ResidentsSectionPatternof theMonth

Small Bowel Obstruction

Received May 25, 2010; accepted after revision May 16, 2011.
Charles P. Mullan
Bettina Siewert
Ronald L. Eisenberg
All authors: Department of Radiology, Beth Israel
Deaconess Medical Center, Harvard Medical School, 330
Brookline Ave, Boston, MA 02115. Address correspondence
to R. L. Eisenberg (rleisenb@bidmc.harvard.edu).
Small bowel obstruction remains an important cause of morbidity,
accounting for up to 15% of surgical admissions for acute nontraumatic
abdominal pain. Clinical evidence of complete small-bowel obstruction or
complications such as strangulation necessitates emergent surgical management.
Traditional medical teaching advocated early operative management of small-
bowel obstruction (Never let the sun rise or set on an obstructed abdomen.)
because clinical features were often unreliable in determining whether
complications were present. Radiologic imaging has assumed a paramount role in
directing the management of small bowel obstruction, promoted by the
widespread availability of MDCT. The key question for a clinician managing a
case of suspected small bowel obstruction is how to optimally treat the patient.
MDCT accurately answers this question by determining if small bowel
obstruction is present, identifying the site and cause of mechanical obstruction,
and detecting complications. The sensitivity and specificity of MDCT in this
clinical setting is more than 95%, with high accuracy reported in distinguishing
small bowel obstruction from adynamic ileus in postoperative patients. Imaging is
therefore pivotal in determining whether the patient can be managed
conservatively and in guiding the operative approach if surgical management is
required.

Imaging Modalities
Radiography
Most patients presenting with clinical features suggestive of small bowel
obstruction will first undergo abdominal radiography. Radiographs have accuracy
of 6783% in the diagnosis of small bowel obstruction, with reported sensitivity
of 6482% and specificity of 7983% [1,2]. The radiologic hallmark of
mechanical small bowel obstruction is dilatation of the proximal small bowel
(transverse diameter > 3 cm from outer wall to outer wall) with nondilated distal
bowel loops. Associated findings in a patient with small bowel obstruction include
dilatation of the stomach, absence of colonic dilatation (normal caliber or
collapsed colon), and the presence of multiple gas-fluid levels on upright or
decubitus abdominal radiographs (Fig.1). The presence of air-fluid levels greater
than 2.5 cm in width and air-fluid levels differing more than 5 mm from each
other within the same loop of small bowel are additional findings indicative of
small bowel obstruction on erect radiographs [2]. Free intraperitoneal gas may be
visualized on radiographs in complicated small bowel obstruction. However, it is
not always possible to reliably distinguish adynamic ileus and other causes of
small bowel dilatation (Table 1) from mechanical obstruction on radiography.
This is particularly problematic in the postoperative setting when electrolyte
imbalance and the administration of medication are frequent causes of adynamic
ileus. The transition point between dilated and nondilated small bowel is not
usually visualized on radiography, making it difficult to determine the site or
cause of obstruction (Fig. 1).
TABLE 1: Nonobstructive Causes of Small Bowel Dilatation
Adynamic ileus
Recent surgery or trauma
Shock
Electrolyte abnormality
Medications (opiates, anticholinergics)
Celiac disease
Scleroderma
Ischemia

A B
Fig. 1Small bowel obstruction.
A, Supine abdominal radiograph shows dilated loops of
small bowel.
B, Erect abdominal radiograph shows small bowel
dilatation with multiple air-fluid levels. Air-fluid level
wider than 2.5 cm (horizontal line) and differential
air-fluid levels within same small bowel loop (vertical line)
are identified.
C, Axial CT image shows transition point in mid ileum
(arrows), confirming mechanical obstruction due to ileal
stricture.

The severity of small bowel obstruction may be underestimated on

abdominal radiographyif the dilated bowel loops are predominantly fluid-filled
(Fig. 2). The presence of a gasless abdomen on radiography in a patient with
suggestive clinical features should raise the possibility of small bowel obstruction.
The string of pearls sign may be seen in predominantly fluid-filled loops of small
bowel on erect or decubitus radiographs as small amounts of intraluminal gas
collecting along the superior wall separated by the valvulae conniventes (Fig. 3).
Fluoroscopy and Follow-Through Examination
Fluoroscopy and follow-through examination with oral contrast agents
have a limited role in the diagnosis of small bowel obstruction but may be useful
in determining the severity of obstruction. Patients with acute small bowel
obstruction often tolerate oral contrast material poorly because of nausea and
vomiting. Surgeons prefer not to have large quantities of barium in the small
bowel lumen if emergent surgery is a possibility. Water-soluble contrast agents
become diluted as they pass through dilated fluid-filled bowel loops.
Consequently, the degree of opacification may be insufficient to identify the
transition point at the site of obstruction. The prolonged transit of contrast
material through obstructed bowel means that followthrough radiographs may
have to be obtained for several hours, delaying diagnosis. Figure 4B shows the
expected fluoroscopic findings in small bowel obstruction, with dilated loops of
proximal small bowel opacified with contrast material and a change in the caliber
of the small bowel at the transition zone. If high-grade obstruction is present,
minimal or no contrast material will opacify small bowel loops distal to the
transition zone on delayed radiographs.
MDCT
MDCT has been established as the modality of choice for imaging suspected acute
small bowel obstruction and is widely available. Isotropic imaging facilitates
reconstruction in multiple planes, enabling tortuous small bowel to be followed in
the search for a transition point. The reported accuracy of CT for high-grade small
bowel obstruction is 95%, with sensitivity of 9094% and specificity of 96% [3,
4]. Other published data indicate that the accuracy of CT is reduced for lowgrade
obstruction [5]. The diagnosis of small bowel obstruction requires the presence of
small bowel dilatation (transverse diameter > 2.5 cm) and the presence of a
discrete transition zone between dilated proximal and nondilated distal bowel. The
transition zone may be a sharply defined point as with band adhesions (Fig. 5) or a
longer segment as with matted adhesions or radiation enteritis (Fig. 6).
The administration of oral and IV contrast material optimizes the data provided by
CT in assessing small bowel obstruction. However, diagnostic information can be
obtained in patients who cannot tolerate oral or IV contrast material and many
centers do not routinely administer oral agents to patients undergoing CT for this
indication. Retained intraluminal fluid provides negative contrast enhancement
within dilated small bowel loops and may be preferable in evaluating ischemic
complications of small bowel obstruction. Lack of bowel wall enhancement, an
early sign of ischemia, is easier to visualize in the absence of oral contrast
material. Other complications, such as perforation, can be identified on CT by the
presence of extraluminal air (Fig. 7). However, the relatively high radiation dose
of MDCT in comparison with other modalities raises concern for its use in
patients requiring repeated imaging studies.
A B
Fig. 2Small bowel obstruction.
A and B, Supine (A) and erect (B) abdominal
radiographs show loop of dilated small bowel in
left lower quadrant, with paucity of bowel gas
elsewhere in abdomen.
C, Coronal CT image shows multiple loops of
dilated small bowel filled with intraluminal fluid,
which are not visible on radiographs. This 35-
year-old patient had small bowel obstruction due
to adhesions from prior laparotomy.

Fig. 3Upright abdominal radiograph shows

stringof-beads sign. (Reprinted with permission
from Eisenberg RL. Gastrointestinal radiology: a
pattern approach. Philadelphia, PA: Lippincott,
2002)
Enteroclysis
In the setting of chronic or intermittent small bowel obstruction,
enteroclysis enables the small bowel to be distended adequately to highlight areas
of luminal stenosis. This technique requires the placement of a nasojejunal tube
for instillation of a large amount of oral contrast material. Traditionally,
enteroclysis has been performed with barium and methylcellulose using
fluoroscopy. The volume challenge caused by methylcellulose administration
accentuates the effect of low-grade obstruction. The transition zone at the site of
obstruction can be missed using enterography or CT without volume challenge
but is readily identified after enteroclysis. CT and MRI are increasingly used in
conjunction with enteroclysis. Cross-sectional imaging provides additional data
that can identify extraintestinal manifestations of Crohn disease.
MR Enterography
MR enterography is an increasingly attractive option for the assessment of
small bowel obstruction. However, the increased time of image acquisition and
the need for repeated breath-holds to obtain high-quality images limits the
application of MRI in patients with acute small bowel obstruction. Therefore, it is
most useful in the setting of chronic small bowel abnormality and lowgrade
obstruction. This is particularly true in Crohn disease, where reducing the
accumulated dose of ionizing radiation in young patients is desired. Multiplanar
MRI can be used in the same way as MDCT to look for evidence of a transition
point and features indicative of complications.