Imaging of Ileus

Bachtiar Murtala
Department of Radiology
Medical Faculty
Hasanuddin University/
RS.dr.Wahidin Sudirohusodo
Makassar
Introduction
 Bowel obstruction is responsible for approximately 20%
of surgical admissions for acute abdominal pain with
small bowel obstruction (SBO) ∾75% and large bowel
obstruction (LBO) ∾ 25%.
 The cause of obstruction varies depending of population
 In a retrospective study of 522 patients, etiology of SBO
was adhesions (74%), Crohn’s disease (7%), neoplasia
(5%), hernia (2%), radiation (1%), miscellaneous (11%)
 In LBO, the three main causes are carcinoma (60%),
volvulus (10-15%), and diverticulitis (10%)

Marincek , Dondelinger. Emergency radiology,2007

Objectives of Imaging in suspected patient of
Ileus
 To confirm the presence of ileus
 To distinguish between obstructive (dynamic) and
paralytic ( adynamic ) ileus
 To determine the level/site of obstruction
 To determine the cause of obstruction
 To look for findings of strangulation
 To allow a good management either medically or
surgically
Diagnostic modalities
 Imaging machines/procedures
 Clinical history and
 Physical examination
Clinical symptoms and signs
Causes of bowel obstruction in adults

Marincek,Dondelinger et al. Emergency radiology,2007

Causes of large bowel obstruction
 Malignant lesions
 Inflammatory strictures
 Diverticulitis
 Inflammatory bowel disease
 Infectious granulomatous disease
 Parasitic desease
 Ischemia
 Wxtrinsic bowel lesions
 Volvulus
 Hernias
 Neoplasms/abscesses/dostemded b;adder
 Endometriosis
 Fecal impaction
 Intussusception
 Aganglionosis of the colon (Hirchsprung’s disease)
 Imperforate anus
 Meconium plug syndrome
 Adhesions
 Retactile mesenteritis
 Bezoar
 Colonic pseudo-obstruction

Eisenberg RL. Gastrointestinal

Radiology:2003
 Simple or complicated obstruction?

Intussusception

Adhesion

Closed-loop obstruction/
strangulation
Diagnosis strategy in patients with suspected bowel obstruction

Marincek,Dondelinger; Emergency radiology,2007

Objectives of Imaging in suspected patient
of Ileus
 To confirm the presence of ileus
 To distinguish between obstructive (dynamic) and
paralytic ( adynamic ) ileus
 To determine the level/site of obstruction
 To determine the cause of obstruction
 To look for findings of strangulation
 To allow a good management either medically or
surgically
Imaging modalities
 Plain abdominal radiography
 CT-scan
 US
 Barium study *
Plain abdominal radiography
 Estimated diagnostic in 50-60% of cases, equivocal in
20-30%, and normal-nonspesific or misleading-in 10%
(Balthazar)
 Commonly performed in supine, upright and
decubitus positions
 Diagnostic clue : dilatation of bowel with air-fluid
level, herring-bone appearance, lack or absence of air
in lower part.
 To determine the site of lesion, it is important to
identify characteristic of small and large bowel
Distinction between SBO and LBO
Small bowel Large bowel
Haustra Absent Present
Valvula conniventes Present in jejenum Absent
Number of loops Many Few
Distribution of loops Central Peripheral
Radius of curvature of loop Small Large
Diameter of loop 30-50 mm 50 mm+
Solid faeces absent May be present

Greinger,Allison. Diagnostic Radiology

adynamic
Volvulus of sigmoid
CT-Scan
To answer :
(1) Is bowel obstructed?
(2) What are the level, severity, and cause of
obstruction?
(3) Is closed-loop or strangulated present?
Diagnostic clues
 Dilated small bowel loops>2.5 cm +/-
air- fluid levels
 “Small bowel feces” sign proximal to obstruction
 Transition zone ( between proximal dilatation and
distal collapse bowel ) critical to define site and
cause of obstruction ( no transition point in paralytic
ileus)
Closed-loop obstruction

Balthazar, AJR;162:1994
Strangulation

Balthazar, AJR;162:1994
O

Obstruction by adhesion
adhesion
Small bowel obstruction

Marincek
Closed-loop obstruction

Balthazar
Balthazar
 In high-grade SBO , the sensitivity of CT is about
96%, specificity 96% and accuracy 95%
 In low-grade SBO, the sensitivity is relatively low (
48% )

Balthazar, AJR;162:1994
Jeffrey at al.Diagnostic imaging Emergency,2007
 CT-Scan particularly recommended in cases :
 Clinical and plain film examination are abnormal, but
nonspecific

 Obstruction associated with specific medical conditions

such as previous abdominal malignant tumor,
inflammatory bowel disease, sepsis, a palpable
abdominal mass, and clinically suggestive of
strangulation

Balthazar, AJR;162:1994
Ultrasonography
Advantages :
 Allow to detect the presence, level and cause of
obstruction
 Easy to observe peristaltic movement
( dynamic or adynamic ileus? )
 Relatively easy to detect bowel tumor, gallstone, or
bezoar
 Safely in critical ill and pregnant patients

Ko YT et al. Radiology 1993;188:649-653

Summary
 Plain abdominal radiography is still the first line tool
in suspected ileus patients, followed by CT-Scan and
US
 The purpose of imaging in suspected ileus patients is
to determine the presence of ileus, to distinguish
between obstructive and paralytic, and to determine
the site and the cause of obstruction
 Clinical history, physical examination, and radiological
findings are very important in making definite
diagnosis and management decision.
Thank you