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Ajr 12 8528
Ajr 12 8528
Ajr 12 8528
Hryhorczuk et al.
Bowel Obstructions in Older Children
Residents’ Section
Pattern of the Month
Residents
I
n older children, bowel obstruction cosa within the diverticulum or inflammation.
Edward Y. Lee1,2 can be due to a variety of congeni- Bowel obstruction due to a Meckel diverticu-
Ronald L. Eisenberg 3 tal and acquired causes that are lum presents in either of two typical patterns:
often different from the causes of First, a distal ileal obstruction can occur sec-
Hryhorczuk A, Lee EY, Eisenberg RL bowel obstruction in neonates or adults. Among ondary to bowel torsion around an omphalo-
neonates, bowel obstruction is almost always mesenteric band (Fig. 1). Second, obstruction
due to congenital causes, including bowel atre- can be due to intussusception of a Meckel di-
American Journal of Roentgenology 2013.201:W1-W8.
sia, malrotation, and Hirschsprung disease. In verticulum (Fig. 2). In addition, Meckel diver-
adults, the list of common causes of bowel ticulum varies in size and can be incidentally
obstruction is relatively short, with the vast seen on CT when very large. It may mimic a
majority arising from postoperative adhesions, single enlarged bowel loop. Notably, patients
incarcerated hernias, or neoplasms. However, with intussuscepting Meckel diverticula are
in older children, the causes of bowel obstruc- usually older than patients with idiopathic in-
tion are more extensive and varied, and a more tussusception. In both cases, surgical resec-
diverse list of diagnoses should be entertained tion of the Meckel diverticulum is essential
(Table 1). for definitive treatment.
Almost all pediatric patients with bowel ob-
structions present with abdominal pain, dis- Malrotation
tention, and vomiting. Because these are not When a child presents with acute bilious
specific, diagnosing a bowel obstruction in an vomiting and clinical signs and symptoms
older child requires imaging to determine its suspicious for bowel obstruction, malrotation
cause, location, and extent. Conventional ab- should be considered as a possible underly-
dominal radiography is often the initial im- ing cause. Although the majority of cases are
Keywords: bowel obstructions, pediatrics
aging study for assessing bowel obstruction seen in the first year of life, older children may
DOI:10.2214/AJR.12.8528 in older children. However, this study is of- also present with malrotation and concomi-
ten rapidly followed by an upper gastrointes- tant midgut volvulus. On upper gastrointes-
Received December 30, 2011; accepted after revision tinal (UGI) or enema study, ultrasound, CT, tinal studies, malrotation with midgut volvu-
March 22, 2012.
or MRI. By understanding the proper selec- lus typically appears as a “beak” of contrast
1
Department of Radiology, Children’s Hospital Boston tion of imaging modalities and developing enhancement at the site of obstruction, with a
and Harvard Medical School, Boston, MA. familiarity with the characteristic appearances corkscrew appearance of proximal small bow-
of common causes of bowel obstruction, the el loops in the right upper abdomen (Fig. 3B),
2
Department of Medicine, Pulmonary Division, Children’s radiologist can assist in optimizing the man- without a normally positioned duodenojejunal
Hospital Boston and Harvard Medical School, Boston, MA.
agement of older children with this condition. junction. In cases of a tight volvulus, contrast
3
Department of Radiology, Beth Israel Deaconess Medical material may not pass distal to the mid duo-
Center and Harvard Medical School, 300 Longwood Ave, Congenital Causes denum, and the classic corkscrew appearance
Boston, MA 02115. Address correspondence to Meckel Diverticulum may be absent; instead, findings will only sug-
R. L. Eisenberg (rleisenb@bidmc.harvard.edu).
A Meckel diverticulum forms when there gest an extremely high-grade proximal small
WEB is incomplete closure of the vitelline duct dur- bowel obstruction. Cross-sectional imaging,
This is a web exclusive article. ing fetal development. Although most Meckel such as ultrasound or CT, may show an ab-
diverticula are asymptomatic, children with normal relationship of the superior mesenteric
AJR 2013; 201:W1–W8 symptoms most commonly present with bow- artery (SMA) and vein (SMV), with the SMA
0361–803X/13/2011–W1
el obstruction (seen in approximately 40%), to the right of the SMV (Fig. 3A), or swirling
with a smaller number developing either pain- of the mesenteric vessels (whirlpool sign). In
© American Roentgen Ray Society less bleeding secondary to ectopic gastric mu- addition to reversal of the normal SMA-SMV
orientation, CT may also show the absence TABLE 1: Causes of Bowel Obstruc- Interloop fluid between the intussuscep-
of a retroperitoneal third portion of the duo- tion in Older Children tum and intussuscipiens should be noted be-
denum (Fig. 4). Treatment of malrotation is Congenital cause this finding is associated with a lower
surgical, with an urgent Ladd procedure per- rate (50%) of successful intussusception re-
Meckel diverticulum
formed in cases of midgut volvulus. duction. Bowel obstruction, free fluid, dimin-
Malrotation ished Doppler flow, and prolonged symptoms
Congenital Inguinal Hernia Congenital inguinal hernia are also indicators suggesting lower rates of
Although congenital inguinal hernias affect Infectious or inflammatory successful intussusception reduction, but these
only 1–2% of children, 10% of these hernias are not absolute contraindications for attempt-
Appendicitis
may be complicated by incarceration and bow- ed reduction. Children with intussusception
el obstruction. Risk factors for bowel obstruc- Intussusception and subsequent bowel obstruction are current-
tion in children with congenital inguinal her- Inflammatory bowel disease ly treated with fluoroscopy-guided reduction
nias include a young age at presentation, male Iatrogenic (Fig. 7C), using either an air or contrast en-
sex, and a right-sided hernia. An inguinal her- ema. Although 80% of intussusceptions are
Adhesions
nia is often a clinical diagnosis managed with reduced with fluoroscopic guidance, surgical
manual reduction and surgical repair without Acquired hernia reduction is reserved for patients in whom flu-
the need for imaging. However, the diagnosis Other oroscopic treatment is not effective. Immedi-
may not be immediately apparent in a patient Ingested foreign body ate surgical intervention is required for chil-
presenting with vomiting, and a further imag- dren who develop bowel perforation during
Distal intestinal obstruction syndrome
ing evaluation may be obtained. In some cas- the reduction procedure, amounting to approx-
es, conventional abdominal radiographs may Note—A popular mnemonic for remembering imately 0.5% of patients.
several common causes of pediatric bowel
show gas within the scrotal sac or an appar-
American Journal of Roentgenology 2013.201:W1-W8.
history of abdominal surgery, bowel obstruc- tients require surgical intervention. Bezoars, Conclusion
tion and adhesive disease are often primary di- which are indigestible masses of foreign mate- Clear knowledge of the spectrum of causes
agnostic considerations when patients present rial, represent a special form of obstructing for- of bowel obstruction is essential for the ap-
with acute vomiting, distention, and abdominal eign body and often require surgical removal. propriate management of older pediatric pa-
pain. Historically, small bowel follow-through Bezoars can occur throughout the gastrointes- tients with bowel obstruction. Although this
was performed in cases of suspected adhesive tinal tract, from the stomach to the rectum, and diverse population may present with similar
bowel obstruction. However, this examination may be rapidly identified as the cause of bow- symptoms of vomiting, abdominal pain, and
has fallen out of favor because the results do el obstruction if abdominal radiographs show distention, the causes of bowel obstruction
not change clinical management and the exam- radiopaque foreign bodies in the presence of are varied and identification is essential for
ination incurs unnecessary costs and radiation multiple dilated bowel loops (Fig. 11). timely and appropriate management.
exposure. Although conventional radiography Among ingested foreign bodies, magnets
may provide adequate diagnostic information merit special attention because of the specific Suggested Reading
in the presence of an appropriate history, many complications that may occur when children 1. D’Agostino J. Common abdominal emergencies
patients may undergo CT for further evaluation, ingest multiple magnets (Fig. 12). If a child in children. Emerg Med Clin North Am 2002;
especially in the more acute postoperative pe- consumes multiple magnets, there is a risk of 20:139–153
riod. Bowel rest and conservative management bowel obstruction and perforation caused by 2. Gee MS, Nimkin K, Hsu M, et al. Prospective
are often the initial treatment in these patients; magnets in distant loops of bowel that may ad- evaluation of MR enterography as the primary im-
however, more than 85% of patients do not re- here together. If this occurs, the child is at risk aging modality for pediatric Crohn disease assess-
spond to conservative management and even- for volvulus and perforation secondary to pres- ment. AJR 2011; 197:224–231
tually require surgical intervention. sure necrosis at the site of magnet adherence. 3. Jabra AA, Eng J, Zaleski CG, et al. CT of small-
Because of this risk, it is imperative that pa- bowel obstruction in children: sensitivity and
Acquired Hernia tients who have ingested magnets receive close
American Journal of Roentgenology 2013.201:W1-W8.
A B
Fig. 2—Intussuscepting Meckel diverticulum in
Fig. 1—Obstructing Meckel diverticulum (surgically confirmed) in 8-year-old girl who presented with acute 11-year-old boy who presented with 3 days of
onset of abdominal pain. abdominal pain. Abdominal radiograph (not shown)
A, Frontal conventional radiograph shows multiple air-fluid levels in dilated loops of bowel (arrows), suspicious revealed multiple dilated bowel loops, concerning for
American Journal of Roentgenology 2013.201:W1-W8.
A B
Fig. 3—Malrotation in 3-week-old boy who presented with lethargy and feeding difficulties. Surgery confirmed presence of malrotation and midgut volvulus. Patient
subsequently underwent Ladd procedure.
A, Transverse ultrasound image (obtained during assessment for possible pyloric stenosis) shows abnormal orientation of superior mesenteric artery (straight arrow) and
superior mesenteric vein (curved arrow). This raised suspicion for possible malrotation.
B, Image from subsequent upper gastrointestinal series shows corkscrew loops of bowel (arrow) in left upper quadrant, consistent with malrotation and midgut volvulus.
A B
American Journal of Roentgenology 2013.201:W1-W8.
Fig. 4—Malrotation in 8-year-old boy who presented with vomiting and abdominal pain. After imaging
evaluation, patient was immediately directed to surgery, which confirmed malrotation with volvulus. Patient
subsequent underwent Ladd procedure.
A, Contrast-enhanced axial CT image shows absence of retroperitoneal third portion of duodenum as well as
apparent reversal of superior mesenteric artery (SMA) (straight arrow) and superior mesenteric vein (curved
arrow).
B, Normally located retroperitoneal third portion of duodenum (arrow) crossing posterior to SMA is shown for
comparison.
C, Enhanced coronal CT image shows dilated proximal bowel loops (asterisk) in right and mid abdomen.
C
A B
Fig. 5—Incarcerated inguinal hernia in 2-year-old
boy who presented with vomiting. Patient underwent
surgical reduction of incarcerated inguinal hernia
without complication.
American Journal of Roentgenology 2013.201:W1-W8.
A B
Fig. 7—Ileocolic intussusception in 3-month-old girl who presented with vomiting. Radiographs (not shown) revealed dilated loops of bowel. Because of incomplete reduction
with air enema, patient subsequently proceeded to operative treatment.
A, Transverse ultrasound image shows right lower quadrant mass (arrow) with characteristic appearance of ileocolic intussusception (alternating hyper- and hypoechoic
layers). Note dilated, fluid-filled adjacent loop of bowel (asterisk), compatible with bowel obstruction.
B, Fluoroscopic image obtained at conclusion of attempted reduction of intussusception shows persistent filling defect (asterisk) in region of cecum, indicating incomplete
reduction.
American Journal of Roentgenology 2013.201:W1-W8.
Fig. 8—Inflammatory bowel disease in 16-year-old Fig. 9—Adhesions in 16-year-old girl with history of complicated appendicitis who
boy who presented with vomiting. Patient improved presented with acute onset abdominal pain and vomiting. Axial CT image shows
with medical therapy and bowel rest. Contrast- dilated loops of proximal small bowel (asterisk) with abrupt right lower quadrant
enhanced coronal CT image provides further transition point (arrow). Patient subsequently underwent lysis of right lower
delineation of location and extent of dilated bowel quadrant adhesion that had caused bowel obstruction.
loops (asterisks). Prominent mesenteric adipose
tissue is also identified (curved arrow) near inflamed
terminal ileum (straight arrow), compatible with
“creeping fat” appearance. B = bladder.
A B
Fig. 10—Iatrogenic diaphragmatic hernia in 3-year-old boy with history of cardiac surgery and pacemaker placement who presented with abdominal pain and vomiting.
Surgical reduction was performed, and hernia was repaired.
American Journal of Roentgenology 2013.201:W1-W8.
A, Frontal abdominal radiograph shows loop of bowel (arrow) projecting over lower chest, above expected area of diaphragm.
B, Sagittal CT image shows diaphragmatic hernia with bowel (B) and omental fat (F) extending through defect in diaphragm (arrows).
Fig. 11—Bezoar in 20-year-old woman with Fig. 12—9-year-old girl who swallowed multiple Fig. 13—Distal intestinal obstruction syndrome in
developmental delay and pica who developed round magnets. Abdominal radiograph shows 19 17-year-old girl with cystic fibrosis who developed
vomiting, with hair elastics identified in vomited radiopaque bodies projecting over distal stomach. abdominal pain and vomiting. Enhanced coronal CT
material. Frontal abdominal radiograph shows These magnets were removed endoscopically. image better shows location and extent of multiple
multiple radiopaque structures within heterogeneous bowel dilatation (asterisks) with fecalization of more
mass that appeared to conform to gastric contour. distal loops of small bowel (straight arrow) extending
Surgical exploration was immediately performed, to terminal ileum (curved arrow).
revealing large gastric bezoar resulting in gastric
outlet obstruction.