Closed loop small bowel obstruction due to adhesive bands - early and late images

Case Discussion

This is very challenging case but highly instructive with the inclusion of the early CT images, where the imaging findings of a closed loop obstruction are extremely subtle. While the first study is abnormal, it is very challenging to determine why there is a single loop of thickened small bowel in the right lower quadrant. The presence of fecalization indicates the presence of slow transit, related to developing obstruction. Beyond this, it is challenging to follow the bowel into and out of the closed loop segment.

As a result, the patient was managed conservatively and had repeated imaging due to worsening symptoms. The second study has increasingly dilated small bowel proximal and within and closed loop, and thus the angulated transition points in the right lower quadrant become much more apparant, although admittedly still fairly subtle because the upsteam small bowel and small bowel within the closed loop look very similar (dilated, fluid-filled, with mild interloop fluid). This case helps to illustrate the importance of running the entire small bowel when it is obstructed to evaluate for a possible cause. 

The radiologist raised concern of a closed loop obstruction and this patient proceeded to the OR, with the surgeon reporting: "we identified injected, erythematous bowel within the right lower quadrant with some ecchymotic-appearing mesentery. There were 2 bands present within the right lower quadrant that has caused a closed-loop bowel obstruction and twisting of a section of ileum approximately 25 cm. The adhesions were lysed and the bowel detorsed".