRI in small- CT can provide additional information such as 4. Maglinte DDT, Balthazar EJ, Kelvin FM, Megibow
bowel obstruction in the past [8]. MRI is un- confirmation of an obstruction, degree and site AJ. The role of radiology in the diagnosis of small-
likely to replace CT for evaluating small- of an obstruction, presence of ischemia, and bowel obstruction. AJR 1997; 168:1171–1180
bowel obstruction because of longer scanning the cause of the obstruction. MRI may have a 5. Schmutz GR, Benko A, Fournier L, et al. Small
time and inferior resolution [8]; however, as role in the future evaluation of small-bowel ob- bowel obstruction: role and contribution of sonog-
availability and technology in MRI continues struction as the technology improves and it in- raphy. Eur Radiol 1997; 7:1054–1058
to improve, it has the potential to be an excel- creases in availability. 6. Furukawa A, Yamasaki M, Furuichi K, et al. Helical
lent diagnostic method for evaluating small- CT in the diagnosis of small bowel obstruction. Ra-
bowel obstruction. dioGraphics 2001; 21:341–355
References 7. Ha HH, Kim JS, Lee MS, et al. Differentiation of
Conclusion 1. Maglinte DDT, Heitkamp DE, Howard TJ, et al. simple and strangulated small bowel obstructions:
Small-bowel obstruction is a common pre- Current concepts in imaging of small bowel ob- usefulness of known CT criteria. Radiology 1997;
sentation, for which safe and effective man- struction. Radiol Clin North Am 2003; 41:263–283 204:507–512
agement depends on rapid and accurate diag- 2. Burkill GJC, Bell JRG, Healy JC. The utility of 8. Regan F, Beall DP, Bohlman ME, Khazan R,
nosis. Imaging can be diagnostic and helpful in computed tomography in acute small bowel ob- Sufi A, Schaefer DC. Fast MR imaging and the
guiding management. Abdominal radiography struction. Clin Radiol 2001; 56:350–359 detection of small-bowel obstruction. AJR 1998;
remains the first-line imaging examination be- 3. Macari M, Megibow A. Imaging of suspected acute 170:1465–1469