Complex closed loop small bowel obstruction - adhesive disease

Case contributed by Dr Michael P Hartung

Presentation

Nausea, vomiting, abdominal pain.

Patient Data

Age: 45 years
Gender: Female

Normal caliber proximal small bowel with a gradation of oral contrast mixing with unopacified contents in the left lower abdomen, into a long segment of thick-walled small bowel with mesenteric edema. This transitions into a narrowed segment in the right lower quadrant leading into an enteroenteric anastomosis, which then transitions into a decompressed clustered segment that partially volvulizes but is not thickened. This exits the closed loop along the same plane as the proximal transition point into the terminal ileum. 

Small ascites, IUD, IVC filter. 

Annotated images highlighting key findings. 

Case Discussion

Postoperative diagnosis: Closed-loop small bowel obstruction due to dense adhesions in the pelvis. 

Procedure: Lysis of adhesions and small bowel resection. 

Operative note excerpt (edited): ..."multiple adhesions of the bowel to the abdominal wall near the pelvis, and adhesed to the ceserean section scar and uterus. Around these adhesions, the bowel twisted itself most likely causing the small bowel obstruction." 

Prior history of small bowel resection due to small bowel injury during cesarean section. Complex case of small bowel obstruction that requires the reader to follow the proximal small bowel into and out of the transition points in the right lower quadrant to make sense of the findings. You can skip ahead to the thickened small bowel in the left lower quadrant where the oral contrast starts to mix with unopacified intraluminal fluid. There are two adjacent narrowed transition points in the left lower quadrant which is fairly typical for adhesive disease, which leads into the small bowel that is twisted and adhered to the abdominal wall. The operative not details extensive lysis of adhesions but did not specifically comment on a band causing the obstruction in/out of the closed loop, which is not uncommon when comparing radiology studies/operative notes due to limited visualization, insufflation, and surgical approach. 

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