Residents’ Section • Pat tern of the Month

Mullan et al.
Small Bowel Obstruction

Residents’ Section
Pattern of the Month

Residents

inRadiology Small Bowel Obstruction

Charles P. Mullan1

S
mall bowel obstruction remains an important cause of morbidity, accounting for
Bettina Siewert up to 15% of surgical admissions for acute nontraumatic abdominal pain. Clinical
Ronald L. Eisenberg evidence of complete small-bowel obstruction or complications such as strangu-
lation necessitates emergent surgical management. Traditional medical teaching
Mullan CP, Siewert B, Eisenberg RL advocated early operative management of small-bowel obstruction (“Never let the sun rise or
set on an obstructed abdomen.”) because clinical features were often unreliable in determin-
American Journal of Roentgenology 2012.198:W105-W117.

ing whether complications were present. Radiologic imaging has assumed a paramount role
in directing the management of small bowel obstruction, promoted by the widespread avail-
ability of MDCT. The key question for a clinician managing a case of suspected small bowel
obstruction is how to optimally treat the patient. MDCT accurately answers this question by
determining if small bowel obstruction is present, identifying the site and cause of mechani-
cal obstruction, and detecting complications. The sensitivity and specificity of MDCT in this
clinical setting is more than 95%, with high accuracy reported in distinguishing small bowel
obstruction from adynamic ileus in postoperative patients. Imaging is therefore pivotal in
determining whether the patient can be managed conservatively and in guiding the operative
approach if surgical management is required.

Keywords: bowel, obstruction, small bowel
DOI:10.2214/AJR.10.4998
Received May 25, 2010; accepted after revision
May 16, 2011.
1
All authors: Department of Radiology, Beth Israel
Deaconess Medical Center, Harvard Medical School, 330
Brookline Ave, Boston, MA 02115. Address correspondence
to R. L. Eisenberg (rleisenb@bidmc.harvard.edu).
WEB
This is a Web exclusive article.
AJR 2012; 198:W105–W117
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© American Roentgen Ray Society
Imaging Modalities
Radiography
Most patients presenting with clinical features suggestive of small bowel obstruction will
first undergo abdominal radiography. Radiographs have accuracy of 67–83% in the diagnosis
of small bowel obstruction, with reported sensitivity of 64–82% and specificity of 79–83% [1,
2]. The radiologic hallmark of mechanical small bowel obstruction is dilatation of the proxi-
mal small bowel (transverse diameter > 3 cm from outer wall to outer wall) with nondilated
distal bowel loops. Associated findings in a patient with small bowel obstruction include dila-
tation of the stomach, absence of colonic dilatation (normal caliber or collapsed colon), and
the presence of multiple gas-fluid levels on upright or decubitus abdominal radiographs (Fig.
1). The presence of air-fluid levels greater than 2.5 cm in width and air-fluid levels differing
more than 5 mm from each other within the same loop of small bowel are additional findings
indicative of small bowel obstruction on erect radiographs [2].
Free intraperitoneal gas may be visualized on radiographs in complicated small bowel
obstruction. However, it is not always possi-
ble to reliably distinguish adynamic ileus TABLE 1: Nonobstructive Causes of
Small Bowel Dilatation
and other causes of small bowel dilatation
(Table 1) from mechanical obstruction on ra- Adynamic ileus
diography. This is particularly problematic Recent surgery or trauma
in the postoperative setting when electrolyte Shock
imbalance and the administration of medica-
Electrolyte abnormality
tion are frequent causes of adynamic ileus.
The transition point between dilated and Medications (opiates, anticholinergics)
nondilated small bowel is not usually visu- Celiac disease
alized on radiography, making it difficult to Scleroderma
determine the site or cause of obstruction
(Fig. 1). Ischemia

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A B

Fig. 1—Small bowel obstruction.

A, Supine abdominal radiograph shows dilated loops
American Journal of Roentgenology 2012.198:W105-W117.

of small bowel.
B, Erect abdominal radiograph shows small bowel
dilatation with multiple air-fluid levels. Air-fluid level
wider than 2.5 cm (horizontal line) and differential
air-fluid levels within same small bowel loop (vertical
line) are identified.
C, Axial CT image shows transition point in mid ileum
(arrows), confirming mechanical obstruction due to
ileal stricture.

The severity of small bowel obstruction may be underestimated on abdominal radiography

if the dilated bowel loops are predominantly fluid-filled (Fig. 2). The presence of a gasless
abdomen on radiography in a patient with suggestive clinical features should raise the possi-
bility of small bowel obstruction. The string of pearls sign may be seen in predominantly
fluid-filled loops of small bowel on erect or decubitus radiographs as small amounts of intra-
luminal gas collecting along the superior wall separated by the valvulae conniventes (Fig. 3).

Fluoroscopy and Follow-Through Examination

Fluoroscopy and follow-through examination with oral contrast agents have a limited role
in the diagnosis of small bowel obstruction but may be useful in determining the severity of
obstruction. Patients with acute small bowel obstruction often tolerate oral contrast material
poorly because of nausea and vomiting. Surgeons prefer not to have large quantities of barium
in the small bowel lumen if emergent surgery is a possibility. Water-soluble contrast agents
become diluted as they pass through dilated fluid-filled bowel loops. Consequently, the de-
gree of opacification may be insufficient to identify the transition point at the site of obstruc-
tion. The prolonged transit of contrast material through obstructed bowel means that follow-
through radiographs may have to be obtained for several hours, delaying diagnosis. Figure 4B
shows the expected fluoroscopic findings in small bowel obstruction, with dilated loops of
proximal small bowel opacified with contrast material and a change in the caliber of the small
bowel at the transition zone. If high-grade obstruction is present, minimal or no contrast ma-
terial will opacify small bowel loops distal to the transition zone on delayed radiographs.

MDCT
MDCT has been established as the modality of choice for imaging suspected acute small bowel
obstruction and is widely available. Isotropic imaging facilitates reconstruction in multiple planes,

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Small Bowel Obstruction

A B

Fig. 2—Small bowel obstruction.

A and B, Supine (A) and erect (B) abdominal
American Journal of Roentgenology 2012.198:W105-W117.

radiographs show loop of dilated small bowel in left

lower quadrant, with paucity of bowel gas elsewhere
in abdomen.
C, Coronal CT image shows multiple loops of dilated
small bowel filled with intraluminal fluid, which are
not visible on radiographs. This 35-year-old patient
had small bowel obstruction due to adhesions from
prior laparotomy.

enabling tortuous small bowel to be followed in the search for a transition point. The reported ac-
curacy of CT for high-grade small bowel obstruction is 95%, with sensitivity of 90–94% and
specificity of 96% [3, 4]. Other published data indicate that the accuracy of CT is reduced for low-
grade obstruction [5]. The diagnosis of small bowel obstruction requires the presence of small
bowel dilatation (transverse diameter > 2.5 cm) and the presence of a discrete transition zone be-
tween dilated proximal and nondilated distal bowel. The transition zone may be a sharply defined
point as with band adhesions (Fig. 5) or a longer segment as with matted adhesions or radiation
enteritis (Fig. 6).
The administration of oral and IV contrast material optimizes the data provided by CT in
assessing small bowel obstruction. However, diagnostic information can be obtained in pa-
tients who cannot tolerate oral or IV contrast material and many centers do not routinely ad-
minister oral agents to patients undergoing CT for this indication. Retained intraluminal fluid
provides negative contrast enhancement within dilated small bowel loops and may be prefer-
able in evaluating ischemic complications of small bowel obstruction. Lack of bowel wall
enhancement, an early sign of ischemia, is easier to visualize in the absence of oral contrast
material. Other complications, such as perforation, can be identified on CT by the presence of
extraluminal air (Fig. 7). However, the relatively high radiation dose of MDCT in comparison
with other modalities raises concern for its use in patients requiring repeated imaging studies.

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Ultrasound
Ultrasound has a limited role in the as-
sessment of small bowel obstruction because
of poor visualization of gas-filled structures.
It is usually restricted to assessment of ab-
dominal wall hernias that may be the site of
incarcerated small bowel.

Enteroclysis
In the setting of chronic or intermittent small
bowel obstruction, enteroclysis enables the
small bowel to be distended adequately to high-
light areas of luminal stenosis. This technique
requires the placement of a nasojejunal tube for
instillation of a large amount of oral contrast
material. Traditionally, enteroclysis has been
3—Upright abdominal radiograph shows string-
performed with barium and methylcellulose us- Fig. of-beads sign. (Reprinted with permission from
ing fluoroscopy. The volume challenge caused Eisenberg RL. Gastrointestinal radiology: a pattern
by methylcellulose administration accentuates approach. Philadelphia, PA: Lippincott, 2002)
the effect of low-grade obstruction. The transi-
tion zone at the site of obstruction can be missed
American Journal of Roentgenology 2012.198:W105-W117.

using enterography or CT without volume challenge but is readily identified after enteroclysis.
CT and MRI are increasingly used in conjunction with enteroclysis. Cross-sectional imaging
provides additional data that can identify extraintestinal manifestations of Crohn disease.

MR Enterography
MR enterography is an increasingly attractive option for the assessment of small bowel obstruc-
tion. However, the increased time of image acquisition and the need for repeated breath-holds
to obtain high-quality images limits the application of MRI in patients with acute small bowel
obstruction. Therefore, it is most useful in the setting of chronic small bowel abnormality and low-
grade obstruction. This is particularly true in Crohn disease, where reducing the accumulated dose
of ionizing radiation in young patients is desired. Multiplanar MRI can be used in the same way
as MDCT to look for evidence of a transition point and features indicative of complications.

Causes of Small bowel Obstruction

There are numerous causes of mechanical small bowel obstruction (Table 2). In developed
countries, up to 70% of cases of small bowel obstruction are caused by adhesions within the

A B
Fig. 4—Small bowel obstruction.
A, Supine abdominal radiograph shows dilated small bowel loops throughout abdomen.
B, Follow-through radiograph obtained after oral administration of barium shows dilated jejunum on left
flank. Tapering of lumen in proximal ileum (arrow) without distal passage of contrast material indicates site of
obstruction, which was due to adhesion.

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Small Bowel Obstruction

TABLE 2: Causes of Small Bowel Obstruction

Adhesions
Previous surgery
Peritonitis
Idiopathic
Crohn disease
Abdominal hernias
Inguinal
Ventral
Femoral
Internal
Neoplasms
Metastases to small bowel and peritoneum
Primary small bowel neoplasms
Carcinoid, lymphoma, adenocarcinoma, gastrointestinal stromal tumor
Intussusception
Intraluminal causes
American Journal of Roentgenology 2012.198:W105-W117.

Bezoar
Gallstone ileus
Radiation enteritis
Small bowel hematoma
Endometriosis

abdomen or pelvis. Historically, abdominal hernias were the major cause of small bowel ob-
struction but now account for less than 10% of cases. The elective repair of inguinal and
ventral hernias is the main reason for the decline in hernia-related small bowel obstruction.
Crohn disease and intraabdominal neoplasms are other causes of small bowel obstruction.

Adhesions
Adhesions are not visible on radiologic imaging. Therefore, this is a diagnosis of exclusion
if no other cause can be identified at the site of abrupt transition between dilated proximal
small bowel and nondilated distal loops (Fig.
5). Approximately 80% of patients with
small bowel obstruction due to adhesions
have a history of prior intraabdominal sur-
gery; the remainder have prior peritonitis or
no precipitating cause. Band adhesions are
more likely than matted adhesions to cause
complete small bowel obstruction or other
complications requiring operative manage-
ment. Appendectomy and gynecologic sur-
gery predispose to band adhesion formation
more than colorectal surgery.

Fig. 5—Adhesion causing small-bowel obstruction
in 50-year-old woman with prior surgery for Crohn
disease. Axial CT image shows sharp transition point
(arrows) at site of band adhesion, which required
surgical repair. “Small bowel feces” sign, presence
of particulate material visible in proximal dilated
segment of intestine, is useful in identifying site of
obstruction because particulate matter tends to be
most prominent just proximal to transition zone.
Crohn Disease
Small bowel obstruction may occur in Crohn
disease by the direct effect of strictured and
inflamed segments of bowel or by adhesions
caused by prior surgical procedures. Obstruc-
tion caused by Crohn disease is usually chronic
and low grade in nature. The long-standing na-
ture of disease symptoms may mean that small

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Fig. 6—Radiation enteritis in 53-year-old man who

underwent radiation therapy for colorectal neoplasm.
A and B, Axial (A) and sagittal (B) CT images show
segment of small bowel with mural thickening
(arrows) containing intraluminal contrast material.
This finding corresponds to radiation enteritis,
producing zone of transition in small bowel rather
than discrete transition point.

A B
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Fig. 7—Ischemic small bowel in 74-year-old woman

presenting with acute abdominal pain.
A, Supine abdominal radiograph obtained at
admission shows no small bowel dilatation, with fecal
material visible in large bowel.
B, Axial IV contrast-enhanced CT image shows small
bowel with generalized mural thickening (white
arrows) and hypoenhancement relative to normal
small intestine (black arrows).
C, Axial CT image shows whirled appearance in
left hemipelvis, with twisting of mesentery (white
arrows) and collapsed segment of small bowel (black
arrowheads) at site of volvulus. Edematous bowel
is noted (black arrows) There is edema in adjacent
mesenteric fat. At surgery, internal hernia caused
by prior gynecologic surgery was indentified, and
necrotic small bowel required extensive resection
and end-to-end anastomosis.
A

B C

bowel obstruction is not suspected clinically. Although CT is accurate in depicting small bowel
abnormality due to Crohn disease (Fig. 8), radiation dose is a consideration in this group of pa-
tients, who often require multiple imaging studies over a lifetime. MR enterography may there-
fore be suitable for selected patients with Crohn disease who have acute small bowel obstruction,
provided they can tolerate the longer imaging time and need for breath-holding (Fig. 9).

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Fig. 8—Crohn disease in 22-year-old man.

A, Coronal CT image shows grossly dilated segment
of small bowel in lower left flank.
B, Axial CT image shows long segment of ileum with
circumferential wall thickening from wall edema,
and discrete transition point is seen between this
segment and dilated proximal bowel (arrow).
C, Axial image shows stranding in mesenteric fat
immediately superior to thickened segment of small
bowel (arrows), consistent with active inflammatory
disease.

A
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B C

Fig. 9—MR enterography in Crohn disease in 31-year-

old woman.
A, Coronal T2-weighted image shows fluid with high
signal intensity in dilated loops of jejunum in left flank.
B and C, Axial T2-weighted (B) and axial contrast-
enhanced T1-weighted fat-suppressed (C) images
show discrete mid ileal segment with circumferential
mural thickening and enhancement (arrows),
consistent with active Crohn disease. There is
transition point between inflamed segment of ileum
and dilated proximal bowel.
A

B C

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Fig. 10—Femoral hernia in elderly woman with acute

abdominal pain.
A and B, Axial (A) and coronal (B) abdominal CT images
show loop of small bowel (white arrow) protruding into
right groin. There is dilatation of proximal small bowel.
Orifice of hernia arises inferior in relation to inguinal
ligament and lateral to pubic tubercle (black arrow, A),
consistent with femoral hernia.

A B
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A B
Fig. 11—Richter’s hernia with strangulated small bowel in 54-year-old patient with no prior surgical history.
A and B, Sagittal (A) and axial (B) CT images show small defect in musculature of right anterior abdominal
wall that developed spontaneously. Antimesenteric wall of segment of small bowel protrudes into hernial sac
(arrows, B). Proximal small bowel is only mildly dilated because luminal obstruction is not complete; herniated
portion of small bowel, however, was strangulated and required surgical resection.

Abdominal Hernias
Hernias occur at sites of muscular or ligamentous weakness in the abdominal wall. Ingui-
nal, femoral, and ventral hernias usually can be detected on clinical examination. Internal
hernias occur though acquired or congenital defects in the mesentery, through which bowel
may traverse. Although in some cases only fat may protrude into the hernia sac, at times small
or large bowel may become incarcerated within the hernia, leading to obstruction (Fig. 10)
and possible strangulation. Elective repair is therefore commonly performed for these defects.
A Richter hernia occurs when only the antimesenteric portion of a segment of small bowel
protrudes through a narrow defect in the abdominal wall (Fig. 11). Although Richter hernias
do not usually cause small bowel obstruction, they are associated with a high rate of ischem-
ic complications. The vascular supply to the herniated portion of bowel wall often becomes
compromised by the narrow orifice, leading to strangulation.

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Fig. 12—58-year-old woman with ovarian carcinoma.

A, Sagittal IV contrast-enhanced CT image shows
transition point (arrows) between markedly dilated
small bowel and distal bowel, without luminal
dilatation. Widespread peritoneal metastases are
present in abdomen and pelvis.
B, Axial IV contrast-enhanced CT image shows
segment of ileum with relative luminal narrowing
(arrows) in left hemipelvis surrounded by enhancing
soft tissue (arrowheads), consistent with confluent
serosal metastatic implants.
American Journal of Roentgenology 2012.198:W105-W117.

A B

A B
Fig. 13—Intussusception in 35-year-old man with melanoma.
A, Axial CT image shows mass in right lower quadrant of abdomen with target-like appearance due to
multiple adjacent bowel wall layers (arrows). Findings were due to ileocolic intussusception, with small bowel
metastasis acting as lead point.
B, Coronal image shows intussusception in longitudinal axis. There is clear transition point between
intussusception and proximal dilated small bowel (arrows).

Neoplastic Disease
Metastatic disease is the most frequent neoplastic cause of small bowel obstruction. Tu-
mors with a propensity to cause widespread peritoneal metastases include ovarian, colonic,
pancreatic, and gastric neoplasms. This may lead to multiple serosal metastases of the small
bowel, forming confluent soft-tissue masses that surround the bowel. Obstruction occurs by
extrinsic compression of the small bowel lumen (Fig. 12) or tethering of bowel loops by the

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A B
Fig. 14—Gallstone ileus in elderly woman with small bowel obstruction due to gallstone ileus.
A, Axial CT image of pelvis shows large laminated calculus within dilated loop of distal ileum in midline (arrow).
B, Axial CT image through liver shows pneumobilia (arrows), consistent with biliary-enteric fistula.
American Journal of Roentgenology 2012.198:W105-W117.

A B
Fig. 15—Phytobezoar in 65-year-old diabetic patient who consumed vegetarian diet composed predominantly
of chickpeas.
A, Axial CT image shows intraluminal particulate material within dilated segment of bowel in right lower
quadrant (arrow). Other proximal loops of distended small bowel contain gas-fluid levels.
B, Sagittal CT image shows transition point in mid ileum with collapsed small bowel distally (arrows). Operative
findings confirmed presence of phytobezoar.

serosal deposits. Metastases to the wall of the small bowel in tumors, such as melanoma, can
cause endoluminal obstruction. Primary neoplasms of the small bowel are a less frequent
cause of mechanical obstruction but include adenocarcinoma, lymphoma, and gastrointesti-
nal stromal tumors. These lesions may cause luminal narrowing or intussusception.

Intussusception
Intussusception refers to telescoping of a segment of bowel within another portion of bow-
el. This results in a target-like appearance on CT or ultrasound because of multiple layers of
bowel wall adjacent to one another and the interposition of mesenteric fat between the tele-
scoped layers of bowel (Fig. 13). Ileocolic intussusception is a common cause of acute abdo-
men during infancy. Because most childhood cases are idiopathic, air enema may be suffi-
cient for reduction. In adults, intussusception is most frequently a transient finding identified
on CT, without significant clinical features. Intussusception length of 3.5 cm or less predicts
a self-limiting lesion that will resolve spontaneously, and follow-up imaging is not required

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A B
Fig. 16—Closed-loop obstruction due to internal hernia in contiguous axial images in 75-year-old woman with
no significant medical history who presented with acute abdominal pain.
A and B, There is whorled appearance of mesentery containing blood vessels (arrows, A), situated just above
U-shaped loop of dilated small bowel (line, B). Although vascular supply was compromised at laparotomy,
segment of small bowel reperfused normally when hernia was reduced, and small bowel resection was not
required.
American Journal of Roentgenology 2012.198:W105-W117.

A B
Fig. 17—Closed-loop obstruction with bowel infarction in 49-year-old man.
A, Axial contrast-enhanced image shows jejunoileal intussusception, with interposition of mesenteric fat
between telescoped portions of bowel.
B, Coronal CT image shows dilated C-shaped portion of bowel (line) centered on area of mesentery containing
blood vessels (white arrow). At time of surgery, lead point of intussusception was found to be submucosal
jejunal neoplasm, later confirmed as gastrointestinal stromal tumor. Torsion of mesentery at site of
intussusception led to closed-loop obstruction, resulting in infarction of segment of small bowel. Black arrows
show focal areas of hypoenhancement in liver due to hepatic metastases from small bowel tumor.

for these patients. For intussusception greater than 3.5 cm in length, further CT after 30 min-
utes may be considered to confirm resolution. Small bowel obstruction because of intussus-
ception is rare in adults and is usually due to an underlying bowel lesion acting as a lead point.
Causes include benign and malignant neoplasms, Meckel diverticulum, and inflammatory
lesions. Symptomatic adult patients with intussusception that does not resolve spontaneously
will require operative management to identify and resect the underlying lesion.

Intraluminal Obstruction
Small bowel obstruction is rarely caused by intraluminal material. The site of obstruction
is usually at the ileocecal valve, where the lumen of the bowel is smallest. Gallstone ileus
occurs when a large gallbladder calculus passes into the small bowel via a biliary-enteric

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A B
American Journal of Roentgenology 2012.198:W105-W117.

Fig. 18—77-year-old woman with 2-day history of left

flank pain and no previous abdominal surgery.
A, Axial CT image shows vascular engorgement
(white arrows) and edema in mesentery of left flank
(black arrow), with ascites identified in right flank.
B, Coronal CT image shows luminal narrowing at
site of internal hernia in anterior aspect of left lower
abdomen (arrow) and presence of ascites.
C, Sagittal CT image through left side of abdomen
shows hypoenhancement and mural thickening of
loop of small bowel (black arrows) consistent with
ischemia. There is edema of adjacent mesenteric
fat and engorgement of mesenteric veins (white
arrows). At surgery, transomental internal hernia was
reduced, and resection of long segment of infracted
small bowel was performed.
C
TABLE 3: CT Findings of Small fistula (Fig. 14). Other imaging findings of
Bowel Ischemia
gallstone ileus are the usually large gallstone
Bowel wall and biliary air.
Poor or absent enhancement A bezoar is composed of ingested material
Delayed hyperenhancement that is not digested within the gastrointestinal
tract and causes an obstructing intraluminal
Mural thickening
mass. A phytobezoar is formed by undigested
Pneumatosis plant or vegetable matter (Fig. 15); a tricho-
Mesentery bezoar is caused by ingestion of hair.
Engorgement of mesenteric vessels
Management Strategies
Mesenteric edema
The ultimate role of radiologic imaging in
Mesenteric hemorrhage small bowel obstruction is to determine
Other findings whether the patient can be managed with con-
Portal and mesenteric venous gas
servative measures or surgery is required. In-
dications for emergency surgery include evi-
Ascites dence of complete obstruction with absence of

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gas or fluid in the distal gastrointestinal tract
and signs of strangulation or bowel perfora-
tion. A closed-loop obstruction occurs when a
segment of small bowel becomes obstructed at
two adjacent points. Strangulation is defined
as bowel ischemia occurring due to torsion of
the mesentery providing vascular supply to the
closed loop. Early identification and surgical
reduction of a closed-loop obstruction will re-
store vascular supply to the ischemic segment
of small bowel (Fig. 16). However, delayed
intervention may result in infarction of the af-
fected small bowel, requiring resection of the
nonviable segment (Figs. 7, 17, and 18). It is
often difficult to confidently diagnose small
bowel ischemia on CT. Table 3 illustrates the
findings of small bowel ischemia on CT ex-
amination [6, 7]. The presence of a combina-
tion of these signs increases the reliability of
diagnosing ischemia.
American Journal of Roentgenology 2012.198:W105-W117.
Conclusion
Small bowel obstruction remains an im-
portant cause of acute abdominal pain in pa-
tients presenting to the emergency depart-
ment. MDCT is the modality of choice for
identifying the cause of small bowel obstruc-
tion and determining whether emergent sur-
gery is required. Adhesions are by far the
most common cause of small bowel obstruc-
tion. Other less frequent causes include Crohn
disease, neoplasms, and abdominal hernias.
Identifying the transition point between dilat-
ed and nondilated small bowel, although not
required to make the diagnosis of obstruction,
is the key to establishing the site and cause of
small bowel obstruction.
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