Gastroenterol Clin N Am

31 (2002) 777799

Intestinal obstruction
Role of CT
David Frager, MD*
Columbia University College of Physicians and Surgeons, St. Lukes Roosevelt Hospital Center,
Department of Radiology, 1111 Amsterdam Avenue, New York, NY 10025, USA

Despite more than 120 years of surgical experience dealing with bowel
obstruction, controversy still exists regarding optimal methods for diagnosis
and treatment [1]. It is generally agreed that complete small bowel or large
bowel obstruction requires surgery, although partial small bowel obstruction (SBO) can be managed conservativelyat least initially. The nal management of both partial small bowel and colonic obstruction obviously
depends on the specic diagnosis. Because the clinical ndings in bowel
obstructionincluding obstipation, abdominal distention, colicky pain,
nausea, and vomitingare not specic, the abdominal radiograph or obstructive series has, over the decades, played a critical role in determining the
nal diagnosis. SBO could be diagnosed with the demonstration of dilated
loops of small intestine with air uid levels and no or little colonic gas, while
colonic obstruction appears as colonic distention [1].
Unfortunately, the plain-lm examination is diagnostic in only 46% to
80% of SBO cases [2,3]. The lower percentage probably reects the radiographic ndings at the patients initial presentation, while the higher percentage includes patients who received follow-up plain-lm studies [4].
Therefore, approximately 20% of patients never have diagnostic plain lms,
and may have their surgery delayed for several days. This delay can be
lethal. The major morbidity and mortality associated with SBO is related
to associated intestinal ischemia or infarction resulting from strangulation.
As much as 42% of patients with SBO have strangulation obstruction [3]. In
patients who have strangulation, surgery performed within 36 hours of the
onset of symptoms has a mortality rate of 8%, while surgery delayed more
than 36 hours has a mortality of 25%, at least according to one study [5].
There is no reliable clinical method or laboratory test that can denitively distinguish between simple and strangulation obstruction of the small
* E-mail address: makshan@aol.com
0889-8553/02/$ see front matter 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 8 8 9 - 8 5 5 3 ( 0 2 ) 0 0 0 2 6 - 2

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intestine [3]. In fact, strangulation usually occurs with an underlying closedloop obstruction, which is the very situation for which plain-lm examination
is least diagnostic [6]. Plain abdominal radiographic signs of strangulation
have been described such as the so-called pseudotumor signed; however,
they are very unusual, and usually misinterpreted [7,8]. As opposed to the
typical gaseous distention seen in simple obstruction, a gasless abdomen is
not uncommon in closed-loop or strangulating obstruction where the obstructed loops are uid lled [6] (Fig. 1).
Contrast studies including upper gastrointestinal series, small bowel series, barium enema, gastrogran small bowel series, and gastrogran enema
have been used over the years but their accuracy is awed [2]. Although the
passage of contrast into the colon indicates the SBO is not complete, it does
not exclude the need for eventual surgery. Furthermore, in high-grade partial obstruction water-soluble contrast is considerably diluted even if some is
reconstituted in the colon, and barium can take 1224 hours to reach the
colon under those circumstances. In the interim, no diagnostic information
is provided in many of these cases. Enteroclysis is an excellent method in
diagnosing SBO. In particular, it is an excellent method in grading partial
obstruction and delineating multifocal obstruction [9]. The disadvantages
of this technique are that it is operator dependent, uoroscopy sta must
be available on an emergency basis, it is time-consuming, and requires a
considerable amount of radiation. Additionally, the wall of the small bowel
is not visualized directly such that strangulation may be dicult to appreciate. Furthermore, barium used in enteroclysis precludes utilization of other
cross-sectional imaging studies or angiography when there is no obstruction.
Ultrasound can readily detect distended uid-lled loops, which certainly
suggests the possibility of obstruction, but dening the location type and

Fig. 1. (A) Supine frontal abdominal radiograph (KUB) demonstrates paucity of bowel gas. (B)
CT demonstrates intestinal volvuluswhirl sign (arrow) with disappearing uid-lled loops of
nonenhancing small bowel consistent with strangulation and infarction.

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cause of obstruction is extremely operator dependent, and therefore very

variable. Also, where gaseous distention predominates, ultrasound is technically limited.
The diagnosis of SBO was revolutionized by CT. In the 1980s, isolated
case reports demonstrated the utility of CT in diagnosing unusual SBOs.
In 1991, Megibow et al published the rst large series of patients demonstrating utility and ecacy of the CT in diagnosing SBO and determining
its cause [10]. In this series of high-grade intestinal obstruction the sensitivity
of CT was 96%, specicity was 96%, and accuracy 95%. Numerous subsequent studies showed sensitivities ranging from 78% to 100% for high-grade
or complete SBO [2,11]. Partial SBOs, especially low-grade partial SBOs,
have yielded results with sensitivities ranging from 48% to 100% [2,11]. Subsequently, CT signs of strangulation were developed.
Technique
CT diagnosis of bowel obstruction does not require the most sophisticated equipment now available. Any relatively fast scanner, namely, less
than or equal to 4 seconds per scan, can be used. However, spiral CT scanners, which are now widely available across the United States, provide faster
and more artifact free examinations. Multidetector spiral CT scanners provide for even further improvements. Although the gastroenterologist does
not primarily determine the CT technique that would be utilized in diagnosing bowel obstruction, he or she should be aware of the techniques that are
utilized because only the clinician many times is aware of other medical
problems such as swallowing diculties and intravenous contrast risks,
which would necessitate changes in the technical protocol. Radiologists differ as to whether there is utility in administering oral contrast. There is obviously a risk of aspiration, particularly if the the stomach is already distended
and no nasogastric tube has been inserted. However, if these risks can be
minimized, it is this authors opinion that oral contrast, especially watersoluble iodinated contrast, for example, Gatrogran, should be utilized.
This is for three reasons: (1) to diagnose the proximal small bowel in contradistinction to the more distal small bowel; (2) to be utilized as a followthrough in grading the degree of obstruction, namely, whether high-grade
or low-grade; and (3) for possible therapeutic value in stimulating peristalsis
and breaking up thickened intestinal contentssmall bowel feces/loose
bezoar. Similarly, bowel obstruction can be diagnosed without intravenous
contrast; however, intravenous contrast is very helpful, and probably the
most specic method by which to diagnose strangulation as well as in delineating enhancing tumors and inammatory changes as well. In addition, if
there is no obstruction, intravenous contrast is helpful in characterizing
other pathology such as superior mesenteric artery or superior mesenteric
vein thrombosis, both of which can produce an ileus that mimics obstruction. These issues will be further discussed later on.

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CT diagnosis of complete or high-grade small bowel obstruction

The CT diagnosis of SBO requires a dilated proximal small bowel and
collapsed distal bowel. A diameter of 2.5 cm or greater is considered a
dilated small intestine. A collapsed bowel devoid of luminal contents often
has a diameter of 1 cm or less [2,10]. The most reliable and specic sign of
bowel obstruction is present with proximal dilatation with an identiable
focal transition to the collapsed bowel. The transition zone is often dicult
to detect and characterize. The presence of small bowel (and not colonic)
feces, that is, succus entericus mixed with gas bubbles, is usually located
at or within a few centimeters of the actual transition zone in cases of higher
grade obstructions [2] (Fig. 2). Occasionally, this small bowel feces actually
represents an impacted bezoar, and aggravates the underlying obstruction.
If these signs do not suce to identify the point of obstruction/transition
zone, additional thin section cuts and, if necessary, two-dimensional and
three-dimensional reconstructions can be helpful [12]. These reconstructed
and reformatted images with the advent of multidetector CT scanners will
play an even greater role. CT enteroscopy, although more complicated than
CT colonoscopy, will undoubtedly become practical in the near future, and
simplify matters as well.
From a practical standpoint suspected SBO should be divided initially
between low-grade partial obstructionparalytic ileus (nonsurgical)and
high-grade partial obstructioncomplete obstruction (surgical). The presence or absence of colonic uid or gas and a gradual or abrupt transition
is used to distinguish between the two. However, an early complete obstruction, particularly with a closed-loop obstruction, can demonstrate colonic
dilatation, and as such, be misleading. Physiologically complete colonic
evacuation can take between 24 and 48 hours, depending on several factors
[13]. Therefore, even under these circumstances CT signs of closed-loop
obstruction need to be sought and excluded before diagnosing ileus/lowgrade partial obstruction. On the other hand, massive jejunal dilatation in
and of itself does not imply the presence of SBO despite the fact that the dis-

Fig. 2. CT shows dilated ileum with small bowel feces (arrow) at transition with collapsed distal
bowel due to adhesion.

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781

tal ileum appears relatively collapsed. In reality, under these circumstances

the ileum is actually of normal caliber. The jejunum is more distensible than
the ileum, which maintains its tone longer even in the face of ileus. Invariably, in this particular situation there is at least a moderate amount of
colonic gas and uid initially without an abrupt transition, and there is subsequent passage, usually within 6 hours, of oral contrast into the colon.
Nonetheless, it is very easy to fall into the trap of diagnosing SBO when
there is massive small bowel dilatation. This appearance of pseudo-SBO is
most commonly seen due to the ileus or peritonitis with or without free air
and in intestinal ischemia [2] (Fig. 3). Almost invariably the colon is distended under those circumstances with gas and uid. If there is peritonitis,
the diagnosis of obstruction should not be made unless there is an extremely
abrupt transition and an empty colon. The cause of the peritonitis, such as
appendicitis diverticulitis, should be sought and diagnosed. (Incidentally, it
should be noted that both of these entities can produce some degree of SBO.)
Intestinal ischemia should also be diagnosed fairly readily, with secondary signs of bowel wall thickening and/or pneumatosis, or specically diagnosed with the actual visualization of the embolus or thrombus in the
mesenteric artery or vein.
CT diagnosis of partial small bowel obstruction
Depending on the type of gastroenterology practice, the clinical problem
of partial SBO may be more frequently encountered than the acute highgrade obstruction, which may fall under a general surgeons purview. The
consensus currently is that routine CT examination is insensitive in diagnosing low-grade partial SBO [2,11]. Incomplete or intermittent obstruction
rarely results in strangulation and, therefore, can be managed conservatively,
at least initially. The CT denition of partial obstruction in the presence of
mildly dilated small bowel is an ill-dened transition, incomplete collapsed

Fig. 3. PeritonitisCT shows gradual transition (arrow), uid in the colon (curved arrow), and
inltration of the omentum.

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distal bowel, and moderate colonic uid gas (Fig. 4). In light of the previous
discussion of complete high-grade obstruction, however, this denition
obviously overlaps with paralytic ileus and early high-grade obstruction. The
passage of oral contrast material into the colon within 6 hours, either
demonstrated on a delayed abdominal X-ray or repeat CT scan, conrms the
lack of complete obstruction and the need for immediate surgery.
The current practice at our institution in the acute presentation is, therefore, to perform the CT, and if there is no CT evidence of strangulation and
no oral contrast within the colon, to repeat the examination in 2 to 4 hours
to conrm partial or high-grade obstruction. If the contrast does reach the
colon at that point then the patient is managed conservatively with nasogastric suction and feeding trials over the next several days. If the patient is still
symptomatic and there is a signicant gastric residual, the patient will then
undergo surgery.
The more dicult problem and the one gastroenterologists are likely to
encounter is that of recurrent chronic partial SBO. The best time to perform

Fig. 4. (A) KUBconsistent with partial SBO. (B) CTjust proximal to transition is an
unusual hypodensity with gas bubbles (arrow). (C) Enteroclysis delineates the partial
obstruction as being caused by a foreign body; in this case, a mistakenly swallowed baby
aspirin plastic bottletop (arrow).

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783

CT examination in this situation is when the patient is most symptomatic.

Otherwise, the CT examination is likely to be negative. In the past, the optimal
way to evaluate these patients was with enteroclysis [9]. The proponents of
this examination have recently modied the examination utilizing CT to perform so-called CT enteroclysis [14]. By combining the techniques, the distention of enteroclysis and the more detailed evaluation of overlapping loops
on CT is combined. Enteroclysis and/or CT enteroclysis will better demonstrate adhesions and small tumors that might be overlooked on standard CT
examination where there is usually limited opacication of the intestines.
Also, unexpected pathology might be encountered, which, although not producing severe obstruction, might simply by their appearance warrant excision.

CT diagnosis of closed-loop obstruction

The importance of recognizing a closed-loop obstruction is that it is
the most common precursor to strangulation obstruction [1]. It should be
realized, however, that not every closed loop necessarily becomes a strangulation obstruction because some will resolve spontaneously or with nasogastric suction. A closed loop is a bowel loop that is obstructed at two points
along its course by one constriction. The length of the involved bowel loop
or loops can be quite variable, ranging from the tiny Richter hernia (Fig. 5)
to volvulus of the entire midgut (Fig. 1). The classic closed loop is represented by the external hernia, or for that matter, the internal hernia. Incarceration of a closed loop results in bowel obstruction, and constriction of
the vascular pedicle supplying this loop leads to strangulation or ischemia.
A closed-loop conguration provides the backdrop for subsequent volvulus,
which produces the most pronounced vascular insuciency.
The CT signs of the closed loop have been described [7] and include
(Fig. 6) (1) radial distribution of incarcerated bowel with mesenteric vessels
converging towards the torsion; (2) a coee bean C or V loop; (3) two adjacent collapsed round, oval, or triangular loops forming an arrowhead

Fig. 5. Richter hernia (A) proximally at beginning of the obstruction (arrow). (B) Entrapped
wall of loop in the inguinal canal (arrow).

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Fig. 6. (A) C loopCT demonstrates closed loop of proximal jejunum entrapped in the
lesser sac (internal hernia) (C). (B) Upper gastrointestinal (UGI) series demonstrates the same.
(C) Beak sign (arrow).

conguration; (4) the beak sign; and (5) the whirl sign (Fig. 1). In our experience with 500 patients who underwent surgery for SBO we could condently dignose closed-loop obstruction before surgery approximately 60% of
the time, excluding cases of external hernias. The radial conguration c-loop
beak sign and whirl sign in isolation are nonspecic. Even in combination
these signs and the diagnosis of a closed loop are dicult to ascertain in
many instances. One author states that the beak sign may be seen in 80%
of simple nonclosed-loop obstructions [15]. Nonetheless, all of the above
signs should be sought, and are of value in determining the likelihood of
strangulation obstruction.

CT diagnosis of strangulation obstruction

Strangulation develops when the circulation is cut o to the obstructed
intestines. Strangulation can be classied into viable or nonviable ischemia.
Using this comprehensive denition the incidence of strangulation in complete or high-grade obstruction has been reported as high as 42% [3].
Reported incidences in the range of 5% to 10% may use the narrower denition of bowel infarction and/or include cases of partial obstruction in the
denominator [16]. The surgical diagnosis of strangulation is made by visual
inspection for signs of tissue ischemia. These are hypoxic discoloration, loss

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of arterial pulsations, subserosal hemorrhage, and ultimately gangrene.

Strangulation can accompany any type of SBO, but is usually associated
with external internal hernia or with adhesive bands and associated volvulus
(closed loop). Although, as previously stated, a closed loop is the most common precursor (80% in our ongoing series), it is by no means a prerequisite
for strangulation. Although physiologically a simple obstruction by an
adhesive band at one location cannot produce a small bowel intraluminal
pressure above 12 mm H2O experimentally [17], at the point of constriction
pressures may be higher and the vessels kinked, which can lead to ischemia
and infarction. Also, in elderly or debilitated patients who may be vasoconstricted or have generalized hypotension the increased intraluminal pressure
may be enough under those circumstances to interfere with intestinal perfusion, which then can proceed to ischemia and infarction. The increased
intraluminal pressure even in normal individuals will produce bowel edema
and leakage of uid into the mesentery and bowel lumenthe so-called
third spacingwhich further worsens mesenteric circulation. Only rarely,
however, does infarction occur without some kind of kink with, or compression of, the intestinal vasculature. Thus, the CT signs of strangulation are
those of intestinal ischemia in general [7,16] (Figs. 7 and 8), namely; (1)
thickening of the bowel wall with or without the target sign; (2) pneumatosis; (3) portal venous gas; (4) increased density of bowel bowel wall on CT
without intravenous contrast; (5) mesenteric haziness, uid, or hemorrhage
often associated with generalized ascites; (6) on intravenous contrastenhanced CT, nonenhancement [18], or rarely increased enhancement of the
bowel wall. This latter nding may be more pronounced on delayed scanning through the aected loops, and is related to decreased outow due to
venous congestion and constriction and slower vasoconstricted arterial
inow (Fig. 8). Other authors describe a serrated beak sign in strangulation
obstruction [15]. In our experience with a large series of surgically proven
complete or high-grade SBO, using two of the CT signs (not including the

Fig. 7. Closed-loop obstruction with strangulation. (A) CT demonstrates bowel wall thickening
and pneumatosis (arrow). Converging loopsarrow sign indicates closed loop obstruction
(open arrow). (B) Portal venous gas in the same patient.

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Fig. 8. Closed-loop obstruction with strangulation. CT demonstrates left upper quadrant

jejunal loops in a radial conguration with mesenteric hemorrhage and complete nonenhancement (disappearing loops) indicating infarction (open arrows). Converging loopsarrow sign
also present (arrow).

serrated beak sign) to diagnose strangulation, no cases of strangulation were

overlooked [16]. However, compared to surgical inspection, CT was oversensitive, with many false positives using these criteria. The inability of
CT to be more accurate and specic is related to the fact that the CT signs
for strangulation of bowel wall thickening mesenteric uid ascites are nonspecic, and can accompany other inammatory processes including peritonitis appendicitis diverticulitis or Crohns disease. In these settings
strangulation cannot be diagnosed accurately. The more specic CT signs
of intestinal ischemia of portal venous gas and pneumatosis are relatively
uncommonly seen in patients with SBO. The most specic sign is abnormal
bowel wall enhancement patterns, but many of the patients undergoing CT
for suspected bowel obstruction will not receive intravenous contrast material because of renal insuciency or other factors. Finally, the discrepancy
between CT in the surgical ndings can be related to the relative timing
of the CT examination and the surgeryand perhaps more importantly,
because surgical inspection may underestimate the presence of mucosal
ischemia in the face of obstruction. For this reason surgeons use intraoperative Doppler and uorescin perfusion to evaluate primary mesenteric
ischemia [16,19].
To improve CT accuracy in diagnosing strangulation other authors have
adopted stricter CT criteria, and have achieved accuracies in the range of
90% in the preoperative diagnosis of strangulation [20]. This is still far better
than the clinical criteria, which produces an accuracy of 50% [3]. Common
sense and logic dictate that the greater the number and severity of the CT
ndings, the more likely strangulation will be diagnosed by the surgeon.
Thus, not surprisingly with limited CT ndings suggesting strangulation,
conservative management may occasionally lead to resolution of the acute

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787

obstruction. Furthermore, chronic strangulation may accompany partial

SBO such as an incomplete or intermittently incarcerated closed loop requiring surgery months or years later for ischemic stricture. Chronic ischemic
changes can also be present in external hernias, particularly ventral hernias.
Generally, however, strangulation is rare in partial and intermittent obstruction. CT therefore does play a signicant role in the preoperative diagnosis
of strangulation. From a practical standpoint, with ndings suggesting
closed-loop obstruction, lack of bowel wall enhancement, as well as other
additional ndings of strangulation on CT, immediate surgery is mandated.
Whether it is the gastroenterologist or radiologist who insists that surgery is
necessary based upon these ndings is dependent upon their respective
expertise and relationship to the covering surgeon.

Etiology of small bowel obstruction

CT is highly eective in determining the cause of SBO. Table 1 lists the
etiology of SBO by percentage in the 500 surgically proven cases operated
upon in our institution.
These percentages have changed since our original study because more
and more on a routine basis patients with bowel obstruction go to CT scanning before surgery in our institution where the vast majority of cases are
due to adhesions. When we rst started doing CT scanning for SBO it was
done in a large number of patients who did not have previous surgery. The
accuracy of CT in prospectively diagnosing the etiology of the SBO is currently approximately 90% in our institution.
Adhesive obstruction
Adhesive obstruction in the United States is by far the most common
cause of SBO, usually from previous surgery. Rarely congenital bands are
the cause of obstruction in a patient who never underwent surgery. As a
rule, adhesions are invisible on CT except in the early postoperative period
where there is an acute inammatory component or hematoma with
Table 1
Etiology of SBO (500 cases)
Adhesive obstruction including internal hernias and volvulus related to adhesions
External hernias
Primary and secondary neoplasms
Colon carcinoma presenting as small bowel obstruction
Crohns disease
Diverticulitis
Other (gallstone ileus, appendicitis, hematoma, idiopathic intussusception,
tuberculosis, foreign body/bezoar, abscesses, and peritonitis)
Total

81%
4%
4%
4%
2%
2%
3%
100%

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reaction [21] (Fig. 9). CT usually demonstrates an abrupt transition of luminal

caliber at the site of the adhesion (Fig. 2). Benign strictures occasionally
occasionally appear the same. When adhesions are caused by other factors
such as: previous peritonitis resulting from tuberculosis, chronic peritoneal
dialysis, bowel perforation, appendicitis, diverticulitis, Crohns disease, or
peritoneal carcinomatosis, they appear as bands of soft tissue coursing
through the mesenteric fat. Congenital bands also are usually not visible
on CT, but the associated volvulus or malrotation may well be.
External hernias
CT is an exquisite modality for diagnosing all types of external hernias
[22]. Although seemingly superuous to the physical examination, in many
instances these hernias are undetectable or not detected on physical examination, and with unusual hernias, sometimes only diagnosable with CT. The
best example of the latter is the obturator hernia (Fig. 10). The diculty with
interpreting the CT lies not with diagnosing the presence or absence of a
hernia but in determining whether the hernia is the cause of SBO. Many
patients have small hernias that are unrelated to the acute obstruction.
Small femoral or Richter hernias (Fig. 5) appear benign, yet they notoriously cause signicant obstruction and strangulation (Fig. 11). A spurious
gap between the proximal dilatation of the small bowel and the hernia may
make the bowel dilatation and the hernia seem disconnected [2]. Thus, in
cases of SBO and external hernias occurring simultaneously, the hernia
should be presumed as the cause of obstruction unless there is another
obvious point of transition.

Fig. 9. Early postoperative small bowel obstrutionpartial. (A) CT shows small bowel loops
adhesed by hematoma and brosis (arrow). (B) Enteroclysis demonstrates aected loops
(arrows).

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Fig. 10. Obturator hernia. CT demonstrates entrapped bowel between the obturator internus
and externus.

SBO caused by neoplasm

Primary and secondary neoplasms involving the small intestine with or
without obstruction are easily diagnosed by CT [23] (Figs. 1114). Nonobstructing neoplasms require complete opacication and distention of bowel
loops for greatest sensitivity. CT enteroclysis plays a role in this regard as
well [14]. A discrete mass at the transition zone in obstructing cases indicates
the cause of obstruction. Thickened nodular bands and xed bowel loops
with luminal constriction and proximal dilatation are diagnostic of metastatic disease in the proper clinical setting. Chronic peritonitis such as that
resulting from tuberculosis can produce a similar appearance. Crohns disease or ischemia may be associated with an enhancing focus in the region of
obstruction that could be mistaken as a neoplasm as well.

Fig. 11. Primary adenocarcinoma in the distal jejunum producing partial obstruction (arrow).

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Fig. 12. Metastatic ovarian carcinoma with cystic and solid components with involved ileum.

Colon carcinoma
Colon carcinoma will be discussed under colonic obstruction.
Crohns disease
Bowel obstruction is a well-known complication of Crohns disease. Usually operative treatment is not required, as the obstruction is only partial
and/or reversible with resolution of acute inammation with medical therapy. If the concentric rings of mural stratication (target sign) are present
at the point of bowel obstruction on contrast-enhanced CT, then the
obstruction should be assumed reversible with medical therapy (Fig. 15).
If there is a nonenhancing thickened loop with no target sign at the site
of obstruction than the obstruction should be assumed to be xed and likely
to require surgery [24]. Fistulae may contribute to the need for surgery, but
again, with the newer medical therapies surgery should be delayed and/or

Fig. 13. Partially obstructing carcinoidatypical appearance.

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791

Fig. 14. Small intestinal lymphyoma. (A) Large jejunal mass (arrow). (B) Ileal intussecepting
mass (arrow). (C) Small bowel series of the same.

avoided. Disproportionate bowel thickening with or without stulae and

lack of response to conservative medical treatment may indicate the presence of the dreaded complication of carcinoma, and again, the need for
surgery (Fig. 16).
Diverticulitis
In the more severe forms of colonic diverticulitis, particularly sigmoid
diverticulitis, there is often a reex ileus and partial obstruction related to
phlegmon/abscess surrounding adjacent small bowel loops (Fig. 17). Occasionally obstruction can be complete or high grade. CT can be very specic
in establishing the diagnosis in characterizing the associated obstruction
[25]. Surgery would be necessary depending on the degree and complications
of the diverticulitis over and above the presence or absence of SBO. Occasionally, after the diverticulitis has responded to medical therapy, brosis
and adhesions involving the adjacent small bowel loops may lead to the subsequent need for surgery due to recurrent or residual obstruction.

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Fig. 15. (A) Partial obstruction due to ileal Crohns disease on CT. Note enhancement and
mural straticationmultilayered appearance (arrow). (B) Small bowel series shows diseased
terminal ileum (arrow).

SBO in the immediate postoperative period

Abdominal/intestinal distention in the immediate period following
abdominal surgery is virtually universal. The distention is due to the fact
that the bowel resumes its normal functions/peristalsis asynchronously. The
stomach, followed by the small intestine, followed by the colon, resume peristalsis in this order over a 34-day period of time [13]. Persistent bowel
distention beyond this period of time may be due to physiologic delay, medications and/or a cause for ileus such as abscess. In a majority of patients in our
series the cause of obstruction was usually an adhesion [21] (Fig. 9). Idiopathic intussusception and other rare entities do occur. Plain-lm examination during this time frame is often confusing because there is always bowel
dilatation, which may be seemingly disproportionate. CT, however, is extremely valuable, and readily makes the distinction between high-grade

Fig. 16. Obstruction due to carcinoma complicating Crohns disease. (A) CT demonstrates
heterogeneously enhancing lesion at point of obstruction (arrow). (B) Small bowel series
demonstrates stricture and stulae (arrows).

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Fig. 17. SBO due to sigmoid diverticulitis. (A) KUB consistent with SBO. (B) CT demonstrates
diverticular abscess (A) compressing ileal loop (arrow).

or complete obstruction from partial obstruction or reex ileus [21]. The

former usually requires surgery while the latter do not. Again, the ndings
that diagnose the particular etiology of the obstruction and the presence or
absence of strangulation or a closed loop are the same as with any SBO
except that there are expected inltrative changes within the mesentery and
abdominal wall.
Colonic obstruction
The situation with colonic obstruction is somewhat dierent. Most
patients who have symptoms and signs of colonic obstruction such as constipation obstipation change in stool caliber will not have plain-lm ndings
diagnostic in the majority of cases because some degree of colonic distention
and stool impaction of the colon are common ndings on abdominal radiographs, particularly in elderly patients [26]. These patients usually require
contrast enema studies or colonoscopy to diagnose their partially obstructing lesion. Colonic distention with a sigmoid colon diameter >45 cm,
transverse colon diameter >56 cm, or cecal diameter >10 cm is far less
common at the time of clinical presentation [1]. It is in these patients, however, that CT is very valuable in distinguishing between true anatomic
obstruction and pseudoobstruction (Fig. 18). Other causes of colonic distention such as colitis are often readily diagnosed by CT as well (Fig. 19). The
leading cause of obstruction in our series of 47 patients was colonic carcinoma (Fig. 20) followed by diverticulitis (Fig. 21). These are usually distinguishable by CT, although there is always the diculty in distinguishing
between the inammatory reaction secondary to diverticulitis versus perforation of colonic carcinoma [27]. Most perforating carcinomas show much

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D. Frager / Gastroenterol Clin N Am 31 (2002) 777799

Fig. 18. Colonic pseudoobstruction. (A) KUBcolonic and small bowel distention. (B)
CTbowel dilatation is continuous to uid-lled nonobstructed rectum (R).

more in the way of bowel wall thickening than with diverticulitis. Obviously
there is overlap in that colonic wall thickening in patients with diverticulitis
may be quite pronounced, and some colon cancers have minimal thickening
and still produce obstruction. Another problem with CT as opposed to
endoscopy or contrast enema is that a short annular lesion may be overlooked, depending on technical factors (Fig. 22). This is particularly a problem in cases of dilatation of the ascending and transverse colon with collapse
of the colon beyond the splenic exure. This pattern is not uncommon in
pseudoobstruction. Air insuation or contrast instillation per rectum in

Fig. 19. Colon obstruction due to Crohns colitis. (A) KUBtoxic megacolon pattern. Cannot
rule out obstruction. (B) CTNarrowed inamed descending colon with sinuses/stulae
(arrow).

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Fig. 20. Colon obstruction due to cancer. (A) sigmoid carcinoma (arrow). (B) Hepatic exure
carcinoma (arrow).

these questionable situations or shifting colonic gas by means of decubitus

positioning will enhance and improve overall accuracy of the CT examination [26]. CT colonography has also been studied in patients with obstructing carcinoma, and obviously would be valuable in evaluating all colonic
obstructions including partial obstructions [19]. Adequate colonic preparation or ability to digitally subtract feces, however, is important for this
evaluation.
The issue of strangulation is actually pertinent in all cases of colonic
obstruction with a competent ileocecal valve. In these instances the colon
is essentially a closed loop obstruction. Intraluminal pressures can rise under
these circumstances to a point where there is insucient mucosal perfusion
and resulting ischemia [1]. With cecal diameter acutely increasing beyond 12
cm there is the likelihood of perforation because of the Laplace rule and
resulting cecal wall ischemia or infarction at that point. Colon volvulus, usually sigmoid or cecal, does occur, and is diagnosable with the same signs

Fig. 21. Colon obstruction due to sigmoid diverticular disease. CT demonstrates thickening of
the sigmoid colon diverticulae and pericolic inammation.

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D. Frager / Gastroenterol Clin N Am 31 (2002) 777799

Fig. 22. (A) CT demonstrates short annular desmoplastic obstructing cancer with little mass
(arrow). (B) Barium enema conrms the above.

described under SBO except in this case the involved bowel is obviously the
colon (Fig. 23). Usually in cases of suspected sigmoid volvulus by plain-lm
examination it is advisable to perform sigmoidoscopy to diagnose and treat
any volvulus that may be present. For cecal volvulus, CT or contrast enema
can be performed in instances where the plain lms are not clear-cut.
With an incompetent ileocecal valve or a uid-lled colon plain-lm
examination may demonstrate small bowel dilatation alone that mimics
radiographically SBO (see Table 1). Clinically, the suspicion for a colonic
etiology of the obstruction is greater in elderly individuals who never
had abdominal surgery. Again, CT is usually superb in diagnosing what is

Fig. 23. (A) KUBmassively dilated sigmoid. (B) CT demonstrates vovulus and actual twist
(arrow).

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Fig. 24. (A) KUBconsistent with SBO. (B) CTobstructing carcinoma of the transverse
colon (open arrows) and synchronous lesion ascending colon (open arrow). Superior mesenteric
vein is thrombosed (arrow).

usually a right colonic mass (Fig. 24). Contrast enemas or colonoscopy can
be reserved under these circumstances for equivocal cases.
The major downside of CT is cost and radiation exposure [28]. It is the
authors opinion that the benets of CT evaluation, particularly in older
patients who may be in a life-threatening situation, far outweigh these detriments. In younger individuals where radiation exposure is more of an issue
that matter is less clear-cut and still subject to debate.
The continued advances in MRI technology using fast-scan techniques
makes it a reasonable alternative to CT, especially in these patients [29,30].
Summary
CT has signicantly advanced the evaluation of small and large bowel
obstruction, especially in the acute situation where high-grade or possibly
strangulating obstruction is being encountered. Any physician involved in
evaluating patients with bowel distention and abdominal pain where
obstruction becomes a distinct diagnostic possibility should be aware of
the attributes and limitations of this modality to provide the best patient
care. New technological advances will hopefully limit radiation exposure
and provide even more denitive information in the diagnosis of bowel
obstruction.
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