Intestinal Obstruction 27

Intestinal Obstruction 4
Jae Hoon Lim

CONTENTS is becoming the first-line diagnostic method in the

diagnosis of bowel obstruction (Patak et al. 2005).
4.1 Introduction 27 Sonography is not considered helpful in most
4.2 Pathology of Bowel Obstruction 27
patients with intestinal obstruction. This is easily
appreciated if one remembers that the presence of
4.3 Small Bowel Obstruction 28 abundant gas in the intestinal tract prevents satis-
4.4 Colon Obstruction 32 factory examination of the abdomen, and that adhe-
4.5 Paralytic Ileus 32 sions, the most common cause of intestinal obstruc-
tion, are not visible on a sonogram (Wilson 1991);
References 34
however, when the obstructed bowel segments are
dilated and filled with fluid, the dilated segments of
the bowel loops are well demonstrated and the cause
of obstruction can be demonstrated by sonogra-
4.1 phy using the fluid-filled bowel as a sonic window
Introduction (Fig. 4.1). Judicious use of sonography in evaluating
patients with bowel obstruction may be helpful in
The diagnosis of bowel obstruction used to be made confirming the presence of obstruction, in determin-
by means of clinical history, physical examination, ing the level of obstruction, and in identifying of the
and plain abdominal radiography; however, abdomi- cause of obstruction (Ko et al. 1993a).
nal radiographs are not confirmatory or are even con- The use of sonography in the era of multi-detector
fusing, and the cause of obstruction is rarely detected. CT scanning is controversial. A CT diagnosis of intes-
For the management issue of whether to initiate tinal obstruction has a decided advantage in terms of
immediate surgical intervention or to recommend accuracy in diagnosis of bowel obstruction and in dem-
a trial of conservative management, it is mandatory onstration of the cause. Furthermore, interpretation of
to identify the cause of bowel obstruction. Barium multi-detector CT images is not as operator dependent
studies are not always satisfactory (Herlinger and as sonography; however, sonography is much more
Maglinte 1989; Mucha 1987; Dunn et al. 1984). widely available than multi-detector CT, much cheaper,
Computed tomography (CT) has been shown to be and there is no radiation hazard; therefore, sonographic
useful in revealing the level and cause of obstruc- examination may be attempted in patients with normal
tion (Megibow et al. 1991; Taourel et al. 1995), and plain radiographs or gasless abdomen, suspected
recently, multidetector CT scanning has been proven obstruction in proximal bowel loops, in children, or in
to be very useful (Sinha and Verma 2005a; Sinha pregnant women (Ko et al. 1993b).
and Verma 2005b). Furthermore, multiplanar refor-
matted imaging may help identify the site, level, and
cause of obstruction, and to increase diagnostic con-
fidence (Furukawa et al. 2001) when axial CT find-
ings are indeterminate; therefore, multidetector CT 4.2
Pathology of Bowel Obstruction
J. H. Lim, MD
Department of Radiology and Center for Imaging Science, Bowel obstruction is characterized by dilatation of the
Samsung Medical Center, Sungkyunkwan University School of intestinal segments proximal to the site of obstruc-
Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, Korea tion and collapse of the segment distal to the obstruc-
28 J. H. Lim

a b c

Fig. 4.1a–d. Ileal obstruction due to stromal tumor. a Abdominal radio-

graph in supine position shows multiple dilated jejunal loops filled with
gas. Dilated ileal loops are not visible because they are filled with fluid.
These fluid-filled bowel loops are a good acoustic window through
which the dilated bowel loops and the cause of obstruction can be
visualized. b Sonogram of the jejunum shows dilatation with markedly
increased peristalsis, the fluid and tiny gas bubbles moving actively in
the dilated bowel lumen. Note thick and compact valvulae conniventes.
c Sonogram of the ileum shows dilatation with increased peristalsis.
Note virtually absent valvulae conniventes (arrows). d Sonogram of the
lower abdomen discloses a lobulated tumor (short arrows) arising from
d the ileum. Note dilated ileal loops (long arrows)

tion. The dilated bowel contains a large amount of

fluid, food stuff, or gas. There is increased peristalsis 4.3
to attempt to pass the luminal content beyond the Small Bowel Obstruction
obstruction site. Bowel obstruction can be due to
obturation by blockage of the lumen by bowel content, Characteristic sonographic findings of small bowel
such as food stuff, bezoar, or gallstone, due to bowel obstruction is demonstration of dilated bowel loops
wall abnormality, such as neoplasm or stenosis, and with active peristalsis (Ko et al. 1993a). Multiple seg-
due to extrinsic causes, such as adhesion and hernia. ments of dilated bowel loops can be readily dem-
In paralytic ileus, the bowel is dilated and filled with onstrated when the lumen is filled with fluid. The
fluid and gas, but there is no peristaltic movement. fluid may be clear or there may be air bubbles or
 Intestinal Obstruction 29

debris. The dilated loops are continuous, the diameter

of the bowel lumen being over 2.0 cm and the seg-
ments being longer than 10 cm. Valvulae conniven-
tes, or intestinal folds, are prominent and compact
along the jejunum and are thin and sparse along
the ileum (Fig. 4.1). Sometimes, there is no valvulae
conniventes in the distal ileum and the bowel wall
is flat. Increased peristalsis of the proximal segment
of the bowel can be directly observed. The dilated
bowel loop changes in caliber as well as in position,
very vigorously, sometimes with some pauses. The
fluid and tiny gas bubbles in the involved bowel show
to-and-fro or whirling motion (Fig. 4.2). When the
lumen is filled with gas, bowel dilatation is not easily
recognized and it is difficult to make a diagnosis of
bowel obstruction with sonography (Fig. 4.3). Usu-
ally, the bowel contains both fluid and gas. Sonogra-
pher should try to avoid gas filled lumen by pressing a
the abdomen with the transducer or change the posi-
tion of the patient.
The causes of bowel obstruction can be demon-
strated (Ko et al. 1993a). Small bowel bezoar is usu-
ally caused by persimmons and orange, sometimes
by cabbage, sauerkraut, potato peel, or grapefruit.

Fig. 4.3a,b. Gas-filled distended bowel loops. a Sonogram of

the gas-filled jejunum shows air trapping in the valvulae con-
niventes (arrows). b Sagittal sonogram along the right side
of the abdomen shows gas-filled, distended ascending colon.
Note a haustral indentation (arrow)

Patients who have had subtotal gastrectomy or gas-

trojejunostomy are prone to develop bezoars.
Sonographically, bezoars are seen as an intralumi-
nal mass with a hyperechoic arc-like surface casting
a clear posterior acoustic shadow (Fig. 4.4; Ko et al.
1993b; Tennenhouse and Wilson 1990). Phyto-
Fig. 4.2. Increased peristalsis. Sonogram of the jeju-
num shows dilated loop with increased peristalsis.
bezoar or trichbezoar are the same in sonographic
The dilated loop shows vigorous change in caliber appearances. The obstructed small bowel loops usu-
and position. Tiny gas bubbles in the lumen show ally contain a large amount of air and bezoars can
to-and-fro and whirling motion be overlooked if sonographic examination is not per-
30 J. H. Lim

Fig. 4.4a,b. Phytobezoar in the

jejunum. a Sonogram of upper
abdomen shows hyperechoic,
arc-like echo with clear acous-
tic shadow within a loop of
the jejunum (arrows). Bowel
loops proximal to the bezoar
are dilated and filled with fluid.
b Small bowel follow-through
examination shows a large
intraluminal filling defect at
the end of the dilated jejunum,
representing bezoar (arrow)

a b

a b

Fig. 4.5a,b. Gallstone ileus. a Sonogram shows hyperechoic arc-like echo with posterior acoustic shadow within a
dilated loop of ileum, representing a large gallstone (arrows). b Sonogram of the right upper abdomen discloses
the gallbladder, which is empty (arrows)

formed meticulously. Sonographic findings of gall- Small bowel tumor, either primary or metastatic,
stone ileus are identical to those of bezoars (Fig. 4.5; can be identified as a cause of bowel obstruction
Ko et al. 1993a; Davir et al. 1991). Air in the biliary (Ko et al. 1993a). At the end of dilated small bowel
tree or nonvisualization of the gallbladder lumen or between the dilated bowel loops, a tumor can be
may be a clue for gallstone ileus. identified when the tumor is fairly large (Fig. 4.1).
 Intestinal Obstruction 31

Fluid within the bowel may comes into direct con- and these cases require rapid surgical decompres-
tact with that the mass indicating the mass arises sion (Ko et al. 1993a).
from the bowel. There may be vascular structure in It has been reported that the accuracy of preopera-
the mass visualized by Doppler study. Small bowel tive sonography in establishing the diagnosis of small
intussusception can be diagnosed by demonstration bowel obstruction was 89% (Ko et al. 1993a). The
of bowel-within-bowel by recognizing characteristic cause of obstruction, such as tumor, bezoar, gallstone,
multiple concentric rings, caused by invaginating or recurrent cancer in afferent loop syndrome may
layers of telescoped bowel, seen in cross section of be predicted (Ko et al. 1993a; Meiser and Meissner
the bowel loop. 1985). Sonography has definite advantages in the
Intestinal adhesion, the most frequent cause diagnosis of proximal obstruction, such as duode-
of bowel obstruction, cannot be demonstrated on nal or proximal jejunal obstruction (Ko et al. 1993a):
sonography. Likewise, internal hernia and congen- in these cases, simple abdominal radiographs are
ital fibrotic band can rarely be identified at sono- often normal or do not show gas, because frequent
graphy. Previous history of abdominal operation vomiting results in lack of air in the obstructed seg-
in patients without a sonographically visible cause ment (Fig. 4.6). Afferent loop syndrome can be reli-
of obstruction can lead to a diagnosis of adhesive ably diagnosed with sonography (Lee et al. 1991).
ileus. The superior mesenteric artery and vein are useful
By virtue of demonstrating the vascular flow landmarks in the diagnosis of duodenal obstruction
signal from the vessels of the dilated bowel wall, such as afferent loop or proximal jejunal obstruction,
sonography may be useful in demonstrating the since the dilated lumen of the third portion of the
bowel segment at risk of strangulation. The sono- duodenum crosses the midline anterior to the aorta
graphic finding of a thickened bowel wall, valvulae and behind the superior mesenteric artery and vein
conniventes, and localized ascites within the leaves (Fig. 4.7). By careful examination, recurrent tumor at
of the small bowel mesentery, is suggestive of com- the gastric stump as a cause of afferent loop can be
plicated obstruction such as infarction or gangrene, diagnosed sonographically (Lee et al. 1991).

a b

Fig. 4.6a,b. Duodenal obstruction by adenocarcinoma. a Sagittal sonogram of the right upper abdomen discloses
a mass (arrows) with dilated first part of the duodenum (d). b Upper gastrointestinal series shows near-complete
obstruction by adenocarcinoma (arrows)
32 J. H. Lim

Fig. 4.7a,b. Afferent loop syndrome. a Supine abdominal ra-

diograph shows virtually absent bowel gas because of fre-
quent vomiting. b Sagittal color Doppler sonogram of the up-
per abdomen shows the dilated third part of the duodenum
(D3) anterior to the abdominal aorta and posterior to the
a superior mesenteric artery (arrows)

4.4 in position, each segment of colon is identified by

Colon Obstruction position.
The causes of colon obstruction can be identified
The most common cause of colonic obstruction is (Kojima et al. 1992). It has been reported that sono-
carcinoma, either primary or metastatic, whereas the graphy predicted the cause of colon obstruction in
most common cause of small bowel obstruction is 81% (Lim et al. 1994). As the majority of colon obstruc-
adhesions; therefore, it is necessary to differentiate tions are due to colon cancer or ileocecal intussuscep-
colonic obstruction from small bowel obstruction. tion, sonography may reveal an obstructing mass or
Radiographs of the abdomen may be useful for the segmental thickening of the colon wall at the end of
diagnosis of colonic obstruction in 60–70% of cases the dilated colon (Fig. 4.8; Ko et al. 1993a), or charac-
(Gore and Eisenberg 1994). Once colonic obstruc- teristic concentric rings along the sausage-like, invagi-
tion is suspected, contrast enema, is indicated to nated bowel loops in intussusception (Weissberg et al.
confirm the obstruction and to determine its level, 1977). Sometimes, a soft tissue mass as a leading point
severity, and cause (Amberg 1994). In the CT era, of intussusception can be demonstrated (Fig. 4.9).
multidetector row CT examination is the best method Sonography is particularly useful in child intussuscep-
for the evaluation of patients with acute abdomen tion (Woo et al. 1992; Verschelden et al. 1992).
including colon obstruction (Sinha and Verma
2005b; Patak et al. 2005).
Identification of the colon with sonography is
relatively difficult because the colon is filled with
gas and feces, rather than fluid. As gas and feces are 4.5
present in various amounts in the normal colon, the Paralytic Ileus
diagnosis of obstruction can be made only when
the colon is found to be dilated continuously to the Paralytic ileus can be reliably diagnosed by sonog-
level of the lesion (see Fig. 4.3), where abnormal raphy by demonstrating very quilt or aperistaltic
distension ends abruptly, with the colon distal to it dilated bowel loops (Fig. 4.10). When the bowel loops
free of gas (Wilson 1994). Since the colon is fixed are filled with more gas than fluid, sonography may
 Intestinal Obstruction 33

a b

Fig. 4.8a,b. Transverse colon obstruction due to adenocarcinoma. a Transverse sonogram of the right upper abdomen discloses
circumferential thickening of the wall of the transverse colon (arrows) and fluid-filled dilated proximal colon. b CT image shows
encircling thickening of the wall of the transverse colon (arrow) due to adenocarcinoma and dilated ascending and transverse
colon

Fig. 4.10. Paralytic ileus. Sonogram of the lower abdomen

shows dilated jejunum filled with fluid and debris. The
dilated loops are essentially static and the bowel contents
do not move. Note debris in the dependent part of the di-
lated loop (arrows), indicating no peristaltic movement

Fig. 4.9a,b. Ileocolic intussusception due to lymphoma. a Sagit-

tal sonogram of the right abdomen shows an oval mass (M) in
intussusception. Note folded bowel wall at the orifice of intus-
suscepted bowel (arrow). b CT image shows a round mass (M)
surrounded by a thin line of fat invaginated into the ascending
b colon (arrow). Note slightly dilated jejunum and ileum
34 J. H. Lim

be of little value. Some difficulty may arise when the Lim JH, Ko YT, Lee DH et al (1994) Determining the site
obstruction becomes prolonged and the obstructed and causes of colonic obstruction with sonography. Am J
Roentgenol 163:1113–1117
segment becomes paralytic, and thus may be mis- Megibow AJ, Balthazar EJ, Cho KC, Medwid SW, Birnbaum
taken for paralytic ileus. BA, Noz ME (1991) Bowel obstruction: evaluation with CT.
Radiology 180:313–318
Meiser G, Meissner K (1985) Sonographic differential diagno-
sis of intestinal obstruction: results of a prospective study
of 48 patients. Ultraschall Med 6:39–45
Mucha P (1987) Small intestinal obstruction. Surg Clin North
References Am 67:597–620
Patak MA, Mortele KJ, Ros PR (2005) Multidetector row CT of
Amberg JR (1994) Overview: the acute abdomen. In: Margulis the small bowel. Radiol Clin North Am 43:1063–1077
AR, Burhenne HJ, (eds) Alimentary tract radiology, 5th edn. Sinha R, Verma R (2005a) Multidetector row computed tomo-
Mosby, St. Louis, pp 2118–2119 graphy in bowel obstruction. Part 1. Small bowel obstruc-
Davir RJ, Sandrasagra FA, Joseph AEA (1991) Ultrasound diag- tion. Clin Radiol 60:1058–1067
nosis of gallstone ileus. Clin Radiol 43:282–284 Sinha R, Verma R (2005b) Multidetector row computed tomog-
Dunn JT, Halls JM, Berne TV (1984) Roentgenographic con- raphy in bowel obstruction. Part 2. Large bowel obstruc-
trast studies in acute small bowel obstruction. Arch Surg tion. Clin Radiol 60:1068–1075
119:1305–1308 Taourel PG, Fabre JM, Pradel JA, Seneterre EJ, Megibow AJ,
Furukawa A, Yamasaki M, Furuichi K et al (2001) Helical CT Bruel JM (1995) Value of CT in the diagnosis and manage-
in the diagnosis of small bowel obstruction. Radiographics ment of patients with suspected acute small bowel obstruc-
21:341–355 tion. Am J Roentgenol 165:1187–1192
Gore RM, Eisenberg RL (1994) Large bowel obstruction. In: Tennenhouse JE, Wilson SR (1990) Sonographic detection of a
Gore RM, Levine MS, Laufer I (eds) Textbook of gastroin- small bowel bezoar. J Ultrasound Med 9:603–605
testinal radiology. Saunders, Philadelphia, pp 1247–1258 Verschelden P, Filiatrault D, Garel L et al (1992) Intussuscep-
Herlinger H, Maglinte DDT (1989) Small bowel obstruction. tion in children: reliability of US in diagnosis: a preopera-
In: Herlinger H, Maglinte DDT (eds) Clinical radiology of tive study. Radiology 184:741–744
the small intestine. Philadelphia, Saunders, pp 479–509 Weissberg Dl, Scheible W, Leopold GR (1977) Ultrasono-
Ko YT, Lim JH, Lee DH, Lee HW, Lim JW (1993a) Small bowel graphic appearance of adult intussusception. Radiology
obstruction: sonographic evaluation. Radiology 188:649– 124:791–792
653 Wilson SR (1991) The gastrointestinal tract. In: Rumack CM,
Ko YT, Lim JH, Lee DH, Yoon Y (1993b) Small bowel phytobe- Wilson SR, Charboneau JW (eds) Diagnostic ultrasound.
zoars: sonographic detection. Abdom Imaging 18:271–273 Mosby, St. Louis, pp 181–206
Kojima Y, Tsuchiyama T, Niimoto S, Nakagawara G (1992) Wilson SR (1994) The acute abdomen of gastrointestinal tract
Adult intussception caused by cecal cancer and diagnosed origin: sonographic evaluation. In: Margulis AR, Burhenne
preoperatively by ultrasonography. J Clin Ultrasound HJ (eds) Alimentary tract radiology, 5th edn. Mosby, St.
20:360–363 Louis, pp 2099–2117
Lee DH, Lim JH, Ko YT (1991) Afferent loop syndrome: sono- Woo SK, Kim JS, Suh SJ, Paik TW, Choi SO (1992) Childhood
graphic findings in seven cases. Am J Rogentgenol 157:41– intussusception: US-guided hydrostatic reduction. Radiol-
43 ogy 182:77–80