Closed loop small bowel obstruction - adhesions

Case contributed by Dr Michael P Hartung

Presentation

Abdominal pain. History of appendectomy 20 years prior.

Patient Data

Age: 70
Gender: Female

Mildly dilated proximal small bowel with gradual admixture of oral contrast with enteric fluid as the bowel progresses distally. Two adjacent angulated transition points correspond to the "closed loop" segment, and form a "waist"-like appearance in the right mid abdomen on the axial images. The closed loop portion is dilated, fluid-filled, and has mesenteric edema/interloop fluid. No pneumatosis. 

Photo

Intraoperative photo

Laparoscopic images from surgery indicated a tight adhesive band as the cause of obstruction (arrows). 

CT

Annotated images

Arrows indicate the site of small bowel entering the internal hernia defect. Note how both segments of bowel are angulated toward each other. 

Case Discussion

There are several subtle clues indicating a closed-loop obstruction in this case. The proximal small bowel is mildly dilated, but less so that then closed loop segment in the right lower quadrant. The small bowel in the closed loop sticks out as more abnormal than any other segment in the abdomen: more dilated, no oral contrast, and mesenteric edema. The axial images give it away (see annotated image) - the two sites of obstruction are adjacent to each other, indicating a closed loop obstruction. This appearance could be due to internal hernia or (as in this case) adhesive bands.  

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Case information

rID: 59078
Published: 20th Mar 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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