Closed loop small bowel obstruction due to adhesive band, with intramural hemorrhage and ischemia
Presentation
Abdominal pain, nausea, vomiting.
Patient Data
Cluster of thick-walled, hypoenhancing small bowel in the right mid abdomen with mesenteric edema. Increased density of the thick-walled portion on noncontrast series. Two adjacent transition points lead in and out of this cluster, with segmental narrowing and angulation. The distal transition point corresponds to the distal ileum. The upstream bowel is dilated with gradual dilution of oral contrast and air/fluid levels. Pessary. Incidental node of nutcracker physiology of the left renal vein which drains via the gonadal vein.
Annotated
Annotated coronal image shows transition points and hemorrhagic bowel wall within the closed loop. Annotated sagittal image shows both transition points in parallel.
Case Discussion
Closed loop small bowel obstruction due to an adhesive band. At surgery, they found the ileum was hemorrhagic and ischemic and volvulized within the closed loop, and resected 65 cm of small bowel.
Teaching points:
- Don't let the upstream small bowel dilation fool you - notice the difference in wall enhancement, thickening, interloop fluid, clustered/swirled appearance, and lack of oral contrast
- Carefully follow the transition points into and out of the closed-loop. Notice the narrowed, angulated appearance, and how they are next to each other but can be relatively thin, subtle, and hard to follow the exiting segment on axial and coronal. However, sagittal reformats clearly show both segments in parallel. I have found that at least one of the reformats will often clearly show both transition points in the same plane, so use all of your available images!
- Clearly state your concerns in the impression section to guide efficient surgical management. In this case, you might report: "Closed loop small bowel obstruction involving a long segment of ileum in the right mid abdomen, complicated by hemorrhage and ischemia.
- In this case, hemorrhage likely occurred as a complication of edema and elevated venous pressure from volvulus/narrowing of the venous outflow
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