Bowel Obstruction in the Adult: What the Radiologist Should

Know

Poster No.: C-0626

Congress: ECR 2018
Type: Educational Exhibit
Authors: 1 2
A. B. Barba Arce , E. herrera romero , F. Pozo Piñon , V.
2

3 3 3
Fernandez-Lobo , E. Montes Figueroa , Y. Lamprecht , E.
3 3 3
Marín Diez , P. Gallego Ferrero , C. González-Carrero Sixto ;
1 2
Torrelavega, Cantabria/ES, Santander, Cantabria/ES,
3
Santander/ES
Keywords: Emergency, Abdomen, CT, Contrast agent-intravenous,
Obstruction / Occlusion
DOI: 10.1594/ecr2018/C-0626

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to third-
party sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.

Page 1 of 47
www.myESR.org

Page 2 of 47
Learning objectives

1. To review the imaging findings of bowel obstruction.

2. To emphasize the role of the radiologist on their early diagnose.

3. To describe with the CT the level of the obstruction, the degree, the cause and the
indication of an urgent surgical treatment if required.

Page 3 of 47
Background

Intestinal obstruction is a common pathology in medical emergencies. 7% of patients

with abdominal pain have an obstructive condition, constituting up to 20% of the surgical
abdomens.

Intestinal obstruction is the stopping of passage of the intestinal contents at some point
along the digestive tract, secondary to a mechanical cause that prevents the progression
of the intestinal contents. We must differentiate from the ileus, that is a failure of normal
intestinal motility in the absence of mechanical obstruction. This phenomenon is common
after abdominal surgery. Fig. 1 on page 5, Fig. 2 on page 5

The most common radiological diagnostic techniques used in the diagnosis of intestinal
obstruction are the simple abdominal X-ray and the abdominopelvic CT.

It's important to know the most important semiologic findings of bowel obstruction in CT,
as well as its main etiological causes.

The main causes in the small bowel are hernias (extrinsic lesions), tumors (intrinsic
lesion) and intraluminal causes. While in the large bowel the most frequent etiologies are
neoplastic, acute diverticulitis and volvulus.

The main complications are ischemia and intestinal perforation.

Page 4 of 47
Images for this section:

Fig. 1: Intestinal obstruction with mechanical cause, with dilatation of small bowel loops.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 5 of 47
Fig. 2: Patient operated the day before, begins with abdominal distension and pain. There
is distension of small bowel loops and all colon. Findings in relation to adynamic ileus.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 6 of 47
Findings and procedure details

CLINICAL PRESENTATION

The classic clinical features of bowel obstruction are: colicky abdominal pain, vomiting,
abdominal distension and absolute constipation.

The order and timescale in which these appear vary depending on whether there is large
or small bowel obstruction. Absolute constipation and pain are more prominent early on
in large bowel obstruction while vomiting is the predominant early feature of small bowel
obstruction.

Additional features depend on the exact underlying pathology.

FIVE QUESTIONS TO ADDRESS IN SUSPECTED OBSTRUCTION

The radiologist must answer five key questions in the evaluation of a patient with
suspected obstruction:

1. Is there obstruction?

2. Where is the location of the obstruction?

3. What is the cause of the obstruction?

4. How severe is the obstruction?

5. Are there any complications associated?

1. IS THERE OBSTRUCTION?

The first radiological examination should always be a simple abdominal x-ray. This
confirms the diagnosis in 50-80% of the cases.

- Findings of mechanical Small Bowel obstruction (SBO) are:

• A dilatation of the proximal small bowel (transverse diameter > 3 cm) with
nondilated distal bowel loops. Fig. 3 on page 17

Page 7 of 47
 • Predominantly central dilated loops
• Absence of colonic dilatation (normal caliber or collapsed colon).
• Absence of rectal gas.
• Multiple gas-fluid levels (>2) on upright or decubitus abdominal radiographs.
Fig. 4 on page 17
• Dilatation of the stomach might be present.

- Findings of mechanical Large Bowel obstruction (LBO) are:

• Colonic distension: gaseous secondary to gas-producing organisms in

feces. Fig. 5 on page 18
• Collapsed distal colon.
• Small bowel dilatation, depends on the duration of obstruction and the
incompetence of the ileocaecal valve.
• In advanced cases, one may see the stigmata of an ischaemic colon:
intramural gas (pneumatosis coli), portal venous gas, free intra-abdominal
gas (pneumoperitoneum).

The CT presents itself as the gold-standard examination for the evaluation of obstruction,
it isn't only able to confirm the diagnosis and localize the location of obstruction but in
most instances also is able to identify the cause.

- The radiologic findings suggestive of mechanical SBO in CT are:

• A small-bowel caliber of greater than 2.5 cm, calculated from outer wall to
outer wall, is considered dilated.
• The transition point often resembles a beak and is described as the beak
sign.
• The "small-bowel feces" sign as a result of stasis and mixing of small-bowel
contents.

- The radiologic findings suggestive of mechanical LBO in CT are:

• A caliber of greater than 6 cm (9 cm in the cecum) should be considered

dilated. In colonic obstruction, the cecum is most distensible.
• If the ileocecal valve is incompetent, dilated small-bowel loops may
accompany a large bowel obstruction.
• The large bowel will be distended with a thinned stretched wall but should
enhance (unless ischaemic).

The use of positive oral contrast is currently not recommended in guidelines due to its
disadvantages: nausea, vomiting, risk of aspiration, it demands a minimum delay of 2-3h
before the acquisition of CT images and it limits the evaluation of the bowel wall.

Page 8 of 47
2. WHERE IS THE LOCATION OF THE OBSTRUCTION?

The objective is to identify the transition point.

A systematic approach begins at the rectum and proceeds proximally toward the cecum
to determine if the large or small bowel is involved.

The transition point is determined by identifying a caliber change between dilated

proximal and collapsed distal small-bowel loops. Identification of the transition point is
generally more difficult in jejunal obstruction.

Multiplanar reformations may aid in determining the site and level of obstruction.

3. WHAT IS THE CAUSE OF THE OBSTRUCTION?

To determine the cause, it's important to distinguish whether the obstruction involves
the small or large bowel because the causes, symptoms, and treatment are often quite
different.

• SMALL BOWEL OBSTRUCTION (SBO)

Small bowel obstruction accounts for 80% of all mechanical intestinal obstruction.

Causes can be divided into congenital and acquired. In the adult, most of the causes are
acquired, and can be extrinsic causing compression, intrinsic, or luminal.

1. EXTRINSIC CAUSES.

1.1. FIBROUS ADHESIONS

Adhesions are the main cause of small bowel obstruction, ranging from 50%-80% of all
cases. Almost all of them are postoperative, with a minority being secondary to peritonitis.

The diagnosis of SBO due to adhesions is primarily one of exclusion because adhesive
bands are not seen at conventional CT; only an abrupt change in the caliber of the
bowel is seen with no identifiable cause (no masses, no inflammation, no wall thickening).
This finding combined with a history of abdominal surgery and associated kinking and
tethering of the adjacent nonobstructed bowel usually suggests the diagnosis. Fig. 6 on
page 19, Fig. 7 on page 20

1.2. ABDOMINAL HERNIA

Page 9 of 47
Hernias are considered the second most common cause of SBO, responsible for 10% of
cases. In developing countries, they are still considered the foremost cause.

Hernias are classified according to the anatomic location of the orifice through which the
bowel protrudes. They are broadly classified as external or internal.

- An external hernia results from a defect in the abdominal and pelvic wall at sites of
congenital weakness or previous surgery. Fig. 8 on page 21, Fig. 9 on page 22,
Fig. 10 on page 23

- An internal hernia is less common, it occurs when there is protrusion of the viscera
through the peritoneum or mesentery and into a compartment within the abdominal cavity.

1.3. ENDOMETRIOSIS

Endometriosis is the presence of functional endometrial glands and stroma outside the
uterine cavity and musculature. It affects about 5% of women of reproductive age.

Endometrial implants are typically located on the antimesenteric edge of the bowel, and
their appearance is variable, being the most common like a solid nodule with positive
enhancement contiguous with or penetrating the thickened bowel wall.

1.4. MASSES

• Extrinsic neoplasm. Fig. 11 on page 24

• Intra-abdominal abscess.
• Aneurysm.
• Haematoma.

2. INTRINSIC BOWEL WALL CAUSES

2.1. INFLAMATTION, e.g. Crohn, tuberculosis, eosinophilic gastroenteritis…

- Crohn Disease:

Small bowel obstruction in Crohn disease can be a manifestation of three clinical

situations that can occur in this disease.

1. The acute presentation is characterized by bowel luminal narrowing secondary to the

transmural acute inflammatory process. The radiologist may see bowel wall thickening
with stratification, mucosal hyperenhancement, and the comb sign. Fig. 12 on page
25, Fig. 13 on page 26

Page 10 of 47
2. In the chronic phase, the luminal stenosis is predominantly of a cicatricial/fibrotic
etiology and there is fat deposition in the bowel wall.

3. Finally, it can be secondary to adhesions, incisional hernias, exacerbation of the

inflammatory condition, or postoperative strictures in patients who have undergone
previous intestinal surgery.

2.2. TUMOUR

Primary small bowel neoplasms are rare (<2% of gastrointestinal malignancy) and usually
advanced at the time of SBO. The most common include adenocarcinoma, lymphoma,
gastrointestinal stromal tumors (GIST) and carcinoid tumors. The findings in the CT
depend on the type of tumor. In the case of adenocarcinoma, it shows an irregular and
asymmetric mural thickening with luminal narrowing at the transition point. Fig. 14 on
page 27, Fig. 15 on page 28

Metastatic disease is the most frequent neoplastic cause of SBO. It is more frequent in
the form of peritoneal carcinomatosis, which is suggested when extrinsic serosal disease
involving the small bowel wall is seen in association with a transition point. Fig. 16 on
page 29

Tumors with a propensity to cause widespread peritoneal metastases include ovarian,

colonic, pancreatic, and gastric neoplasms.

2.3. RADIATION ENTERITIS

Radiation enteritis causes obstruction in the late phase one year after radiation therapy,
usually to the pelvis by fibrotic changes and mesenteric adhesions. Therefore, the ileal
loops are the most affected.

CT shows narrowing of the lumen secondary to mural thickening, an angular bowel wall
due to adhesions, and retraction of the mesentery. There may also be an abnormal
enhancement of the thickened bowel wall caught in the line of the radiation Field.

2.4. INTESTINAL ISCHAEMIA

Occlusion or stenosis of the mesenteric arterial or venous vascular supply to the bowel
usually produces bowel ischemia, which subsequently causes wall thickening in the
affected loops with noncircumferential or asymmetric wall enhancement, resulting in
obstruction.

Page 11 of 47
In advanced cases, a bowel infarct may be present, which manifests at CT as
pneumatosis and air in the portal venous system. Fig. 17 on page 30, Fig. 18 on page
31, Fig. 19 on page 43

2.5. INTRAMURAL HAEMATOMA

Intramural small bowel hematoma may occur secondary to anticoagulant therapy,

iatrogenic intervention or trauma. The development of obstruction is usually due to
luminal narrowing. If this condition is suspected, nonenhanced CT should be performed,
as it will show a spontaneously hyperattenuating clot.

CT also demonstrates circumferential, homogeneous, regular, and spontaneously

hyperattenuating wall thickening with moderate mesenteric infiltration.

2.6. INTUSSUSCEPTION

Intussusception is a relatively rare condition in adults, accounting for less than 5% of

SBOs. Only lead-point intussusceptions secondary to neoplasms, adhesions, or foreign
bodies are associated with SBO. Transient intussusceptions are not associated with this
condition.

At CT, the presence of a bowel-within-bowel configuration with or without mesenteric fat

and mesenteric vessels is pathognomonic for intussusception.

We can find three patterns depending on the severity and duration of the disease: the
target sign, a sausage-shaped mass with alternating layers of low and high attenuation,
and a reniform mass. Fig. 20 on page 32

3. INTRALUMINAL CAUSES

3.1. FOREIGN BODY, BEZOAR

Bezoars:

Obstruction secondary to a bezoar is rare, but the number of cases has increased owing
to the high frequency of gastric outlet surgery. Such surgery prevents adequate digestion
of vegetable fibers, which become impacted, causing obstruction.

At CT, a bezoar appears as an intraluminal mass with an ovoid shape and a mottled
gas pattern.

Foreign body:

Page 12 of 47
It usually occurs in children or in emotionally disturbed or mentally disabled patients.

At CT, the findings consist of SBO with evidence of a foreign body at the transition point.
Fig. 21 on page 33

3.2. GALLSTONE ILEUS

Gallstone ileus is a rare complication of recurrent cholecystitis, caused by migration of a

large gallstone through a biliaryintestinal fistula with subsequent impaction in the small
bowel.

CT findings are pathognomonic, corresponding to the radiographic triad of pneumobilia,

ectopic gallstone, and small bowel obstruction.

3.3. MECONIUM ILEUS (or meconium ileus equivalent, distal intestinal obstruction
syndrome).

Distal intestinal obstruction syndrome is a cause of obstruction that usually occurs in

older children and adults with cystic fibrosis. The obstruction is secondary to impaction
of thick stool, which is probably related to inadequately controlled intestinal absorption
secondary to pancreatic insufficiency. This condition responds to medical treatment.

At CT, the findings consist of SBO with feculent filling defects in the small bowel.

• LARGE BOWEL OBSTRUCTION (LBO)

Large bowel obstructions are far less common than small bowel obstructions, accounting
for only 20% of all bowel obstructions

The causes of LBO may be classified into three categories:

1. LUMINAL OBSTRUCTIONS: intussusceptions, fecal impaction, fecaliths, gallstones

and foreign bodies.

1.1. FAECAL IMPACTION / FAECALOMA (most common cause in debilitated elderly).

Fecal impaction occurs when a hard piece of stool becomes lodged in the colon. It is
most often seen in people with long-term constipation, as the stools become dry, hard
and difficult to pass. Fig. 22 on page 34, Fig. 23 on page 35

Page 13 of 47
2. INTRINSIC CAUSES (colonic wall lesions): colorectal tumors, diverticulitis,
inflammatory bowel disease, and ischemic colitis.

2.1. COLON CARCINOMA

Colon carcinoma is the most common cause of LBO (60% of cases), and mortality is high
(10%-30%) in patients requiring emergency surgery. The two most frequent locations of
obstruction due to colonic malignancy are the sigmoid colon and the splenic flexure. Fig.
24 on page 36

Right-sided tumors with an incompetent ileocecal valve can mimic SBO. Left-sided
malignancies cause diffuse distension of the colon up to the level of obstruction.

CT findings include asymmetric and short-segment colonic wall thickening or an

enhancing soft-tissue mass centered in the colon that narrows the colonic lumen with or
without findings of ischemia and perforation.

Colonic malignancy may mimic diverticulitis if there is pericolonic spread with infiltration
of the pericolonic fat.

The identification of pericolonic lymph nodes larger than 1 cm in short axis should raise
the suspicion of malignancy.

2.2. COLONIC DIVERTICULITIS

Although less common (10% of all cases of LBO), patients with acute diverticulitis can
present with LBO due to bowel wall edema and pericolonic inflammation. High-grade
obstruction is less common in the setting of diverticulitis; more commonly, obstruction
occurs in the setting of multiple episodes of diverticulitis, which causes narrowing and
stricture formation. Chronic diverticulitis can produce both LBO and a chronically dilated
colon.

2.3. ISCHEMIC COLITIS

Ischemic colitis refers to inflammation of the colon secondary to vascular insufficiency

and ischemia. Fig. 25 on page 37

Complications of ischemic colitis can include bowel perforation, peritonitis, persistent

bleeding, protein-losing colopathy, and symptomatic intestinal strictures causing
obstruction.

3. EXTRINSIC CAUSES: volvulus, hernia, adhesion, peritoneal dissemination, and

compression by diseases in adjacent organs.

Page 14 of 47
3.1 VOLVULUS

Acute colonic volvulus accounts for approximately 10%-15% of LBO.

Volvulus is defined as a twisting of the intestine upon itself that causes obstruction. If the
twist is greater than 360°, the volvulus is unlikely to resolve without intervention. Vascular
compromise at the site of volvulus leads to ischemia, necrosis, and perforation.

Sigmoid volvulus is more common than cecal volvulus. Fig. 26 on page 38

A major predisposing factor leading to a colonic volvulus is a mobile redundant colon on

a mesentery and a fixed point about which the colon can twist.

3.2. HERNIA

It's less common than small bowel hernias.

CT: the colon will be found in a hernia with dilated proximal colon and decompressed
distal colon. Fig. 27 on page 39

4. HOW SEVERE IS THE OBSTRUCTION?

The objective is to grade the severity of obstruction: complete or high-grade obstruction

versus partial or low-grade obstruction.

It's determined by the degree of distal collapse, proximal bowel dilatation and transit of
ingested contrast material (used on rare occasions).

In a high-grade obstruction, there is a 50% difference in caliber between the proximal

dilated bowel and the distal collapsed bowel and can be the presence of the "small bowel
feces" sign.

Passage of contrast material through the transition zone into the collapsed distal bowel
indicates a partial bowel obstruction.

5. ARE THERE ANY COMPLICATIONS ASSOCIATED?

It's very important to differentiate a simple obstruction from a complicated one, such as
a closed loop or strangulated bowel obstruction.

Page 15 of 47
A closed-loop obstruction is a form of mechanical obstruction in which a loop of small
bowel is occluded in two points along its course, virtually isolating the segment between
those two points from the remainder of the GI tract. Fig. 28 on page 40

In a closed loop or incarcerated small-bowel obstruction, a U-shaped or radial

configuration of fluid-filled dilated bowel loops is typically seen, with mesenteric vessels
converging toward the point of obstruction. At the site of obstruction, there may be a whirl
sign, a beak sign, or triangular configuration of adjacent collapsed loops.

Strangulation obstruction indicates that blood flow is compromised, which may lead to
intestinal ischemia, necrosis, and perforation. Obstruction to venous outflow is the most
common cause of ischemia in bowel obstruction. Fig. 29 on page 41

This condition often results from an increase in intraluminal pressure as a function of

bowel distention, the bowel becomes edematous and leaks fluid into the lumen, resulting
in progressive dilatation, and into the peritoneal cavity, causing ascites. There is more
risk of intestinal perforation due to the great distension. Fig. 30 on page 42

The CT findings associated with ischemic bowel include bowel with thickening,
mesenteric edema and/or fluid in the adjacent mesentery or peritoneal space, abnormal
decreased bowel wall enhancement, and pneumatosis with or without associated gas in
mesenteric or portal veins.

Intestinal ischemia and infarction are the major causes of morbidity and mortality in
patients with bowel obstruction.

Page 16 of 47
Images for this section:

Fig. 3: A dilatation of the proximal small bowel (transverse diameter > 3 cm) with
nondilated distal bowel loops. Predominantly central dilated loops.The sign of a stack
of coins is observed. Absence of colonic dilatation (normal caliber or collapsed colon).
Absence of rectal gas.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 17 of 47
Fig. 4: Abdominal radiography in standing. Multiple gas-fluid levels (>2), indicative of
small bowel obstruction.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 18 of 47
Fig. 5: Colonic distension. This image corresponds to a sigma volvulus

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 19 of 47
Fig. 6: A 72-year-old woman with a history of partial gastrectomy, went to the emergency
department for abdominal pain, constipation and abdominal distension. Images A-C:
Dilatation of small bowel loops, normocaptants, until the proximal jejuno-ileum transition,
observed in said zone the "small-bowel feces" sign (red arrow), where the change of
caliber is objectified. Distal at this point the terminal ileum is normal. The patient was
operated observing that the cause of the obstruction was due to fibrous adhesions.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 20 of 47
Fig. 7: Woman 87 years old. Small intestine loops dilated, showing a change in caliber
in the ileum, without a clear objective morphological cause that justifies it, that probably
must be secondary to fibrous adhesions given the antecedent surgical of the patient.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 21 of 47
Fig. 8: A 65-year-old woman with an umbilical hernia with terminal ileal loops inside, that
causes a retrograde dilation of the small bowel loops. The loops in the hernia sac don't
show signs of suffering. Hernial ring 4 cm.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 22 of 47
Fig. 9: 90 year old man with direct inguinal left incarcerated hernia. Intestinal obstruction
of loops of distal jejunum and proximal ileum conditioned by left inguinal hernia, with
content of loops inside, with data of suffering (discrete parietal hipoattenuation and fluid
inside). The hernia has a hernial orifice of 3.1 cm.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 23 of 47
Fig. 10: 87-year-old woman with intestinal obstruction due to a right crural hernia. A. Axial
plane. Showing loops in the right crural hernial sac (red arrow). B-C. Coronal and axial
planes. Dilation of the small bowel loops is observed retrogradely. D. Sagittal plane. The
change in caliber in the hernia is observed.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 24 of 47
Fig. 11: A 54-year-old patient with a history of urothelial carcinoma operated with Bricker
reconstruction (yelow arrow), went to the emergency service due to suspicion of intestinal
obstruction. Images A-D. Tissue / mass in the peritoneal cavity at the hypogastrium
level (red arrow) that includes the small and large intestine and the Bricker, with ill-
defined limits, with a tumoral aspect, which causes a high-grade obstruction with dilation
of proximal small bowel loops that reaches a diameter of 8 cm.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 25 of 47
Fig. 12: Concentric thickening of about 10 cm of terminal ileum, with areas hyper-
enhancement, with retrograde dilation of all the loops, to the proximal jejunum, this being
of normal caliber. A geographic collection (green arow) is observed that contacts the
medial wall of the ileum and the roof bladder 16 x 17 mm with a fistulous path to the
bladder lumen. Findings compatible with inflammatory bowel disease, with signs of small
bowel obstruction and areas of microabscesses and enterovesical fistula

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 26 of 47
Fig. 13: The previous patient was treated conservatively. 7 days later the patient gets
worse from her pain. Signs of involvement due to inflammatory bowel disease at the
level of the terminal ileum in its last 20 cm. They result in a marked thickening of
the intestinal wall of stenosing character that conditions a high-grade obstruction with
significant dilatation of the proximal loops to said point. Signs of intestinal perforation
with abundant intraperitoneal free fluid (blue arrow), hydropneumothorax (green arrow)
and signs of peritoneal irritation. The small bowel loops appear markedly thickened
and appear edematous in relation to secondary inflammation. This a case of Intestinal
obstruction secondary to stenant inflammatory bowel disease at the terminal ileum level
with signs of peritonitis with perforation of hollow viscus.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 27 of 47
Fig. 14: A 39-year-old woman with obstructive symptoms, with no previous surgical
history. Dilation of the gastric chamber, duodenum, ileopelvic jejunum where a change in
caliber is observed in front of the uterine fundus,with previus "small bowel feces" sign (red
arrow). Discrete presence of free fluid (yellow arrow) in the mesentery and lower pelvis,
all in relation to intestinal obstruction with signs of suffering. The patient was operated,
identifying a tumor at the level of the middle jejunum, small but very stenosing with
secondary obstruction proximal to said point. The pathological anatomy gave a carcinoid
tumor result.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 28 of 47
Fig. 15: Intestinal obstruction due to a spiculated mass compatible with carcinoid tumor.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 29 of 47
Fig. 16: A 58-year-old woman with a history of colon and ovarian neoplasia with
peritoneal carcinomatosis. Marked patchy dilatation of the small bowel loops, some of
them with edematous walls and hyperdensity of the mucosa. Free liquid in moderate
amount (green arrow). In the mesosigma a spiculated-looking mass is observed (red
arrow) that infiltrates the wall of the sigma, compatible with neoformation of sigma vs
metastatic implant. Pneumoperitoneum of moderate amount without observing a point of
perforation (blue arrow). The findings described in the clinical context suggest us as the
first diagnostic option Secondary changes Transient ischemic intestinal suffering, with
microperforation.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 30 of 47
Fig. 17: Intestinal ischemia secondary to low cardiac output after cardiorespiratory arrest,
with dilatation of the intestinal loop, parietal pneumatosis (red arrow) and hypoperfusion
of ileal loops. Kidney infarcts are also observed.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 31 of 47
Fig. 18: Male 71 years old. Hepatopathy OH with portal hypertension. Dilatation of
the jejunum and part of the proximal ileum. Change in size in FID conditioned by
wall thickening of about 20 cm in length with loss of definition of the walls although
with preserved enhancement. Edema of the mesentery of this thickened segment.
Thrombosis of the superior mesenteric vein (red arrow) that affects 50% of its light.
Chronic liver disease with severe portal hypertension, with a large amount of ascites
(yelow arrow). The diagnosis is VENOUS ISCHEMIA.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 32 of 47
Fig. 20: 32 year old girl. Ileo-ileal intussusception with the target sign (red arrow) without
any cause that justifies it.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 33 of 47
Fig. 21: Foreign bodies: batteries. A 32-year-old patient who is in prison with habitual
battery ingestion

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 34 of 47
Fig. 22: Faecaloma (red arrow).

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 35 of 47
Fig. 23: Patient with abdominal distension secondary to constipation.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 36 of 47
Fig. 24: 90 year old man. Circumferential thickening with a length of 4 cm of sigma (red
arrow) that stenosing the light and causing a retrograde dilatation of the rest of the colon
suggestive of neoformation. Pneumatosis cecal (yelow arrow).

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 37 of 47
Fig. 25: COLITIS WITH PERFORATION. Distension of the entire colon until the sigma,
observing a discrete parietal thickening together with effacement of the adjacent fat
suggesting nonspecific colitis. The distension of the cecal area is very significant reaching
a maximum size of 10 cm (red arrow). Abundant pneumoperitoneum (green arrow). Free
liquid of moderate amount.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 38 of 47
Fig. 26: SIGMA VOLVULUS. Dilation of the entire colon (10cm), identifying a double
change in caliber at the centroabdominal level, with rotation of the meso and
vascularization (red arrow). Additionally, intraabdominal free fluid which translates
suffering from loops (green arrows).

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 39 of 47
Fig. 27: Abdominal wall eventration, containing small bowel and colon loops.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 40 of 47
Fig. 28: 36-year-old woman with a history of recent cesarean. Closed loop obstruction
of a loop of preterminal ileum (red arrow), which has edematous walls, with diminished
enhancement, effacement of fat and adjacent free fluid and a maximum caliper of 3 cm.
The patient was operated with a diagnosis of closed loop obstruction due to internal
hernia.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 41 of 47
Fig. 29: 60 year old woman with MELAS disease. She presents great abdominal
distension and sepsis. Large dilatation of the colon, with parietal pneumatosis in the
caecum and portal pneumatosis, for INTESTINAL ISCHEMIA.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 42 of 47
Fig. 30: The same previous patient was not operated, ending in a bowel PERFORATION.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 43 of 47
Fig. 19: Intestinal obstruction of small bowel, with parietal pneumatosis (red arrow)
and portal pneumotosis (yelow arrow) and superior mesenteric vein. The diagnosis is
INTESTINAL ISCHEMIA.

© Department of Radiology, Hospital Universitario Marqués de Valdecilla - Santander/ES

Page 44 of 47
Conclusion

Bowel obstruction is a serious and prevalent pathology in the emergency department,

in which the radiologist plays an important role in the diagnosis and characterization the
associated findings, as well as to determine the presence or not of complications, which
are going to be key in the planning of the surgery and the urgency of the surgery.

Page 45 of 47
Personal information

Ana Belén Barba Arce

University Hospital " Marqués de Valdecilla"

Department of Radiology

Avd. valdecilla s/n . 39008. Santander. Spain

Page 46 of 47
References

1. Silva AC, Pimenta M, Guimarães LS. Small bowel obstruction: what to look
for. Radiographics. 29 (2): 423-39.
2. Boudiaf M, Soyer P, Terem C et-al. Ct evaluation of small bowel obstruction.
Radiographics. 2001;21 (3): 613-24.
3. Review of small-bowel obstruction: the diagnosis and when to worry.
Radiology. 2015;275 (2): 332-42.
4. Khurana B, Ledbetter S, Mctavish J et-al. Bowel obstruction revealed by
multidetector CT. AJR Am J Roentgenol. 2002;178 (5): 1139-44.
5. Jaffe T, Thompson WM. Large-Bowel Obstruction in the Adult: Classic
Radiographic and CT Findings, Etiology, and Mimics. Radiology. 2015;275
(3): 651-63.
6. Aguirre DA, Santosa AC, Casola G et-al. Abdominal wall hernias: imaging
features, complications, and diagnostic pitfalls at multi-detector row CT.
Radiographics. 2005;25 (6): 1501-20.

Page 47 of 47