Closed loop small bowel obstruction - adhesive disease and hemorrhagic ischemia
Presentation
Nausea, vomiting, abdominal pain.
Patient Data
Dilated mid small bowel leading into a cluster of abnormal small bowel in the right lower quadrant. Radial orientation of vasculature, asymmetric mesenteric edema, mild wall thickening, and transition points in/out of this cluster indicating a closed loop. Distal small bowel decompressed. Small ascites.
Annotation of key findings; notice how axial, coronal and sagittal images help to understand the pathology.
Case Discussion
Operative report excerpt:
...There was hemorrhagic ascites. Right lower quadrant small bowel was dark purple and hemorrhagic. Adhesion in the right lower quadrant which created an internal hernia-like defect. We lysed this adhesive band and proceeded to resect the nonviable bowel...
Pathology report excerpt:
32 cm segment of ileum; mucosal ischemia, muscularis propria atrophy and extensive hemorrhage
Several typical findings of closed-loop small bowel obstruction. Notice how all three planes help you understand the disease process. The asymmetric mesenteric edema, clustered orientation of loops, and radial orientation are clues that you are dealing with a closed loop. Carefully running the small bowel in/out in all planes helps to confidently identify the proximal and distal transition points (with characteristic "beak") so you can be certain of this diagnosis. Notice how the closed-loop segment has a mildly thickened and "dense" appearing wall - this is not hyperenhancement, but rather due to transmural hemorrhage of the wall (a non-contrast would have confirmed this).
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