Closed loop small bowel obstruction - adhesions and infarct

Case contributed by Michael P Hartung
Diagnosis certain


Severe abdominal pain.

Patient Data

Age: 85 years
Gender: Female

Reflux of contrast into dilated hepatic veins and IVC. Small ascites. No proximal obstruction. Cluster of mildly dialted small bowel loops in the left lower quadrant which are slightly swirled and radially oriented toward the anterior abdominal wall, and notably hypoenhancing on the portal venous phase (almost blending in with the ascites). At least one transition point is seen where narrowed small bowel enters or exits this segment. Small component of left inguinal hernia. 

Case Discussion

Typical findings of closed loop obstruction include clustered, dilated small bowel with mesenteric edema radially oriented toward the transition point due to it herniating through an adhesive band. Notice how the small bowel is difficult to distinguish from ascites on the portal venous phase due to ischemia. 

Operative note edited excerpt: "We found a hemorrhagic segment of infarcted small bowel in left lower abdomen. We attempted to free this bowel and elevate it, but it was tethered...there was a dense fibrous band of tissue in the left lower abdomen extending to the lateral abdominal wall through which a large portion of jejunum had herniated. This band was divided with electrocautery which allowed the intestine to be freed, and was the only band identified. We ran the small bowel from the ligament of trietz and found a 3-foot segment of hemorrhagic, infarcted small bowel..."

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