Abstract
The purpose of this study is to illustrate computed tomography (CT) findings suggestive of small bowel strangulation. We have performed the precontrast and postcontrast CT with single and multidetector CT scanners and evaluated the bowel wall changes and mesentery changes and correlated them with the operative findings. The direct CT findings suggestive of small bowel strangulation included high-density bowel wall on precontrast scans; lack of, or diminished contrast enhancement of the involved bowel wall; localized mesenteric fluid accumulation (mesenteric congestion); and localized pneumatosis. The indirect CT signs included C- or U-shaped loops with mesenteric vessels converging toward the obstruction site, ascites, target sign, two adjacent collapsed round loops, and whirl sign. We particularly emphasize the importance of contrast enhancement of bowel mucosa for early diagnosis to differentiate strangulation from a mechanical obstruction without bowel ischemia, and also the importance to differentiate proximal secondary gas-filled dilated small bowel loops from distal primary involved fluid-filled small bowel loops because these two types of small bowel loops are present in the single peritoneal cavity. As early recognition of small bowel strangulation may help improve the patient outcome because the involved bowel loops can be preserved without resection, it is essential to become familiar with the CT signs suggested small bowel obstruction strangulation.
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References
Meigbow AJ (1994) Bowel obstruction: evaluation with CT. Radiol Clin North Am 32:861–870
Bizer LS, Liebling RW, Delany HM, Gliedman ML (1981) Small bowel obstruction. Surgery 89:407–413
Bas KN, Jones B, Bulkley GB (1998) Current management of small-bowel obstruction. Adv Surg 31:1–34
Sarr MG, Bulkley GB, Zuidema GD (1983) Preoperative recognition of intestinal strangulating obstruction: prospective evaluation of diagnostic capability. Am J Surg 145:176–182
Silen W, Heim MF, Goldman L (1962) Strangulation obstruction of the small intestine. Arch Surg 85:121–129
Balthazar EJ (1994) George W. Holmes lecture. CT of the small bowel obstruction. Am J Roentgenol 162:255–261
Ha HK, Kim JS, Lee MS, Lee HJ, Jeong YK, Kim PN et al (1997) Differentiation of simple and strangulated small bowel obstructions: usefulness of known CT criteria. Radiology 204:507–512
Frager D, Baer JW, Medwid SW, Rothpearl A, Bossart P (1996) Detection of intestinal ischemia in patients with acute small bowel obstruction due to adhesions or hernia: efficacy of CT. Am J Roentgenol 166:67–71
Balthazar EJ, Lieheskind ME, Macari M (1997) Intestinal ischemia in patients in whom small bowel obstruction is suspected: evaluation of accuracy, limitation, and clinical implication of CT in diagnosis. Radiology 205:519–522
Mellins HZ, Rigler LG (1954) The roentgen findings in strangulating obstructions of the small intestine. Am J Roentgenol 71:404–415
Frimann-Dahl J (1951) Radiological experiences in true strangulating obstruction. Acta Radiol 35:85–100
Balthazar EJ, Birnbaum BA, Meigbow AJ, Gordon RB, Whelan CA, Hulnick DH (1992) Closed-loop and strangulating intestinal obstruction: CT signs. Radiology 185:769–775
Furukawa A, Yamasaki M, Furuichi K et al (2001) Helical CT in the diagnosis of small bowel obstruiction. RadioGraphics 21:341–355
Silva AC, Pimenta M, Guimaraes LS (2009) Small bowel obstruction: what to look for. RadioGraphics 29:423–439. doi:10.1148/rg.292085514
Furukawa A, Kanasaki S, Kono N, Wakamiya M, Tanaka T, Takahashi M et al (2009) CT diagnosis of acute mesenteric ischemia from various causes. Am J Roentgenol 192:408–416. doi:10.2214/AJR.08.1138
Macari M, Chandarana H, Balthazar EJ, Babb J (2003) Intestinal ischemia versus intramural hemorrhage: CT evaluation. Am J Roentgenol 180:177–184. doi:10.2214/AJR.06.0712
Wiesner W, Khurana B, Ji H, Ros PR (2003) CT of acute bowel ischemia. Radiology 226:635–650. doi:10.1148/radiol.2263011540
Chou CK, Wu RH, Mak CW, Lin MP (2006) Clinical significance of poor CT enhancement of the thickened small bowel wall in patients with acute abdominal pain. Am J Roentgenol 186:491–498. doi:10.2214/AJR.04.1362
Macari M, Megibow AJ, Balthazar EJ (2007) A pattern approach to the abnormal small bowel: observations at MDCT and CT enterography. Am J Roentgenol 188:1344–1355. doi:10.2214/AJR.06.0712
Jancelewicz T, Vu LT, Shawo AE, Yeh B, Gasper WJ, Harris HW (2009) Predicting strangulated small bowel obstruction: an old problem revisited. J Gastrointest Surg 13:93–99. doi:10.1007/s11605-008-0610-z
Furukawa A, Yamasaki M, Takahashi M et al (2003) CT diagnosis of small bowel obstruction: scanning technique, interpretation and role in the diagnosis. Semin Ultrasound CT MR 24:336–352. doi:10.1016/j.sult.2003.08.001
Lane MJ, Katz DS, Mindelzum RE, Jeffrey RB Jr (1997) Spontaneous intramural small bowel hemorrhage: importance of non-contrast CT. Clin Radiol 52:378–380
Balthazar EJ, Megibow AJ, Opulencia JF (1987) Computed tomography of intramural intestinal hemorrhage and bowel ischemia. J Comput Assist Tomogr 11:67–72
Warshauer DM, Lee JK, Mauro MA, White GC II (2001) Superior mesenteric vein thrombosis with radiologically occult cause: a retrospective study of 43 cases. Am J Roentgenol 177:837–841
Zielinsky MD, Eiken PW, Heller SF et al (2011) Prospective, observational validation of a multivariate small-bowel obstruction model to predict the need for operative intervention. J Am Coll Surg 212:1068–1076. doi:10.1016/j.jacollsurg.2011.02.023
Wayne E, Ough M, Wu A, Liao J, Andersen KJ, Kuehn D, Wilkinson N (2010) Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases. J Gastrointest Surg 14:437–448. doi:10.1007/s11605-009-1143-9
Sebastia G, Quiroga S, Espin E, Boye R, Alvarez-Castells A, Armengol M (2000) Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. RagioGraphics 20:1213–1224
Wiesner W, Mortele KJ, Glickman JN, Ji H, Ros PR (2001) Pneumatosis intestinalis and portomesencephalic venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome. Am J Roentgenol 177:1319–1323
Kernagis LY, Levine MS, Jacobs JE (2003) Penumatosis intestinalis in patients with ischemia: correlation of CT findings with viability of the bowel. Am J Roentgenol 180:733–736
Zalcman M, Sy M, Donckier V, Closset J, Gansheke DV (2000) Helical CT signs of the diagnosis of intestinal ischemia in small bowel obstruction. Am J Roentgenol 175:1601–1607
Jang KM, Min K, Kim MJ, Koh SH et al (2010) Diagnostic performance of CT in the detection of intestinal ischemia associated with small-bowel obstruction using maximal attenuation of region of interest. Am J Roentgenol 194:957–963. doi:10.2214/AJR.09.2702
Sandhu PS, Joe BN, Coakley FV, Qayyum A, Webb EM, Yeh BM (2007) Bowel transition points: multiplicity and posterior location at CT are associated with small-bowel volvulus. Radiology 245:160–167. doi:10.1148.radiol.2443061370
Donckier V, Closset J, Van Gansbeke D, Zalcman M, Sy M, Houben JJ et al (1998) Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction. Br J Surg 85:1071–1074
Duda JB, Bhatt S, Dogra VS (2008) Utility of CT whirl sign in guiding management of small bowel obstruction. Am J Roentgenol 191:743–747. doi:10.2214/AJR.07.3386
Gollub MJ, Yoon S, Smith LM, Moskowitz CS (2006) Does the CT whirl sign really predict small bowel volvulus? Experience in an oncologic population. J Comput Assist Tomogr 30:25–32
Nicolau S, Kai B, Ho S, Su J, Ahamed K (2005) Imaging of acute small-bowel obstruction. Am J Roentgenol 185:1036–1044
Kim JH, Ha HK, Kim JK, Eun HW, Park KB, Kim DS (2004) Usefulness of known computed tomography and clinical criteria for diagnosing strangulation in small-bowel obstruction: an analysis of true and false interpretation groups in computed tomography. World J Surg 28:63–68. doi:10.1007/s00218-003-6899-6
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Hayakawa, K., Tanikake, M., Yoshida, S. et al. CT findings of small bowel strangulation: the importance of contrast enhancement. Emerg Radiol 20, 3–9 (2013). https://doi.org/10.1007/s10140-012-1070-z
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DOI: https://doi.org/10.1007/s10140-012-1070-z