Closed loop small bowel obstruction - adhesions

Case contributed by Dr Michael P Hartung

Presentation

Abdominal pain and nausea.

Patient Data

Age: 60
Gender: Female

Abnormal segment of dilated, fluid-filled small bowel in the right abdomen with associated mesenteric edema/interloop fluid. Two adjacent transition points entering and exiting this segment can be seen on the same axial image, consistent with closed loop configuration. Proximal to the narrowing entering the obstruction, there is a segment of mildly dilated small bowel mid abdomen. The proximal small bowel is relatively decompressed. Abdominal aortic aneurysm. Small amount of free pelvic fluid.

CT

Annotated image

Annotated image showing buckling of the small bowel at the location of adhesive band. 

Operation

Exploratory laparotomy with lysis of adhesions.

Description

Bringing this omentum up, there were some adhesions to the anterior abdominal wall from a prior open cholecystectomy site. This was dissected free with electrocautery a bit. I was able to elevate the right lateral abdominal wall and indeed a loop of the small bowel was ischemic in nature. Further palpation found a band from the omentum to the lateral side pelvic wall. This was freed with blunt dissection. Good hemostasis was noted. The bowel was delivered up into the incision and inspected. There was a mesentery that was a little cyanotic. The areas of the small bowel where the band of adhesion was constricting the bowel were inspected. There was no cyanosis or no areas of perforation. I then placed the bowel back into anatomical position and we waited 15 minutes. The bowel did pink up. There was still a little bit of cyanotic areas but the bowel wall felt thick and not thin/ suspicious for a perforation. There are no obvious perforations presently. The bowel was placed back into its anatomical position.

Case Discussion

Adhesions are the most common cause of closed-loop obstruction. Internal hernia is the second most common cause. See further discussion on my two companion cases:

Closed loop obstruction due to adhesions

Closed loop obstruction due to internal hernia

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Case information

rID: 59269
Published: 30th Mar 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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