eMedicine Specialties > Radiology > Gastrointestinal

Small-Bowel Obstruction: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Coauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; John MT Howat, MB, BCh, MD, FRCS, Consultant General and Colorectal Surgeon, North Manchester General Hospital, UK
Contributor Information and Disclosures

Updated: Sep 11, 2009

Intervention

Many patients with small-bowel obstruction respond to an initial trial of decompression of the stomach and small bowel by fasting and nasogastric aspiration, with intravenous fluid and electrolyte replacement. This treatment is particularly useful in patients in whom the etiology of the small-bowel obstruction is believed to be postoperative adhesions; in these patients, the obstruction is often only partial or incomplete. This treatment should be abandoned if clinical improvement does not occur fairly rapidly, as judged by the bowel sounds, the diminution of the nasogastric aspirate, the passage of flatus, and the resolution of any distention. Surgery is mandatory in these patients. The role of radiologic interventions in the management of small-bowel obstruction is limited and confined to the management of intussusception.

Most institutions choose to perform air-contrast enemas in the evaluation and treatment of intussusception. A barium enema reduction is an alternate choice. One may also choose to perform the reduction under sonographic guidance as opposed to fluoroscopic guidance. Regardless of the technique, reduction of intussusception has a high success rate, with minimal risks. The overall success rate is 80-90% with a complication rate of around 1%. Intestinal perforation is the gravest complication, but the most common complication is a recurrence of intussusception within 72 hours. A recurrent intussusception can be reduced again with an air enema.

Because of the risk of perforation or unsuccessful air enema reduction, the most important consideration in deciding to perform an air enema reduction is to ensure that a pediatric surgeon has examined the child and is readily available. In either case, the child will need to be transported the operating room. The child should be clinically stable, with adequate intravenous access. Contraindications to air reduction include evidence of free air on abdominal radiographs or signs of peritonitis on physical examination. A prolonged process increases the likelihood of ischemia, which decreases the rate of successful reduction and increases the likelihood of a perforation.

A commercial kit is available for performing air reduction (Shiels intussusception air reduction system). A tape plug and rubber disk around the enema tip help to create a tight seal. A tight seal is the key to a successful reduction. A generous amount of athletic-grade tape is necessary. The buttocks are used to create an adequate seal. If air leaks from the rectum, the procedure must be terminated and the enema tip reinserted. Alternatively, manual squeezing of the buttocks may help in minimizing the air leak.

The pressure in the colon should be monitored throughout the examination, and the pressure should not exceed 120 mm Hg. The child is not sedated for the examination because crying increases the intra-abdominal pressure and aids the reduction. The intussusception mass is visualized and, therefore, direct observation of the reduction can be achieved under fluoroscopic guidance. Complete reduction is confirmed with reflux of air into the small bowel. As an alternative, barium enema may be used for the reduction of intussusception. The barium bag should be elevated no more than 3 feet above the rectum to limit the colonic pressure. This leads to the "Rule of Threes," which states that only 3 attempts be made and that 3 minutes of rest should be allowed between each attempt.

Medicolegal Pitfalls

  • The most serious consequences of small-bowel obstruction are strangulation with ischemia, necrosis, perforation, peritonitis, and death. The prevalence of strangulated small-bowel obstruction is 5-42% of all patients. Expeditiously investigate clinical suspected strangulation because a delay may be lethal.
  • The use of barium suspensions for enteroclysis or retrograde examination may cause inspissation of the small bowel and convert a partial obstruction to a complete obstruction; therefore, if CT is available, CT scans should be obtained as an alternative to conventional contrast-enhanced studies.
  • The presence of a closed-loop obstruction and features of ischemia can be missed, even on CT scans. If an obvious discrepancy exists between CT and clinical findings in patients with obstruction, urgent surgery is mandatory.
 


More on Small-Bowel Obstruction

Overview: Small-Bowel Obstruction
Imaging: Small-Bowel Obstruction
Follow-up: Small-Bowel Obstruction
Multimedia: Small-Bowel Obstruction
References
Further Reading
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References

  1. Rhodes AI, Shorvon PJ. Recent advances in small-bowel imaging: a review. Curr Opin Gastroenterol. Mar 2001;17(2):132-139. [Medline].

  2. Calvo AM, Erce R, Montón S, Martínez A, Otero A. [Cavernous haemangioma of the small bowel: an uncommon cause of intestinal obstruction]. An Sist Sanit Navar. Sep-Dec 2003;26(3):437-40. [Medline].

  3. Hanaei AA, Hefny AF, Teraifi HE, Zidan FM. Small-bowel obstruction due to bilharziasis. Scand J Gastroenterol. Mar 2008;43(3):382-3. [Medline].

  4. Gümüstas OG, Gümüstas A, Yalçin R, Savci G, Soylu RA. Unusual causes of small bowel obstruction and contemporary diagnostic algorithm. J Med Imaging Radiat Oncol. Jun 2008;52(3):208-15. [Medline].

  5. Cappell MS, Batke M. Mechanical obstruction of the small bowel and colon. Med Clin North Am. May 2008;92(3):575-97, viii. [Medline].

  6. Maglinte DD, Howard TJ, Lillemoe KD, Sandrasegaran K, Rex DK. Small-bowel obstruction: state-of-the-art imaging and its role in clinical management. Clin Gastroenterol Hepatol. Feb 2008;6(2):130-9. [Medline].

  7. Atri M, McGregor C, McInnes M, Power N, Rahnavardi K, Law C, et al. Multidetector helical CT in the evaluation of acute small bowel obstruction: comparison of non-enhanced (no oral, rectal or IV contrast) and IV enhanced CT. Eur J Radiol. Jul 2009;71(1):135-40. [Medline].

  8. O'Daly BJ, Ridgway PF, Keenan N, Sweeney KJ, Brophy DP, Hill AD, et al. Detected peritoneal fluid in small bowel obstruction is associated with the need for surgical intervention. Can J Surg. Jun 2009;52(3):201-6. [Medline].

  9. Delabrousse E, Lubrano J, Jehl J, Morati P, Rouget C, Mantion GA, et al. Small-bowel obstruction from adhesive bands and matted adhesions: CT differentiation. AJR Am J Roentgenol. Mar 2009;192(3):693-7. [Medline].

  10. Quintana JF, Walker RN, McGeehan A. Child with small bowel obstruction and perforation secondary to ileal bezoar. Pediatr Emerg Care. Feb 2008;24(2):99-101. [Medline].

  11. Burkill G, Bell J, Healy J. Small bowel obstruction: the role of computed tomography in its diagnosis and management with reference to other imaging modalities. Eur Radiol. 2001;11(8):1405-22. [Medline].

  12. Burkill GJ, Bell JR, Healy JC. The utility of computed tomography in acute small bowel obstruction. Clin Radiol. May 2001;56(5):350-9. [Medline].

  13. Jancelewicz T, Vu LT, Shawo AE, Yeh B, Gasper WJ, Harris HW. Predicting Strangulated Small Bowel Obstruction: An Old Problem Revisited. J Gastrointest Surg. Aug 7 2008;[Medline].

  14. Jabra AA, Eng J, Zaleski CG, Abdenour GE Jr, Vuong HV, Aideyan UO, et al. CT of small-bowel obstruction in children: sensitivity and specificity. AJR Am J Roentgenol. Aug 2001;177(2):431-6. [Medline].

  15. DiSantis DJ, Ralls PW, Balfe DM, Bree RL, Glick SN, Levine MS, et al. The patient with suspected small bowel obstruction: imaging strategies. American College of Radiology. ACR Appropriateness Criteria. Radiology. Jun 2000;215 Suppl:121-4. [Medline].

  16. Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. AJR Am J Roentgenol. Jan 2001;176(1):167-74. [Medline].

  17. Delabrousse E, Bartholomot B, Sohm O, Wallerand H, Kastler B. Gallstone ileus: CT findings. Eur Radiol. 2000;10(6):938-40. [Medline].

  18. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol. Jul 1999;40(4):422-8. [Medline].

  19. Furukawa A, Yamasaki M, Furuichi K, Yokoyama K, Nagata T, Takahashi M, et al. Helical CT in the diagnosis of small bowel obstruction. Radiographics. Mar-Apr 2001;21(2):341-55. [Medline].

  20. Boudiaf M, Soyer P, Terem C, et al. CT evaluation of small bowel obstruction. RadioGraphics. May-Jun 2001;21(3):613-24. [Medline].

  21. Chou CK, Mak CW, Huang MC, et al. Differentiation of obstructive from non-obstructive small bowel dilatation on CT. Eur J Radiol. Sep 2000;35(3):213-20. [Medline].

  22. Brown S, Applegate KE, Sandrasegaran K, Jennings SG, Garrett J, Skantharajah A, et al. Fluoroscopic and CT enteroclysis in children: initial experience, technical feasibility, and utility. Pediatr Radiol. May 2008;38(5):497-510. [Medline].

  23. Qalbani A, Paushter D, Dachman AH. Multidetector row CT of small bowel obstruction. Radiol Clin North Am. May 2007;45(3):499-512, viii. [Medline].

  24. Mak SY, Roach SC, Sukumar SA. Small bowel obstruction: computed tomography features and pitfalls. Curr Probl Diagn Radiol. Mar-Apr 2006;35(2):65-74. [Medline].

  25. Hwang JY, Lee JK, Lee JE, Baek SY. Value of multidetector CT in decision making regarding surgery in patients with small-bowel obstruction due to adhesion. Eur Radiol. May 5 2009;[Medline].

  26. Chen SC, Chang KJ, Lee PH, Wang SM, Chen KM, Lin FY. Oral urografin in postoperative small bowel obstruction. World J Surg. Oct 1999;23(10):1051-4. [Medline].

  27. Olson DE, Kim YW, Ying J, Donnelly LF. CT Predictors for Differentiating Benign and Clinically Worrisome Pneumatosis Intestinalis in Children beyond the Neonatal Period. Radiology. Aug 25 2009;[Medline].

  28. Berrocal T, Lamas M, Gutieérrez J, Torres I, Prieto C, del Hoyo ML. Congenital anomalies of the small intestine, colon, and rectum. Radiographics. Sep-Oct 1999;19(5):1219-36. [Medline].

  29. Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, et al. Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol. Jul 14 2009;15(26):3303-8. [Medline].

  30. Delabrousse E, Brunelle S, Saguet O, Destrumelle N, Landecy G, Kastler B. Small bowel obstruction secondary to phytobezoar CT findings. Clin Imaging. Jan-Feb 2001;25(1):44-6. [Medline].

  31. Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in the diagnosis of intestinal ischemia in small-bowel obstruction. AJR Am J Roentgenol. Dec 2000;175(6):1601-7. [Medline].

  32. Gollub MJ, DeCorato D, Schwartz LH. MR enteroclysis: evaluation of small-bowel obstruction in a patient with pseudomyxoma peritonei. AJR Am J Roentgenol. Mar 2000;174(3):688-90. [Medline].

  33. Regan F, Beall DP, Bohlman ME, Khazan R, Sufi A, Schaefer DC. Fast MR imaging and the detection of small-bowel obstruction. AJR Am J Roentgenol. Jun 1998;170(6):1465-9. [Medline].

  34. Umschaden HW, Szolar D, Gasser J, Umschaden M, Haselbach H. Small-bowel disease: comparison of MR enteroclysis images with conventional enteroclysis and surgical findings. Radiology. Jun 2000;215(3):717-25. [Medline].

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Further Reading

Clinical guidelines

Suspected small bowel obstruction.
American College of Radiology.  1996 (revised 2005).  5 pages.  NGC:004782

Practice management guidelines for small bowel obstruction.
Eastern Association for the Surgery of Trauma - Professional Association.  2007.  42 pages.  NGC:006546


Clinical trials

Value of CT-Scan and Oral Gastrografin in the Management of Post Operative Small Bowel Obstruction


Related eMedicine topics

Small-Bowel Obstruction (Pediatrics: General Medicine)

Obstruction, Small Bowel

Small Intestinal Atresia and Stenosis

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Keywords

small bowel obstruction, small-bowel obstruction, partial small bowel obstruction, bowel obstruction, intestinal obstruction, bowel blockage, gastric obstruction, partial bowel obstruction, obstructed bowel, SBO, mechanical ileus, mechanical small bowel obstruction, ileus, bezoar, foreign body obstruction, food bolus obstruction, bowel wall lesional obstruction, bowel stricture, volvulus, hernia, bowel adhesion

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

John MT Howat, MB, BCh, MD, FRCS, Consultant General and Colorectal Surgeon, North Manchester General Hospital, UK
John MT Howat, MB, BCh, MD, FRCS is a member of the following medical societies: Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Medical Editor

Eric P Weinberg, MD, Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital
Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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