Presentation
Sudden onset severe right lower quadrant pain.
Patient Data
Proximal bowel non dilated with oral contrast.
Short segment of dilated, fluid filled small bowel in the left lower quadrant without mesenteric edema.
Abrupt transition to a cluster of mildly dilated, fluid filled loops in the right lower quadrant with another transition point distally.
Both transition points are located near each other and best seen on the sagittal images.
Annotated images indicating key findings.
Case Discussion
This is a challenging case to confidently diagnose, but there are several findings which indicate closed loop obstruction:
1. Isolated loop of mildly dilated bowel with mesenteric edema in the right lower quadrant - this is in contrast to the mildly dilated small bowel leading into the first transition point, which does not have edema because the vascularity is not being compressed in the closed loop.
2. Two distinct transition points located next to each other. These are most clearly seen on the sagittal images, and quite subtle on the axial images. There is a typical hairpin turn/beaked appearance where it is compressed by the adhesive band or mesenteric defect. I have found that for closed loop obstructions, generally the transition points are best seen on one of the three planes - so look carefully on each!
3. Proximal small bowel is non dilated - this is because the patient presents with symptoms before developing overt obstruction of the proximal bowel.
The patient underwent laparoscopic exploration, finding abnormal bowel in the right lower quadrant but no definite closed loop. It may be that the act of insufflation and running the bowel pulled the involved loops from the adhesive band or mesenteric defect and restored normal anatomy. Nonetheless the imaging findings remain convincing for closed loop. This patient did not have a history of surgery, making the cause unclear.
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