Downloaded from www.ajronline.org by 180.246.59.76 on 11/22/17 from IP address 180.246.59.76. Copyright ARRS.

For personal use only; all rights reserved

CT of Small-Bowel Obstruction in
Children: Sensitivity and Specificity
Amal A. Jabra 1 OBJECTIVE. The aim of this study was to determine the sensitivity, specificity, and accu-
John Eng 2 racy of CT in the diagnosis of small-bowel obstruction in children.
Christopher G. Zaleski 3 MATERIALS AND METHODS. The CT scans of 30 children with surgically proven
George E. Abdenour, Jr.1 small-bowel obstruction, 22 children with ileus, and 29 children who served as controls were ret-
rospectively reviewed by two of four interpreters who were unaware of the children’s final diag-
Hao V. Vuong4
noses. Causes of obstruction in the patients included 19 adhesions, six cases of volvulus, five
Uwa O. Aideyan 1
intussusceptions, four strictures, and two cases each of internal hernia and abscess. Eight obstruc-
Elliot K. Fishman 2 tions had multiple causes. The CT scans were evaluated for the presence of small-bowel obstruc-
tion using a scale with five degrees of confidence. In cases of discrepancy of more than one level
of certainty, a third interpreter was consulted. Criteria for small-bowel obstruction included a dis-
crepancy in caliber between the proximal dilated and the more distal small bowels or generalized
small-bowel dilatation (>2.5 cm) in the presence of a collapsed colon. An interpreter’s rating that
an obstruction was either present or probable was considered a positive finding; a rating indicat-
ing that the interpreter was not sure whether an obstruction was present or believed that an ob-
struction was not probable or saw normal anatomic structures was considered a negative finding
for small-bowel obstruction. The cause and level of obstruction also were recorded.
RESULTS. There were 26 true-positive (87%) and four false-negative (13%) interpretations
for small-bowel obstruction. Among the interpretations of scans of patients with ileus, 68% were
true-negative and 32% were false-positive interpretations for small-bowel obstruction. Among
the control group, there were no false-positive readings. Sensitivity of CT was 87%, specificity
was 86%, and accuracy was 86%. In the scans of children 2 years and younger, CT had a sensitiv-
ity of 100% and specificity of 0%. Of the patients with surgically confirmed levels of obstruction,
the correct level of obstruction was described by both interpreters in 12 (86%) of 14 scans. The
causes of obstruction were correctly identified in 14 (47%) of 30 scans.
CONCLUSION. CT is both sensitive and specific for use in diagnosing small-bowel ob-
struction in children, especially in children older than 2 years.

Received September 20, 2000; accepted after revision

February 7, 2001.
1
Department of Radiology, University of Miami School of
Medicine, Jackson Memorial Medical Center, West Wing
279, 1611 N.W. 12th Ave., Miami, FL 33136. Address
correspondence to A. A. Jabra.
2 tion who had undergone abdominal CT scans for a va-
Department of Radiology, The Johns Hopkins Medical
Institutions, 600 N. Wolfe St., Baltimore, MD 21287.
3
Nemours Children’s Clinic, 807 Nira St., P. O. Box 5720,
Jacksonville, FL 32247.
4
Department of Radiology, Baptist Hospital,
8900 N. Kendall Dr., Miami, FL 33176.
AJR 2001;177:431–436
0361–803X/01/1772–431
© American Roentgen Ray Society
T he diagnosis of small-bowel ob-
struction in children is usually
based on the clinical findings, ra-
diographs, or barium examinations. The use of
CT in the diagnosis of small-bowel obstruction
in children has been previously addressed, and
CT has been proposed as a useful adjunct diag-
nostic procedure in detecting the presence of
small-bowel obstruction, its level, and its cause
[1]. Numerous publications have addressed the
sensitivity, specificity, and accuracy of CT in the
diagnosis of small-bowel obstruction in adults
[2–7]. No similar studies are available in pediat-
ric patients. In this study, we retrospectively re-
viewed the CT findings in a series of children
with either small-bowel obstruction or ileus and
a control group to determine the sensitivity,
specificity, and accuracy of CT as an aid in di-
agnosing small-bowel obstruction in children.
Materials and Methods
The study population consisted of 30 consecutive
children with surgically proven small-bowel obstruc-
riety of clinical indications during their preoperative
evaluation. Children with duodenal or neonatal ob-
struction were excluded. Twenty-two consecutive
children who had been given a discharge diagnosis of
ileus and who had undergone abdominal CT as part of
their medical workup were also included. The control
group included 29 consecutive children who had un-
dergone abdominal CT for reasons unrelated to the
gastrointestinal tract—examination for possible me-

AJR:177, August 2001 431


tastasis from previous malignancies or for trauma
workup. Their medical records indicated no gas-
trointestinal pathology. The average age of the chil-
dren in the small-bowel obstruction group was 8.4
years; the average age of those in the ileus group was
10.2 years and of those in the control group, 9.6 years.
The causes of obstruction included 19 patients with
Downloaded from www.ajronline.org by 180.246.59.76 on 11/22/17 from IP address 180.246.59.76. Copyright ARRS. For personal use only; all rights reserved
adhesions, six with volvulus, five with intussuscep-
tions, four with strictures, and two patients each with
internal hernias and abscesses. Eight children had
more than one cause for the obstruction.
The five of the CT scans were performed on a
9800 HiSpeed Advantage scanner (General Electric
Medical Systems, Milwaukee, WI), three were per-
formed on a Somaton DR3 scanner (Siemens, Erlan-
gen, Germany), and two scans were performed on the
DRH Siemens scanner. The remaining 71 scans were
performed on the DRH+ Siemens scanner. Scan pa-
rameters included 140–280 mA, 120–125 kVp, and
0.7–3.0 sec of scanning time. Of the 81 scans per-
formed, 39 of the scans were helical. Collimation was
5–8 mm with data obtained at 5- to 10-mm intervals.
Both the usage and type of contrast medium var-
ied, with some children receiving an oral contrast
agent; some, an IV contrast agent; some, both; and
some, none. All 29 control scans were obtained using
432
Jabra et al.
IV contrast medium, and 28 children in the control
group also received oral contrast medium. Thirteen of
22 scans in the ileus group received IV contrast me-
dium, and 18 received oral contrast medium. Of the
30 patients with obstruction, 15 had IV contrast me-
dium, and 24 received oral contrast medium.
The CT scans of all 81 children were random-
ized, and each scan was retrospectively and indepen-
dently reviewed by a random combination of two of
four interpreters. The interpreters were unaware of
any patient’s final diagnosis. The scans were evalu-
ated for the presence or absence of obstruction on a
scale with five degrees of confidence—obstruction
present, obstruction probable, not sure, obstruction
not probable, and normal study. In the case of a dis-
crepancy of more than one level of certainty between
the two initial interpreters, a third interpreter was
consulted so that a consensus could be reached.
The criteria used for diagnosing a small-bowel ob-
struction have been previously described and include a
discrepancy in caliber between the dilated proximal
and the more distal small bowels [1–3] (Fig. 1) or the
presence of a dilated small bowel with a collapsed co-
lon, particularly the ascending colon [1–3] (Fig. 2). A
dilated small bowel was defined as one having a diame-
ter larger than 2.5 cm for children older than 1 year; for
Fig.1.—8-month-old boy with small-
bowel obstruction resulting from ad-
hesions. CT scan with IV contrast
medium shows difference in bowel
caliber with proximal dilated small
bowel (straight arrows) filled pre-
dominantly with fluid and collapsed
distal small bowel (curved arrows).
Ascites is present.
Fig. 2.—17-year-old boy with small-
bowel obstruction. CT scan was
obtained 5 days after right nephrec-
tomy for trauma. Obstruction was
produced by combination of adhe-
sions, segmental volvulus, and ileo-
ilial intussusception related to
Meckle’s diverticulum. Scan shows
intussusception (arrowheads). Also
note small-bowel dilatation and col-
lapsed colon (arrows).
children younger than 1 year, the presence of a dilated
small bowel was subjectively determined by the inter-
preters. A rating of “obstruction present” or “obstruc-
tion probable” was considered a positive finding for
small-bowel obstruction. A rating of “not sure,” “not
probable,” or “normal study” was considered a negative
finding for small-bowel obstruction. The interpreters
were asked to identify the cause of obstruction. If no
cause of obstruction was identified, a diagnosis of ad-
hesions was inferred. The interpreters were also asked
to determine the level of small-bowel obstruction—
proximal (jejunal) or distal (distal jejunal or ileal).
The interpreters’ diagnostic confidence ratings
were used to calculate receiver operating characteris-
tic (ROC) curves for the detection of small-bowel ob-
struction. The ROCFIT program [8] was used to fit
ROC curves to the confidence rating data.
Proportions were compared using the Fisher’s ex-
act test as calculated by a software program (Stata,
version 6.0; Stata, College Station, TX). A p value of
less than 0.05 was considered statistically significant.
Results
Of the 30 children with small-bowel obstruc-
tion, there were 26 (87%) true-positive interpre-
tations for obstruction (Fig. 1) and four (13%)
false-negative interpretations (Table 1, Fig. 3).
There were no instances among the obstruction
group in which the interpreters were “not sure”
of their interpretations. There were no discrepant
interpretations requiring a third interpreter. In in-
terpreting the scans of children with ileus, 15
(68%) of 22 were true-negative findings (Fig. 4),
and seven (32%) of 22 were false-positive find-
ings for small-bowel obstruction. The former
group of 15 patients included two children
whose scans elicited discrepancies in the evalua-
tions between the two initial interpreters. The
third reviewer was not sure of the correct inter-
pretation. These scans were considered to show
negative findings for small-bowel obstruction.
Among the scans of the 29 controls, the review-
ers had no false-positive interpretations nor did
they have any instances in which they were not
sure of their interpretations.The overall sensitiv-
ity of CT as an aid in diagnosing small-bowel
obstruction in this study was 87%, the specificity
was 86%, and the accuracy was 86%.
Summary of CT Scan
TABLE 1
Interpretations
Scans Scans
Interpreted Scans of
Revealing Revealing
for SBO Controls
SBO Ileus
Positive 26 7 0
Negative 4 15 29
Total 30 22 29
Note.—SBO = small-bowel obstruction.
AJR:177, August 2001
 CT of Small-Bowel Obstruction in Children
Downloaded from www.ajronline.org by 180.246.59.76 on 11/22/17 from IP address 180.246.59.76. Copyright ARRS. For personal use only; all rights reserved

Fig. 3.—12-year-old girl presenting with feeding intolerance and abdominal disten- Fig. 4.—16-year-old boy with ileus. CT scan shows generalized small-bowel dilata-
tion. Patient had undergone previous Nissen fundoplication and spinal instrumentation, tion (straight arrows) as well as dilatation of ascending colon (curved arrow).
which produced artifact. CT scan shows several localized mildly dilated air-filled
small-bowel loops resulting from compression and entrapment by adhesive bands.
Note typical hairpin appearance of bowel loop (arrows) frequently seen in closed-
loop obstruction. Diagnosis of obstruction was missed by both interpreters.

Sixteen of the 30 patients with small-bowel
obstructions had the levels of obstruction de-
scribed in the operative reports. Fourteen ob-
structions were distal, and two were proximal.
In the 16 patients with surgically reported lev-
els of obstruction, 14 were correctly diagnosed
with obstructions by the interpreters, and two
were given false-negative findings. Of the 14
patients correctly diagnosed with obstructions,
the level of obstruction was correctly identified
by both interpreters in 12 (86%). The correct
level of obstruction was identified by at least
one interpreter in all 14 patients. One addi-
Fig. 5.—Graph of fitted receiver operating characteris-
tic curve for the detection of small-bowel obstruction
among the subset of abnormal cases. The area under
the curve is 0.84, with a standard deviation of 0.06.
tional patient was diagnosed with a volvulus
involving most of the bowel. In this patient,
both interpreters reported the level of obstruc-
tion to be distal.
Because the differentiation between ileus and
small-bowel obstruction is often the clinically
relevant question, a ROC curve for the detection
of small-bowel obstruction (Fig. 5) was calcu-
lated from a subset of the data (52 cases), which
includes all patients except those in the control
group. The area under the ROC curve was 0.84,
with a standard deviation of 0.06.
Within the subset of 52 children, 10 chil-
dren were 2 years or younger. In all these
children, a small-bowel obstruction was de-
tected on CT scans, although three had ileus
rather than an obstruction. Therefore, the
specificity for the detection of small-bowel
obstructions on the scans of these children
was 0%, and the sensitivity was 100%. The
remaining 42 children in the group with a
disease were older than 2 years. For these
children, the specificity of CT was 79% (15
of 19 patients) and the sensitivity was 83%
(19 of 23 patients). A comparison of the two
age groups shows a statistically significant
difference in CT specificity (p = 0.02) but no
difference in CT sensitivity (p = 0.5).
The scans for four of the 30 patients with ob-
structions were judged as false–negative for ob-
struction. These included two patients with
adhesions, one with an internal hernia, and one
with a volvulus around an omphalomesenteric
duct. In the remaining 26 patients, the interpret-
ers identified no cause for the obstruction in 16,
including nine with isolated adhesions. The in-
terpreters proposed likely causes for obstruction
in 10 of the patients, including two with multi-
ple causes. Of these, the interpreters correctly
identified three of five intussusceptions, one of
three cases of volvulus, and one abscess. The in-
terpreters reported incorrect causes for the ob-
struction in the remaining five children. None of
the four strictures were identified (one patient
had both a stricture and Crohn’s disease). Nei-
ther of the two patients with an internal hernia
was identified. Of 19 patients with adhesions,
the findings on the scans of two were judged as
false-negative for small-bowel obstruction.
Seven had both adhesions and other causes for
the obstruction. Of the remaining 10 patients
with isolated adhesions, the scan of one was
misinterpreted as showing an intussusception;
nine patients were correctly diagnosed as hav-
ing a small-bowel obstruction with no apparent
cause for the obstruction. Thus, the scans of
these nine patients were correctly diagnosed by
inference as obstruction associated with adhe-
sions. Overall, the interpreters identified the cor-
rect cause for the obstruction in 14 (47%) of 30
scans, including intussusception (3/5), abscess
(1/2), volvulus (1/6), and adhesions (9/12 iso-
lated adhesions).
Discussion
CT is a well-established diagnostic proce-
dure for small-bowel obstruction evaluation
in adults [2–14]. The use of CT in the diag-

AJR:177, August 2001 433


Downloaded from www.ajronline.org by 180.246.59.76 on 11/22/17 from IP address 180.246.59.76. Copyright ARRS. For personal use only; all rights reserved
Fig. 6.—8-month-old girl with prolonged abdominal distention. CT scan ob-
tained 23 days after exploratory laparatomy for unresectable neuroblastoma
shows area of ileoileal intussusception (arrows) causing obstruction, which
was missed by both interpreters. Note lack of fat density in intussusceptum.
nosis of small-bowel obstruction has not
been extensively addressed in the pediatric
literature [1] with available papers generally
representing case reports [15–17]. Although
CT is usually not the initial radiologic diag-
nostic tool for small-bowel obstruction in
children, it can be used in some situations [1],
such as in those patients who have a long-stand-
ing obstruction with marked bowel distention
and for whom contrast studies may be unsuc-
cessful or too lengthy. CT can also be used in-
stead of a barium enema to diagnose distal
small-bowel obstruction if the enema is ex-
pected to be very uncomfortable, such as in
patients who have recently undergone sur-
gery. CT is also a valuable tool for detecting
the extraluminal causes of bowel obstruction.
Children with atypical clinical presentation
and unsuspected small-bowel obstruction
may also first present for a CT study.
To our knowledge, the sensitivity of CT in re-
vealing small-bowel obstructions in children has
not been previously reported, nor has the success
of CT in determining the correct cause of ob-
struction been previously reported in a study in
which the reviewers were unaware of the final
diagnosis. In our study, the sensitivity of CT in
revealing small-bowel obstruction was deter-
mined to be 87%, its specificity was 86%, and its
accuracy was 86%. In adult series, the sensitiv-
ity, specificity, and accuracy values were 63–
94%, 78–100%, and 65–95%, respectively [2–5].
The lower range of values was reported in stud-
ies with a preponderance of patients with low-
434
Jabra et al.
Fig. 7.—Segmental small-bowel volvulus in 7-year-old girl. CT scan shows whirl sign
(arrows) produced by twisted mesenteric vessels.
grade obstruction, and the higher range of values
was reported in studies with a preponderance of
patients with high-grade obstruction. The sensi-
tivity of CT in studies with partial small-bowel
obstruction ranged from 48–100% [4, 5].
In our study, we did not characterize the pa-
tients as having low- versus high-grade ob-
struction, a distinction that was generally not
made in the discharge diagnosis of or operative
notes on the patients. The results of our study
fall within the range of results reported for
adults in the literature. In our study, most of
the scans depicting ileus and small-bowel ob-
struction were not obtained on helical scan-
ners. The use of helical and multidetectors
scanners will likely yield technically better
scans and probably improved results.
In our study, we included a group of 22 pa-
tients with ileus because this diagnosis is likely
the most difficult to differentiate from small-
bowel obstruction, both in clinical presentations
and on radiographs. If the group with ileus is
excluded, the specificity of CT in revealing
small-bowel obstruction increases to 100%. If
the control group is excluded and only the small-
bowel obstruction and the ileus groups are in-
cluded, then the specificity of CT in revealing
small-bowel obstruction decreases to 68%, and
the accuracy decreases to 79% (Fig. 5), values
that are still within the range reported in adult se-
ries. In our study, there were four false-negative
and seven false-positive interpretations for
small-bowel obstruction, which affect the rates
of sensitivity and specificity, respectively.
False-Negative Interpretations
One child with an internal hernia showed no
bowel dilatation on CT, likely because of an in-
termittent obstruction that was not present at the
time the scan was obtained. Another patient
showed a transition between mildly dilated
proximal and nondilated distal bowel. The distal
bowel wall was thickened, and an ileus related
to inflammation rather than obstruction was
considered to be the cause. A third patient’s
scan showed air distention rather than increased
fluid content in the dilated loops. A bowel with
a typical hairpin appearance of a closed-loop
obstruction (the bowel trapped by adhesions)
was missed (Fig. 3). Another patient’s scan
showed a borderline dilated distal small bowel
with mildly thickened walls. The ascending co-
lon was filled with stool. This patient had a vol-
vulus involving the last 60 cm of the ileum
around an omphalomesenteric duct.
False-Positive Interpretations
The CT scans of three children clearly met
the CT criteria for bowel obstruction. In these
children, the interpreters considered the CT
scans as showing positive results for obstruc-
tion. These children improved with conservative
treatment, and their final discharge diagnosis
was ileus rather than obstruction. The readings
were therefore classified as false-positive. These
patients raise a question about the nonsurgical
diagnosis of small-bowel obstruction and the
accuracy of the clinical diagnosis of ileus versus
obstruction when symptoms improve without
AJR:177, August 2001
 CT of Small-Bowel Obstruction in Children
surgical intervention. We know that obstruction
caused by adhesions can improve or resolve
with conservative treatment. In a study by Don-
ckier et al. [10], 28 (76%) of 37 patients thought
to have simple (no strangulation) adhesive
small-bowel obstruction were successfully
Downloaded from www.ajronline.org by 180.246.59.76 on 11/22/17 from IP address 180.246.59.76. Copyright ARRS. For personal use only; all rights reserved
treated conservatively. In another study, 35% of
patients with adhesions were treated conserva-
tively [18]. We believe that these three children
were true-positive for obstruction rather than
false-positive and that their obstructions im-
proved with conservative treatment. If these
three patients are considered as among the true-
positive interpretations for obstruction, then the
specificity as well as the sensitivity in this study
improves. The study population would then
consist of 33 children with obstruction, 19 with
ileus, and 29 controls. The sensitivity increases
from 87% to 88%, and the specificity increases
from 86% to 92%.
Level of Obstruction
The level of obstruction was correctly identi-
fied by both interpreters in most children (86%)
with levels of obstruction documented in the op-
erative records. CT is reported to be successful
in determining the level of obstruction in up to
97% of cases in adult series [5]. The level of ob-
struction was described in the operative records
for only 57% of our children and for most
(88%) of these children, the level of obstruction
was described as distal. This distal location may
reflect the select nature of our small-bowel ob-
struction group; distal obstruction may be more
difficult to differentiate from ileus on conven-
tional radiographs and could thus result in refer-
ral to CT for the unexplained and indeterminate
clinical and radiographic findings.
Cause of Obstruction
In our study, the correct cause of obstruction
was identified in a limited number of patients.
Five had specific causes, and nine were cor-
rectly presumed to have adhesions (because no
cause for the obstruction was evident on the
CT scans). Considering all 30 cases with
small-bowel obstruction (including four false-
negative readings), the correct cause was therefore
made in only 47% of the patients. Excluding the
false-negative readings, the correct cause of ob-
struction was made in 14 (54%) of 26 children.
In adult series, the correct causes of obstruction
have been reported as being detected in 76–
90% of cases [2, 3, 5, 7].
Diagnoses were missed for two of five pa-
tients with intussusception in our study, though
the correct diagnosis of small-bowel obstruction
was made. Neuroblastoma, noted as an abdomi-
AJR:177, August 2001
nal mass, was suggested as the cause of obstruc-
tion by both interpreters in an 18-month-old
child with postoperative intussusception. The
second case of intussusception was missed in a
5-month-old infant with ileoileal intussuscep-
tion. The three cases in which the intussuscep-
tion was correctly identified were older children
(3, 17, and 18 years old). The difficulty in iden-
tifying the two missed intussusceptions is likely
a reflection of the younger age of the patients.
The younger children are physically smaller,
which could make the intussusception area less
obvious. Another reason for the difficulty with
the diagnosis is the relative paucity of mesen-
teric fat, which is usually identified between the
intussusceptum and the intussusception and is
virtually diagnostic. In one series, 14 (88%) of
16 adult intussusceptions showed this fatty area
at CT [19]. In another adult study including CT
scans and a small number of MR imaging stud-
ies, 28 (68%) of 41 intussusceptions showed the
fat on imaging [20]. No reports are available de-
scribing the frequency of visualizing fat within
an intussusception on CT scans in children. The
areas of intussusception in the two missed pa-
tients were obvious in retrospect but were
smaller, with the fat density in the intussuscep-
tion appearing on the scans more like the density
of water than that of fat (Fig. 6); no Hounsfield
unit density measurements were obtained. This
finding is likely related to volume averaging of
the small amounts of fat with the adjacent soft
tissues. In addition, the neuroblastoma may have
satisfied search phenomenon, distracting from
the correct diagnosis in the case of one child.
The difficulty in diagnosing intussusception in
the young child may also explain the statisti-
cally significant lower specificity of differentiat-
ing small-bowel obstruction from ileus in
children younger than 2 years old.
Volvulus was detected correctly in only
one of six patients and by only one inter-
preter. The scan of a second child with vol-
vulus showed a whirl pattern that was
misinterpreted as an intussusception by both
interpreters (Fig. 7). Familiarity with this
pattern in volvulus would improve the diag-
nostic accuracy [10, 17, 21]. In the remain-
ing four children, the volvulus did not have
either the whirl sign or a second pattern typi-
cally seen as radial distribution of dilated
bowel around engorged mesenteric vessels
converging towards the point of obstruction
[9, 22]. One of these four children had an ad-
ditional ileoileal intussusception diagnosed
correctly by one of two interpreters.
Both internal hernias were missed. One of
two internal hernias was in an unusual ret-
ropsoas location and was obvious when re-
viewed retrospectively. There was no bowel
dilatation at the time of scanning, and the
scan was considered to show false-negative
results for small-bowel obstruction. This pa-
tient has been described in detail by Benson
and Strauch [23].
When no cause for the obstruction is iden-
tified at CT in a patient with a history of ab-
dominal surgery, adhesions are usually
assumed to be the cause [2]. Of the 16 pa-
tients for whom our interpreters identified no
cause for obstruction, only nine (56%) had iso-
lated adhesions. Adhesions, however, were
correctly inferred as the diagnosis in nine
(75%) of 12 children with isolated adhesions.
In our study, the interpreters were not re-
quested to determine whether closed-loop ob-
struction or strangulation (ischemia) was
present. This area has received much attention
in the recent adult literature [9, 11, 13, 14, 22,
24, 25]. Our interpreters did not identify the
cause of obstruction in five patients with
closed-loop obstructions (four with segmental
volvulus and one with an entrapped ileal loop
by adhesions) (Fig. 3). To assess the accuracy
of CT in these diagnoses in children, a separate
study performed after familiarizing interpret-
ers with the CT appearance of closed-loop ob-
struction and strangulation obstruction may be
needed. In addition, standardizing the imaging
technique in a prospective study would lead to
more reliable results.
CT has a high sensitivity, specificity, and ac-
curacy in revealing small-bowel obstructions
in children, especially in children older than 2
years. The level of obstruction was correctly
diagnosed in most patients. In this study, CT
had limited success in helping the interpreters
to determine the cause of small-bowel obstruc-
tion. Familiarity with the appearance of ob-
structive lesions on CT images and the use of
helical and multidetector scanners will likely
yield better results. A prospective study with a
standardized imaging technique is needed for
more accurate results.
References
1. Jabra AA, Fishman EK. Small bowel obstruction
in the pediatric patient: CT evaluation. Abdom
Imaging 1997;22:466–470
2. Megibow AJ, Balthazar EJ, Cho KC, Medwid SW,
Birnbaum BA, Noz ME. Bowel obstruction: evalu-
ation with CT. Radiology 1991;180:313–318
3. Fukuya T, Hawes DR, Lu CC, Chang PJ, Barloon
TJ. CT diagnosis of small-bowel obstruction: effi-
cacy in 60 patients. AJR 1992;158:765–769
435

4. Maglinite DT, Gage SN, Harmon BH, et al. Ob-
struction of the small intestine: accuracy and role
of CT in diagnosis. Radiology 1993;188:61–64
5. Frager D, Medwid SW, Baer JW, Mollinelli B,
Friedman M. CT of small-bowel obstruction:
value in establishing the diagnosis and determin-
ing the degree and cause. AJR 1994;162:37–41
Downloaded from www.ajronline.org by 180.246.59.76 on 11/22/17 from IP address 180.246.59.76. Copyright ARRS. For personal use only; all rights reserved
6. Frager DH, Baer JW, Rothpearl A, Bossart PA.
Distinction between postoperative ileus and me-
chanical small-bowel obstruction: value of CT
compared with clinical and other radiographic
findings. AJR 1995;164:891–894
7. Gazelle GS, Goldberg MA, Wittenberg J, Halpern
EF, Pinkney L, Mueller PR. Efficacy of CT in distin-
guishing small-bowel obstruction from other causes
of small-bowel dilatation. AJR 1994; 162:43–478
8. Metz CE. Some practical issues of experimental de-
sign and data analysis in radiological ROC studies.
Invest Radiol 1989;24:234–245
9. Balthazar EJ. CT of small-bowel obstruction.
AJR 1994;162:255–261
10. Donckier V, Closset J, Gansbeke DV, et al. Con-
tribution of computed tomography to decision
making in the management of adhesive small
bowel obstruction. Br J Surg 1998;85:1071–1074
11. Frager D, Baer JW, Medwid SW, Rothpearl A,
436
Jabra et al.
Bossart P. Detection of intestinal ischemia in pa-
tients with acute small-bowel obstruction due
to adhesions or hernia: efficacy of CT. AJR
1996;166:67–71
12. Maglinte DT, Balthazar EJ, Kelvin FM, Megibow
AJ. The role of radiology in the diagnosis of small-
bowel obstruction. AJR 1997;168:1171–1180
13. Balthazar EJ, Liebeskind ME, Macari M. Intesti-
nal ischemia in patients in whom small bowel ob-
struction is suspected: evaluation of accuracy,
limitations, and clinical implications of CT in di-
agnosis. Radiology 1997;205:519–522
14. Ha HK, Kim JS, Lee MS, et al. Differentiation of
simple and strangulated small-bowel obstruc-
tions: usefulness of known CT criteria. Radiology
1997;204:507–512
15. Lerner A, Rossi TM, Hodge C, et al. A CT sign:
the “disappearing mass” as a clue to the diagnosis
of intermittent intestinal intussusception in chil-
dren. Comput Radiol 1984;8:387–390
16. Mori H, Hayashi K, Futagawa S, et al. Vascular
compromise in chronic volvulus with midgut
malrotation. Pediatr Radiol 1987;17:277–281
17. Yoon HK, Han BK. Chronic midgut volvulus
with messenteric lymphangioma: a case report.
Pediatr Radiol 1998;28:611
18. Renzulli P, Krahenbuhl L, Sadowski C, Al-Adili F,
Maurer CA, Büchler MW. Moderne diagnostische Strat-
egie beim Ileus. Zentralbl Chir 1998;123:1334–1339
19. Gayer G, Apter S, Hofmann C, et al. Intussuscep-
tion in adults: CT diagnosis. Clin Radiol 1998;
53:53–57
20. Warshauer DM, Lee JKT. Adult intussusception
detected at CT or MR imaging: clinical-imaging
correlation. Radiology 1999;212:853–860
21. Fisher JK. Computed tomographic diagnosis of
volvulus in intestinal malrotation. Radiology
1981;140:145–146
22. Balthazar EJ, Birnbaum BA, Megibow AJ, Gor-
don RB, Whelan CA, Hulnick DH. Closed-loop
and strangulating intestinal obstruction: CT signs.
Radiology 1992;185:769–775
23. Benson JE, Strauch ED. Retropsoas hernia as a
cause of chronic abdominal pain: CT diagnosis.
Pediatr Radiol 1998;28:312–314
24. Balthazar EJ, Bauman JS, Megibow AJ. CT diag-
nosis of closed loop obstruction. J Comput Assist
Tomogr 1985;9:953–955
25. Zalcman M, Gansbeke DV, Lalmand B, Braudé P,
Closset J, Struyven J. Delayed enhancement of the
bowel wall: a new CT sign of small bowel strangu-
lation. J Comput Assist Tomogr 1996;20:379–381
AJR:177, August 2001