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CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate emergent surgery

Abstract

Purpose

To identify computed tomography (CT) findings associated with successful conservative treatment of closed loop small bowel obstruction (CL-SBO) due to adhesions or internal herniation.

Material and methods

The local institutional review board approved this study while waiving informed consent. Clinical and CT data were collected retrospectively for 96 consecutive patients with a CT diagnosis of CL-SBO due to adhesions or internal herniation established by experienced radiologists who had no role in patient management. Mechanical obstruction with at least two transition zones on the bowel at a single site defined CL-SBO. Two radiologists blinded to patient data independently performed a retrospective review of the CT scans. The patient groups with successful versus failed initial conservative therapy were compared. Univariate and multivariate analyses were performed to look for CT findings associated with successful conservative therapy. Interobserver agreement was assessed for each CT finding.

Results

Of the 96 patients, 34 (35%) underwent immediate surgery and 62 (65%) received first-line conservative treatment, which succeeded in 19 (31%) and failed in 43 (69%). The distance between the transition zones was the only independent predictor of successful conservative therapy (odds ratio, 4.6 when ≥ 8 mm; 95% confidence interval [95% CI], 1.2–18.3). A distance ≥ 8 mm had 84% (95% CI, 60–97) sensitivity and 46% (95% CI, 31–62) specificity for successful conservative treatment. The correlation coefficient for the distance between transition zones between readers 1 and 2 was fair (r = 0.46).

Conclusion

CL-SBO can be resolved without surgery. When there is no CT sign of ischemia, the distance between the transition zones should be assessed.

Key Points

Twenty percent (19/96) of all cases of closed loop small bowel obstruction (CL-SBO) representing 31% of the patients given first-line conservative therapy, were resolved without surgery.

The distance between the transition zones may help to choose between conservative and surgical management in patients with a CL-SBO but no CT evidence of ischemia.

A distance < 8 mm between the transition zones suggests a need for emergent surgery.

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Abbreviations

CL-SBO:

Closed loop small bowel obstruction

CT:

Computed tomography

SBO:

Small bowel obstruction

References

  1. 1.

    Balthazar EJ, Birnbaum BA, Megibow AJ, Gordon RB, Whelan CA, Hulnick DH (1992) Closed-loop and strangulating intestinal obstruction: CT signs. Radiology. 185(3):769–775

  2. 2.

    Balthazar EJ, Liebeskind ME, Macari M (1997) Intestinal ischemia in patients in whom small bowel obstruction is suspected: evaluation of accuracy, limitations, and clinical implications of CT in diagnosis. Radiology. 205(2):519–522

  3. 3.

    Millet I, Boutot D, Faget C et al (2017) Assessment of strangulation in adhesive small bowel obstruction on the basis of combined CT findings: implications for clinical care. Radiology 285(3):798–808

  4. 4.

    Elsayes KM, Menias CO, Smullen TL, Platt JF (2007) Closed-loop small-bowel obstruction: diagnostic patterns by multidetector computed tomography. J Comput Assist Tomogr 31(5):697–701

  5. 5.

    Makar RA, Bashir MR, Haystead CM et al (2016) Diagnostic performance of MDCT in identifying closed loop small bowel obstruction. Abdom Radiol (NY) 41(7):1253–1260

  6. 6.

    Zielinski MD, Eiken PW, Bannon MP et al (2010) Small bowel obstruction-who needs an operation? A multivariate prediction model. World J Surg 34(5):910–919

  7. 7.

    Chang WC, Ko KH, Lin CS et al (2014) Features on MDCT that predict surgery in patients with adhesive-related small bowel obstruction. PLoS One 9(2):e89804

  8. 8.

    Makita O, Ikushima I, Matsumoto N, Arikawa K, Yamashita Y, Takahashi M (1999) CT differentiation between necrotic and nonnecrotic small bowel in closed loop and strangulating obstruction. Abdom Imaging 24(2):120–124

  9. 9.

    Kato K, Mizunuma K, Sugiyama M et al (2010) Interobserver agreement on the diagnosis of bowel ischemia: assessment using dynamic computed tomography of small bowel obstruction. Jpn J Radiol 28(10):727–732

  10. 10.

    Maglinte DD, Gage SN, Harmon BH et al (1993) Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology. 188(1):61–64

  11. 11.

    Nakashima K, Ishimaru H, Fujimoto T et al (2015) Diagnostic performance of CT findings for bowel ischemia and necrosis in closed-loop small-bowel obstruction. Abdom Imaging 40(5):1097–1103

  12. 12.

    Ten Broek RPG, Krielen P, Di Saverio S et al (2018) Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 13:24

  13. 13.

    Rondenet C, Millet I, Corno L, Boulay-Coletta I, Taourel P, Zins M (2018) Increased unenhanced bowel-wall attenuation: a specific sign of bowel necrosis in closed-loop small-bowel obstruction. Eur Radiol 28(10):4225–4233

  14. 14.

    Millet I, Taourel P, Ruyer A, Molinari N (2015) Value of CT findings to predict surgical ischemia in small bowel obstruction: a systematic review and meta-analysis. Eur Radiol 25(6):1823–1835

  15. 15.

    Geffroy Y, Boulay-Coletta I, Jullès MC, Nakache S, Taourel P, Zins M (2014) Increased unenhanced bowel-wall attenuation at multidetector CT is highly specific of ischemia complicating small-bowel obstruction. Radiology. 270(1):159–167

  16. 16.

    Sheedy SP, Earnest F 4th, Fletcher JG, Fidler JL, Hoskin TL (2006) CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation. Radiology. 241(3):729–736

  17. 17.

    Khaled W, Millet I, Corno L et al (2018) Clinical relevance of the feces sign in small-bowel obstruction due to adhesions depends on its location. AJR Am J Roentgenol 210(1):78–84

  18. 18.

    Millet I, Ruyer A, Alili C et al (2014) Adhesive small-bowel obstruction: value of CT in identifying findings associated with the effectiveness of nonsurgical treatment. Radiology. 273(2):425–432

  19. 19.

    Cohen JF, Korevaar DA, Altman DG et al (2016) STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open 6(11):e012799

  20. 20.

    Balthazar EJ (1994) George W. Holmes Lecture. CT of small-bowel obstruction. AJR Am J Roentgenol 162(2):255–261

  21. 21.

    Chou CK (2002) CT manifestations of bowel ischemia. AJR Am J Roentgenol 178(1):87–91

  22. 22.

    Yen CH, Chen JD, Tui CM et al (2005) Internal hernia: computed tomography diagnosis and differentiation from adhesive small bowel obstruction. J Chin Med Assoc 68(1):21–28

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Author information

Correspondence to Ingrid Millet.

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Guarantor

The scientific guarantor of this publication is Dr. Marc Zins.

Conflict of interest

The authors declare that they have no conflict of interest.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Some study subjects (43%) have been previously reported in a published article: C. Rondenet, Eur Radiol, 2018.

Methodology

• retrospective

• diagnostic study

• performed at one institution

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Rondenet, C., Millet, I., Corno, L. et al. CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate emergent surgery. Eur Radiol 30, 1105–1112 (2020). https://doi.org/10.1007/s00330-019-06413-3

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Keywords

  • Intestinal obstruction
  • Small intestine
  • Conservative management
  • Multidetector computed tomography