William Herring, M.D.

2002

Recognizing
SBO, LBO and Ileus

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Abdominal Images
What to Examine
Gas pattern-this lecture
Extraluminal air
Soft tissue masses
Calcifications-other

lectures

Normal Gas Pattern

Stomach
Always

Small Bowel
Two or three loops of non-distended bowel
Normal diameter = 2.5 cm = 1 US quarter

Large Bowel
In rectum or sigmoid almost always

Gas in
stomach

Gas in a few
loops of
small bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

Stomach
Always (except supine film)

Small Bowel
Two or three levels possible

Large Bowel
None normally

Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen

Large vs. Small Bowel

Large Bowel
Peripheral
Haustral markings

don't
extend from wall to wall

Small Bowel
Central
Valvulae

extend across lumen

Maximum diameter of 2"

Complete Abdomen
Obstruction Series

Supine
Prone or lateral rectum
Erect or left decubitus
Chest - erect or supine

Complete Abdomen
Supine

Looking for
Scout film for gas

pattern
Calcifications
Soft tissue
masses
Substitute none

Complete Abdomen
Prone

Looking for
Gas in

rectum/sigmoid
Gas in ascending and
descending colon
Substitute lateral

rectum

Complete Abdomen
Erect

Looking for
Free air
Air-fluid levels

Substitute left

lateral decubitus

Complete Abdomen
Erect Chest

Looking for
Free air
Pneumonia at bases
Pleural effusions

Substitute supine

chest

Abnormal Gas Patterns

Functional Ileus
Localized (Sentinel Loops)
Generalized adynamic ileus

Mechanical Obstruction
SBO
LBO

Localized Ileus
Key Features

One or two persistently dilated loops

of large or small bowel

Gas in rectum or sigmoid

Supine

Sentinel Loops

Prone

Sentinel Loops
Cholecystitis

Pancreatitis
Ulcer

Appendicitis

Diverticulitis
Ulcer
Ureteral calculus

Localized Ileus
Pitfalls

May resemble early

mechanical SBO
Clinical course
Get follow-up

Generalized Ileus
Key Features

Gas in dilated small bowel and

large bowel to rectum

Long air-fluid levels
Only post-op patients have
generalized ileus

Supine

Generalized Adynamic Ileus

Erect

Is It An Ileus?

Is the patient immediately post-op?

Are the bowel sounds absent or

hypoactive?
If no, then it isnt an ileus

Patients dont present to the ER with

a generalized adynamic ileus!

Mechanical SBO
Key Features

Dilated small bowel

Fighting loops
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB

SBO

Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

*Cause may be visible on plain film

Mechanical SBO
Pitfalls

Early SBO may

resemble localized
ileus -get F/O

Mechanical LBO
Key Features

Dilated colon to point of

obstruction
Little or no air in rectum/sigmoid
Little or no gas in small bowel, if
Ileocecal valve remains competent

Prone

Supine

LBO

Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception

Mechanical LBO
Pitfalls

Incompetent ileocecal valve

Large bowel decompresses into small

bowel
May look like SBO
Get BE or follow-up

Supine

Carcinoma of Sigmoid LBO

Decompressed into SB

Prone

Special Cases

Air in
biliary
tree

SBO

Gallstone

Gallstone Ileus

Post-op C-section
Adynamic Ileus

Sigmoid Volvulus

Mesenteric Occlusion

Abnormal Gas Patterns

Review

Localized ileus
Generalized ileus
Mechanical SBO
Mechanical LBO

Abdominal Images
What to Examine
Gas pattern-this lecture
Extraluminal air
Soft tissue masses
Calcifications-other

lectures

Important Points
Look for air in the rectum/sigmoid first
Identify the most dilated loops-are they large

bowel or small bowel?

Sentinel loops are 1-2 dilated loops of small
bowel
Generalized adynamic ileus almost always occurs
in immediate post-op patients
Always correlate the clinical findings with imaging
findings

Identify the Types of

Abnormal Gas Patterns

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What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

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What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

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What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

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What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

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Correct
There are multiple aircontaining and dilated loops
of small bowel with little or
no gas in the colon. The
findings are those of a
mechanical small bowel
obstruction. The patient had
undergone prior surgery
and the cause of this
obstruction was adhesions
form the prior surgery.

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Correct
There is a dilated colon
to the splenic flexure/
Little or no gas is seen
in the rectum or in the
small bowel. The
findings are those of a
mechanical large bowel
obstruction. The cause
was an annular
constricting carcinoma
at the splenic flexure.

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Correct
There are several aircontaining and slightly
dilated loops of small bowel
in the LLQ. These were
persistent. The findings are
those of a localized ileus
(sentinel loops) and their
location would suggest
diverticulitis. The patient had
appendicitis. The sentinel
loops do not always
correspond to the area of
inflammation.
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Correct
All of the bowel is dilated.
There is air in the rectum.
The patient was post-op
abdominal surgery and the
bowel sounds were absent.
This is a generalized
adynamic ileus as is seen
sometimes after abdominal
surgery.

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Wrong
Look Again

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Congratulations, You Graduate

You know
your
bowel gas

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