William Herring, M.D.

© 2002

Recognizing
SBO, LBO and Ileus

In Slide Show mode, advance the slides by pressing the spacebar

Underlined words hyperlink to other slides
 Abdominal Images
What to Examine
 Gas pattern-this lecture
 Extraluminal air
 Soft tissue masses
 Calcifications-other
lectures
Normal Gas Pattern

 Stomach
 Always
 Small Bowel
 Two or three loops of non-distended bowel
 Normal diameter = 2.5 cm = 1 US quarter
 Large Bowel
 In rectum or sigmoid – almost always
 Gas in
stomach

Gas in a few
loops of
small bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

 Stomach
 Always (except supine film)
 Small Bowel
 Two or three levels possible
 Large Bowel
 None normally
 Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen
 Large vs. Small Bowel

 Large Bowel
 Peripheral
 Haustral markings don't extend
from wall to wall
 Small Bowel
 Central
 Valvulae extend across lumen
 Maximum diameter of 2"
Complete Abdomen
Obstruction Series

 Supine
 Prone or lateral rectum
 Erect or left decubitus
 Chest - erect or supine
Complete Abdomen
Supine

 Looking for
 Scout film for gas
pattern
 Calcifications
 Soft tissue
masses
 Substitute – none
 Complete Abdomen
Prone

 Looking for
 Gas in rectum/sigmoid
 Gas in ascending and
descending colon
 Substitute – lateral
rectum
 Complete Abdomen
Erect

 Looking for
 Free air
 Air-fluid levels
 Substitute – left
lateral decubitus
Complete Abdomen
Erect Chest

 Looking for
 Free air
 Pneumonia at bases
 Pleural effusions
 Substitute – supine
chest
Abnormal Gas Patterns

 Functional Ileus
 Localized (Sentinel Loops)
 Generalized adynamic ileus
 Mechanical Obstruction
 SBO
 LBO
 Air in Rectum Air in Small Air in Large
or sigmoid Bowel Bowel

Localized 2-3 distended Air in rectum or

Yes
Ileus loops sigmoid

Generalized Multiple Yes-

Yes
Ileus distended loops Distended

Multiple dilated
SBO No
loops
No

None-unless
Yes-
LBO No ileocecal valve
Dilated
incompetent
Localized Ileus
Key Features

 One or two persistently dilated loops of

large or small bowel
 Gas in rectum or sigmoid
Supine Prone

Sentinel Loops
 Sentinel Loops
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis

Ulcer
Ureteral calculus
 Localized Ileus
Pitfalls

 May resemble early

mechanical SBO
 Clinical course
 Get follow-up
Generalized Ileus
Key Features

 Gas in dilated small bowel and large

bowel to rectum
 Long air-fluid levels
 Only post-op patients have
generalized ileus
 Supine Erect

Generalized Adynamic Ileus

Is It An Ileus?

 Is the patient immediately post-op?

 Are the bowel sounds absent or
hypoactive?
 If “no,” then it isn’t an ileus
 Patients don’t present to the ER with a
generalized adynamic ileus!
Mechanical SBO
Key Features

 Dilated small bowel

 Fighting loops
 Little gas in colon, especially rectum
 Key: disproportionate dilatation of SB
SBO
 Mechanical SBO
Causes
 Adhesions
 Hernia*
 Volvulus
 Gallstone ileus*
 Intussusception

*Cause may be visible on plain film

 Mechanical SBO
Pitfalls

 Early SBO may

resemble localized
ileus -get F/O
Mechanical LBO
Key Features

 Dilated colon to point of obstruction

 Little or no air in rectum/sigmoid
 Little or no gas in small bowel, if…
 Ileocecal valve remains competent
Supine Prone

LBO
Mechanical LBO
Causes
 Tumor
 Volvulus
 Hernia
 Diverticulitis
 Intussusception
Mechanical LBO
Pitfalls

 Incompetent ileocecal valve

 Large bowel decompresses into small
bowel
 May look like SBO
 Get BE or follow-up
 Supine Prone

Carcinoma of Sigmoid – LBO –

Decompressed into SB
 Air in Rectum Air in Small Air in Large
or sigmoid Bowel Bowel

Localized 2-3 distended Air in rectum or

Yes
Ileus loops sigmoid

Generalized Multiple Yes-

Yes
Ileus distended loops Distended

Multiple dilated
SBO No
loops
No

None-unless
Yes-
LBO No ileocecal valve
Dilated
incompetent
Special Cases
 Air in
biliary
SBO tree

Gallstone Gallstone Ileus

Post-op C-section
Adynamic Ileus
Sigmoid Volvulus
Mesenteric Occlusion
Abnormal Gas Patterns
Review

 Localized ileus
 Generalized ileus
 Mechanical SBO
 Mechanical LBO
 Abdominal Images
What to Examine
 Gas pattern-this lecture
 Extraluminal air
 Soft tissue masses
 Calcifications-other
lectures
Important Points

 Look for air in the rectum/sigmoid first

 Identify the most dilated loops-are they
large bowel or small bowel?
 Sentinel loops are 1-2 dilated loops of
small bowel
 Generalized adynamic ileus almost always
occurs in immediate post-op patients
 Always correlate the clinical findings with
imaging findings
Identify the Types of
Abnormal Gas Patterns

Click to go forward

Click to go back
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back Go ahead
Correct

There are multiple air-

containing and dilated loops
of small bowel with little or
no gas in the colon. The
findings are those of a
mechanical small bowel
obstruction. The patient had
undergone prior surgery
and the cause of this
obstruction was adhesions
form the prior surgery.

Go Back Go ahead
Correct

There is a dilated colon

to the splenic flexure/
Little or no gas is seen
in the rectum or in the
small bowel. The
findings are those of a
mechanical large bowel
obstruction. The cause
was an annular
constricting carcinoma
at the splenic flexure.

Go Back Go ahead
Correct

There are several air-

containing and slightly
dilated loops of small bowel
in the LLQ. These were
persistent. The findings are
those of a localized ileus
(sentinel loops) and their
location would suggest
diverticulitis. The patient had
appendicitis. The sentinel
loops do not always
correspond to the area of
inflammation.
Go Back Go ahead
Correct

All of the bowel is dilated.

There is air in the rectum.
The patient was post-op
abdominal surgery and the
bowel sounds were absent.
This is a generalized
adynamic ileus as is seen
sometimes after abdominal
surgery.

Go Back Go ahead
Wrong
Look Again

Click on the “Go Back”

button and look again

Go Back
Congratulations, You Graduate

You know
your
bowel gas

To return to the beginning of this module, Click here