eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Small-Bowel Obstruction: Differential Diagnoses & Workup

Author: Jaime Shalkow, MD, Head of Surgical Oncology, Division of Surgery, National Institute of Pediatrics, Mexico; Head-Professor of Pediatric Surgical Oncology, Universidad Nacional Autonoma de Mexico
Coauthor(s): Jose Asz, MD, Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico; Nicholas A Shorter, MD, Professor of Clinical Surgery and Clinical Pediatrics, State University of New York-Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York-Downstate Medical Center; Bruce Friedberg, MD, Staff Physician, Department of Emergency Medicine, Mount Diablo Medical Center; Mainor Antillon, MD, Director, Pancreaticobiliary Endoscopy and Endosonography Program, Department of Internal Medicine, Division of Gastroenterology, King-Drew Medical Center; Associate Clinical Professor, Department of Medicine, University of California at Los Angeles; Thomas Tsou, MD, Director of Fast Tract and Pediatrics, Associate Professor, Departments of Medicine and Emergency Medicine, Charles R Drew University and University of California at Los Angeles
Contributor Information and Disclosures

Updated: Nov 21, 2008

Differential Diagnoses

Abdominal Trauma
Intestinal Volvulus
Alimentary Tract Duplications
Intussusception
Appendicitis
Irritable Bowel Syndrome
Bowel Obstruction in the Newborn
Meckel Diverticulum
Constipation
Mesenteric and Omental Cysts
Constipation and Bowel Management
Necrotizing Enterocolitis
Cyclic Vomiting Syndrome
Omphalocele and Gastroschisis
Cystic Fibrosis
Pediatric Hernias
Gastroenteritis
Pyloric Stenosis, Hypertrophic
Hirschsprung Disease
Small Intestinal Atresia and Stenosis
Intestinal Atresia, Stenosis, and Webs
Surgical Aspects of Cystic Fibrosis and Meconium Ileus
Intestinal Malrotation
Volvulus

Other Problems to Be Considered

Inflammatory bowel disease
Intestinal pseudoobstruction

Workup

Laboratory Studies

  • The following laboratory tests may be useful in patients with small-bowel obstruction:
    • Serum electrolyte level
    • BUN level
    • Creatinine level
    • Glucose level
    • CBC count
    • Urinalysis
    • ABG level
    • Stool for occult blood
  • Routine laboratory studies usually do not help establish a diagnosis of malrotation with midgut volvulus, although leukocytosis with a left shift may develop late in the disease process.
  • Potassium is an intracellular ion; thus, patients with incarcerated hernias or other conditions that lead to ischemic bowel may present with hyperkalemia.

Imaging Studies

  • Plain abdominal radiography should be the initial radiologic study in suspected cases of small-bowel obstruction.
    • Obtain flat decubitus and upright radiographs of the abdomen.
    • Study radiographs for signs of dilated small-bowel loops and air-fluid levels produced by the layering of air and intestinal content.
    • Absent colonic or rectal gas also indicates a complete bowel obstruction.
    • The pattern of bowel gas on plain radiography can help differentiate between proximal and distal bowel obstructions. Drawing an imaginary line from the right upper quadrant to the left lower one is helpful in establishing the level of the obstruction. The jejunum corresponds to the left upper three fifths of the small bowel, whereas the right lower two fifths of it represents the ileum.
    • When intestinal perforation is suspected and the child cannot be placed in an upright position, a left lateral decubitus film with horizontal beam is helpful in diagnosing free intraperitoneal air because it facilitates identification of free air around the hepatic density.
  • Contrast studies such as upper GI series and contrast enemas can help determine obstruction location. Contrast studies also reveal whether the obstruction is intrinsic or extrinsic to the bowel. Remember to always use hydrosoluble contrast to avoid severe barium peritonitis in patients with a perforation.
  • Abdominal CT scanning should not be obtained when the diagnosis is evident on radiography because this would only delay treatment and subject the child to unnecessary radiation. CT scanning helps identify causes of chronic partial obstructions, as well as abscesses, tumors, and other causes of acute abdominal pain.
  • Ultrasonographic examinations reveal many intestinal abnormalities, including tumors, mesenteric cysts, and intussusceptions.
  • Intussusception imaging includes the following:
    • In approximately 60% of intussusception cases, plain abdominal radiography reveals the head of the intussusceptum projecting into the air-filled colon. Abdominal radiography may also reveal scattered air-fluid levels that suggest an ileus or partial obstruction. A left lateral decubitus film aids in the initial diagnosis of intussusception by revealing air or stool in the cecum and ascending colon.
    • Contrast radiography using a barium enema can be therapeutic as well as diagnostic. A classic sign is a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine. Air and water enemas have been used to reduce intussusception. Pneumatic reduction under fluoroscopic guidance and hydrostatic reduction under ultrasonographic monitoring are the preferred techniques. The aim should be a success rate of at least 90% in idiopathic intussusception.
    • Ultrasonography is useful in some cases and may have high sensitivity in as many as 75% of patients. The characteristic finding is a target or bull's eye configuration, consisting of 2 rings of low echogenicity that are separated by an intermediate hyperechoic ring visible on a cross-sectional image of intussuscepted bowel.
  • Incarcerated hernia imaging includes the following:
    • In complete bowel obstruction, air-fluid levels are visible on plain radiography.
    • The bowel may be visible within the inguinal canal and scrotum.
    • Ultrasonography may reveal the incarcerated viscera in the inguinal canal or the umbilical ring and can be useful in difficult cases.
    • A careful physical examination is more helpful than imaging studies for the diagnosis of incarcerated inguinal or umbilical hernias. Incarcerated hernias are diagnosed clinically, and no imaging studies are required. Determining the level of the obstruction is not that important because the treatment does depend on this finding.
  • Imaging for malrotation of the bowel with midgut volvulus includes the following: Plain abdominal radiography sometimes reveals a double-bubble sign that depicts air-fluid levels in both the stomach and in the distended duodenum. The abdomen often appears gasless on abdominal plain radiography. Distended loops of small bowel are only occasionally visible because the point of obstruction is proximal, in the third portion of the duodenum.
  • Definitive diagnosis of midgut volvulus requires contrast studies. Barium enema findings may provide indirect evidence by revealing an ectopically placed right colon and cecum, but a high or mobile cecum is common in many asymptomatic infants. In fact, 10-15% of patients with malrotation have barium enema findings that appear normal. An upper GI series is a quicker and more direct approach with high sensitivity and accuracy, making it the criterion standard study for malrotation with or without volvulus. The duodenum usually has a "C" shape, and the duodenojejunal junction is localized to the left of the midline. In malrotation, the duodenum lacks its normal shape and does not cross the midline. Duodenal obstructions due to volvulus, Ladd bands, or angulation are evident. The classic patterns of volvulus are the "bird beak" in cases involving complete duodenal obstruction, or the "corkscrew in cases involving incomplete obstruction.
  • Imaging for postoperative adhesive small-bowel obstruction includes the following:
    • Supine and upright abdominal radiography reveals dilated gas-filled loops of small intestine with multiple air-fluid levels scattered throughout the abdomen above the obstruction site. Air in the colon usually indicates a partial obstruction, although determining whether a gas-filled loop is the colon or small bowel is difficult in infants. Demonstrating gas in the rectum is the only way to be certain of gas in the colon.
    • Oral administration of water soluble contrast media (Gastrografin) with subsequent abdominal radiography is useful in deciding whether to perform early operation in cases in which the obstruction cannot be determined to be partial or complete.4,5 If the contrast is found in the large bowel 6-8 hours after administration, the obstruction is presumed to be partial, and the patient can be conservatively managed without an immediate operation. The technique has been successfully used in children.
  • Imaging for duplication cysts is as follows:
    • Plain radiography usually reveals a soft-tissue mass within the abdomen that displaces the adjacent bowel and causes the obstruction.
    • An upper GI contrast series may reveal stenosis or extrinsic compression by a mass.
    • Technetium scanning can be used to image duplications that contain ectopic gastric mucosa.
    • For most abdominal duplications, ultrasonography is more expedient and provides greater detail than conventional contrast radiography. Ultrasonography reveals either a sonolucent mass that has good through transmission because of its clear fluid content, or an echogenic mass secondary to hemorrhage that has inspissated material within the duplication. Intraabdominal enteric duplication cysts are increasingly likely to be prenatally detected.
  • Imaging for annular pancreas is as follows:
    • Although an annular pancreas is often not diagnosed until surgery, plain abdominal radiography may reveal the double-bubble sign characteristic of duodenal obstruction.
    • An upper GI series reveals a diminished duodenal lumen.
    • Ultrasonography provides a reliable method to help diagnose duodenal obstruction, even prenatally in pregnancies complicated by polyhydramnios in the third trimester. It is also a good study to rule out hypertrophic pyloric stenosis as a differential diagnosis.
  • Imaging for necrotizing enterocolitis (NEC) includes the following:
    • Abdominal radiography initially reveals multiple gas-filled loops of intestine and air-fluid levels. Straightening of the bowel wall and bowel wall thickening with intramural air suggest mural edema (railroad sign). A gasless abdomen, a fixed bowel loop, or ground-glass appearance, which suggests free intraperitoneal fluid, is sometimes encountered.
    • Pneumatosis intestinalis is the radiographic hallmark; its presence indicates gas in the bowel wall. Portal venous gas is an ominous sign, and pneumoperitoneum indicates a bowel perforation. Pneumatosis intestinalis and portal venous gas (pylephlebitis) are easily detected using ultrasonography.
  • Mesocolic hernia imaging is as follows:
    • An upper GI study with small bowel follow-through during a hernia episode can support the diagnosis. This study usually reveals the intestines bunched together as if enveloped by a sac.
    • Abdominal CT scanning may reveal a mesocolic hernia during nonherniating periods.
  • Cecal volvulus imaging is as follows:
    • Plain abdominal radiography may reveal a large air-filled loop of colon that occupies the right lower quadrant, in addition to depicting a typical small-bowel obstruction.
    • The characteristic barium enema finding is a bird-beak–shaped deformity, coupled with nonvisualization of the cecum.
  • Jejunoileal atresia and stenosis imaging involves the following:
    • Radiographic findings often reveal thumb-sized intestinal loops and air-fluid levels. A loop of small bowel proximal to the atresia may become grossly distended and filled with fluid, producing the appearance of a mass.
    • A contrast enema is usually indicated to confirm the diagnosis. The preferred methodology is a water-soluble enema, which aids in distinguishing between small- and large-bowel distention, determining the presence or absence of a microcolon, and locating the position of the cecum relative to possible abnormalities of intestinal rotation and fixation.
    • An upper GI series reveals the level of obstruction with a grossly distended proximal bowel. Care must be taken to avoid contrast aspiration.
  • Meconium disease imaging studies are as follows:
    • Abdominal radiographic studies reveal multiple air-fluid levels consistent with small-bowel obstruction. The presence of calcifications throughout the peritoneum suggests a prenatal perforation and meconium peritonitis or meconium pseudocyst.
    • The inspissated meconium often has a ground-glass appearance on radiography. A "soap-bubble" image in the right lower quadrant is characteristic.
    • A contrast enema is diagnostic and, in many cases, therapeutic for both MI and meconium plug syndrome. In most cases, the contrast enema reveals a microcolon (nonused colon) and meconium pellets in either the terminal ileum (MI) or the colon (meconium plug syndrome). Gastrografin is the agent of choice. Its osmotic properties pull water into the lumen, which may unplug the intestine.
  • Duodenal atresia and stenosis imaging studies involve the following:
    • Abdominal radiography usually confirms a duodenal atresia diagnosis. Gas and air-fluid levels are present in the stomach and the dilated duodenal bulb (ie, double-bubble sign), but no air is present in the distal GI tract. These radiographic findings confirm a diagnosis of duodenal obstruction, making further studies unnecessary.
    • An upper GI series adds no information and creates the potential hazard of vomiting with barium aspiration. If the patient has vomited or has been decompressed using a nasogastric (NG) tube prior to abdominal radiography, the stomach and duodenum may be collapsed, making the correct diagnosis difficult. In such cases, a small amount of air (ie, 10-15 mL) may be injected into the stomach through the NG tube, and radiography may be repeated.
    • Upper GI studies are useful in the late diagnosis of duodenal web and stenosis.

More on Small-Bowel Obstruction

Overview: Small-Bowel Obstruction
Differential Diagnoses & Workup: Small-Bowel Obstruction
Treatment & Medication: Small-Bowel Obstruction
Follow-up: Small-Bowel Obstruction
Multimedia: Small-Bowel Obstruction
References
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Further Reading

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Keywords

small-bowel obstruction, small bowel obstruction, SBO, intussusception, incarcerated hernia, malrotation of the bowel with midgut volvulus, postoperative adhesive small bowel obstruction, duplication cysts, annular pancreas, necrotizing enterocolitis, NEC, mesocolic hernia, cecal volvulus, jejunoileal atresia and stenosis, meconium Ileus

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Contributor Information and Disclosures

Author

Jaime Shalkow, MD, Head of Surgical Oncology, Division of Surgery, National Institute of Pediatrics, Mexico; Head-Professor of Pediatric Surgical Oncology, Universidad Nacional Autonoma de Mexico
Disclosure: Nothing to disclose.

Coauthor(s)

Jose Asz, MD, Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico
Disclosure: Nothing to disclose.

Nicholas A Shorter, MD, Professor of Clinical Surgery and Clinical Pediatrics, State University of New York-Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York-Downstate Medical Center
Disclosure: Nothing to disclose.

Bruce Friedberg, MD, Staff Physician, Department of Emergency Medicine, Mount Diablo Medical Center
Bruce Friedberg, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Mainor Antillon, MD, Director, Pancreaticobiliary Endoscopy and Endosonography Program, Department of Internal Medicine, Division of Gastroenterology, King-Drew Medical Center; Associate Clinical Professor, Department of Medicine, University of California at Los Angeles
Disclosure: Nothing to disclose.

Thomas Tsou, MD, Director of Fast Tract and Pediatrics, Associate Professor, Departments of Medicine and Emergency Medicine, Charles R Drew University and University of California at Los Angeles
Thomas Tsou, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jorge H Vargas, MD, Clinical Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition
Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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