Small bowel obstruction

Dr Jeremy Jones et al.

Small bowel obstruction (SBO) accounts for 80% of all mechanical intestinal obstruction with the remaining 20% result from large bowel obstruction. It has a mortality rate of ~5%.

Classical presentation is cramping abdominal pain and abdominal distension with nausea and vomiting.

Aetiology

Causes can be divided into congenital and acquired. Acquired causes may be extrinsic causing compression, intrinsic or luminal.

In developed countries, adhesions are by far the most common cause, accounting for ~75% of obstructions while in developing countries incarcerated hernias are much more common accounting for 80% of obstructions 3.

Congenital
Extrinsic causes
  • fibrous adhesions
    • main cause in developed countries (75% of cases)
    • almost all are related to post-operative adhesions with a small percentage secondary to peritonitis
    • diagnosis of exclusion as adhesive bands are not seen on CT
    • abrupt change in calibre without mass lesion, inflammation or bowel wall thickening at transition point
  • abdominal hernia
    • 10% of cases in developed countries
    • external hernia related to abdominal or pelvic wall defect (congenital weakness or previous surgery)
    • internal hernia with protrusion of viscera through peritoneum or mesentery into another abdominal compartment
  • endometriosis
    • rare cause of SBO
    • endometrial implants are typically on anti-mesenteric edge of the bowel
    • solid enhancing nodule contiguous with or penetrating the thickened bowel wall
    • may infiltrate the submucosa with a hypoattenuating layer between the muscularis and mucosa
  • masses
Intrinsic bowel wall causes
  • inflammation, e.g. Crohn, tuberculosis, eosinophilic gastroenteritis
    • small bowel obstruction in Crohn disease may relate to:
      • acute flare with luminal narrowing secondary to transmural inflammation
      • cicatricial stenosis in long-standing disease
      • adhesions or incisional hernias from previous surgery
  • tumour (rare)
    • primary small bowel neoplasms are rare (<2% all GI malignancy) and usually advanced at time of SBO.
      • GIST, adenocarcinoma, lymphoma
      • asymmetric and irregular mural thickening at transition point
    • small bowel involvement of metastatic disease is more common
    • caecal malignancy involving ileocecal valve
  • radiation enteritis
    • produces adhesive and fibrotic changes in the mesentery with luminal narrowing and dysmotility
    • may cause obstruction in late phase (>1 year after therapy)
  • intestinal ischaemia
    • occlusion or stenosis of the mesenteric arterial or vascular supply
    • produces small bowel wall thickening and obstruction
    • pneumatosis and portal venous gas if advanced
  • Intramural haematoma
    • trauma, iatrogenic, anticoagulant therapy, Henoch-Schonlein purpura
    • produces luminal narrowing
    • better seen on non-enhanced CT with homogenous, regular and spontaneously hyper-attenuating wall
  • intussusception
    • rare in adults (<5% of SBO)
    • lead point may relate to neoplasm, adhesion or foreign body
    • nowel-within-bowel with or without mesenteric fat and mesenteric vessels
    • leading mass should be carefully interpreted and differentiated from the soft-tissue pseudotumor that represents the intussusception itself
Intraluminal causes
  • swallowed, e.g. foreign body, bezoar
  • gallstone ileus
    • rare complication of recurrent cholecystitis
    • biliary-intestinal fistula with impaction of a gallstone in the small bowel
  • meconium ileus (or meconium ileus equivalent, distal intestinal obstruction syndrome)
Abdominal radiograph

Abdominal radiographs are only 50-60% sensitive for small bowel obstruction 3. In most cases, the abdominal radiograph will have the following features:

  • dilated loops of small bowel proximal to the obstruction
  • predominantly central dilated loops
  • three instances of dilatation > 2.5-3 cm ref required
  • valvulae conniventes are visible
  • air-fluid levels if the study is erect, especially suspicious if 8
    • >2.5 cm in length
    • in same loop of bowel but at different heights

However, obstruction (which may be high-grade mechanical obstruction) may also present with the following features:

  • gasless abdomen: gas within the small bowel is a function of vomiting, NG tube placement and level of obstruction
  • string-of-beads sign: small pockets of gas within a fluid-filled small bowel
Ultrasound

Bedside test help to diagnose small bowel obstruction, findings suggestive of small bowel obstruction 7:

  • dilated bowel loop (diameter > 2.5 cm)
  • decrees bowel peristalsis

Findings suggestive of bowel ischaemia/infarction (will need urgent surgical evaluation):

  • fluid-filled distended bowel with extra-luminal free fluid between bowel loops
  • no peristalsis
  • bowel wall thickening > 3mm
CT

CT is more sensitive than radiographs and will demonstrate the cause in ~80% of cases 3. Features on CT may include:

  • dilated small bowel loops >2.5-3 cm from outer wall to outer wall
  • normal calibre or collapsed loops distally
  • small bowel faeces sign

Closed-loop obstructions are diagnosed when a bowel loop of variable length is occluded at two adjacent points along its course. May be partial or complete with characteristic features:

  • radial distribution of several dilated, fluid-filled bowel loops
  • stretched of prominent mesenteric vessels converging towards the point of torsion
  • U-shaped or C-shaped configuration
  • beak sign at site of fusiform tapering
  • whirl sign reflecting rotation of bowel loops around a fixed point

Strangulation is defined as closed-loop obstruction associated with intestinal ischaemia. Mainly seen when the diagnosis is delayed (up to 10% of small bowel obstructions) and associated with high mortality. Features are non-specific and include:

Positive oral contrast is not usually necessary for the diagnosis of small bowel obstruction 4:

  • usually becomes dilute in the setting of SBO and does not usually reach the transition point before the scan occurs
  • may obscure the evaluation of the small bowel wall, limiting evaluation of bowel ischemia

Some literature sources recommend GastrografinTM (diatrizoate meglumine) to shorten the postoperative course of those with nonoperative small bowel obstruction 5.

Share article

Article Information

rID: 6158
Section: Gamuts
Synonyms or Alternate Spellings:
  • Small bowel obstruction (SBO)
  • SBO
  • Small-bowel obstruction

Support Radiopaedia and see fewer ads

Cases and Figures

  • Drag
    Macroscopic - Res...
    Figure 1: gross pathology - small bowel obstruction
    Drag here to reorder.
  • Drag
    Case 1
    Drag here to reorder.
  • Drag
    Case 2
    Drag here to reorder.
  • Drag
    Case 3: from caecal tumour
    Drag here to reorder.
  • Drag
    Case 4
    Drag here to reorder.
  • Drag
    Case 5: paediatric
    Drag here to reorder.
  • Drag
    Gallstone ileus e...
    Case 6: secondary to gallstone ileus
    Drag here to reorder.
  • Drag
    SBO and pregnancy
    Case 7: with concurrent pregnancy
    Drag here to reorder.
  • Drag
    String of pearls ...
    Case 8: with string of beads sign
    Drag here to reorder.
  • Drag
    Case 9: from Roux limb obstruction
    Drag here to reorder.
  • Drag
    Coronal
    Case 10
    Drag here to reorder.
  • Drag
    Case 12: due to a caecal tumour
    Drag here to reorder.
  • Drag
    Case 13: with whirl sign
    Drag here to reorder.
  • Drag
    Case 14: SBO on gastrografin follow-through
    Drag here to reorder.
  • Drag
    Case 15: due to a femoral hernia
    Drag here to reorder.
  • Drag
    Case 16
    Drag here to reorder.
  • Drag
    Case 17: due to a femoral hernia
    Drag here to reorder.
  • Drag
    Case 18
    Drag here to reorder.
  • Drag
    Case 19
    Drag here to reorder.
  • Drag
    Case 20
    Drag here to reorder.
  • Drag
    Case 21
    Drag here to reorder.
  • Drag
    Case 22: Adhesional SBO with transition point
    Drag here to reorder.
  • Updating… Please wait.
    Loadinganimation

    Alert accept

    Error Unable to process the form. Check for errors and try again.

    Alert accept Thank you for updating your details.