Professional Documents
Culture Documents
JUNE-2014
CERTIFICATE
This is to certify that A study on efficacy of helical computed
tomography in determination of cause, site of high grade small bowel
obstruction, bowel viability and correlation with
findings. Is a bonafide work of
intra operative
Madurai
Dr.RameshArdhanari MS.,MCh.(SGE)FRCS
Medical Director,
Sr.Consultant and Head of Department,
Department of Surgical Gastro-enterology ,
Meenakshi Mission Hospital and Research Centre,
Madurai, Tamilnadu.
CERTIFICATE
This is to certify that A study on efficacy of helical computed
tomography in determination of cause, site of high grade small bowel
obstruction ,bowel viability and correlation with
intra operative
findings is a bonafide work has been carried out by the candidate himself
under my direct supervision and the findings presented have been checked
thoroughly by me. I am fully satisfied with the work of Dr.Sathish Ravirala,
which is being presented by him as a dissertation for Diplomate of National
Board in the subject of Radio Diagnosis during his training period at
Meenakshi Mission Hospital and Research Centre, Madurai, Tamilnadu.
Madurai
CERTIFICATE
This is to certify that A study on efficacy of helical computed
tomography in determination of cause, site of high grade small bowel
obstruction ,bowel viability and correlation with
intra operative
findings is a bonafide work has been carried out by the candidate himself
under my direct supervision and the findings presented have been checked
thoroughly by me as a guide , i am fully satisfied with the work of
Dr.Sathish Ravirala, which is being presented by him as a dissertation for
Diplomate of National Board in the subject of Radio Diagnosis during his
training period at Meenakshi Mission Hospital and Research Centre,
Madurai, Tamilnadu.
Madurai
DECLARATION
I declare that this dissertation titled A study on efficacy of helical
computed tomography in determination of cause, site of high grade
small bowel obstruction ,bowel viability and correlation with
intraoperative findings has been conducted by me under the guidance and
supervision of Dr.N.S.MANI., MD., DMRD., Consultant, Department of
Imaging sciences, Meenakshi Mission Hospital and Research Center,
Madurai. It is submitted as part of fulfillment of the requirement for the
award of the D.N.B. RadioDiagnosis, June 2014 examination held under
National Board of Examinations, New Delhi.
ACKNOWLEDGEMENT
I am extremely thankful to the Chairman, ViceChairman and
Medical Director of Meenakshi Mission Hospital and Research Center,
Madurai, who have been kind enough to permit me to use the hospital
resources. I thank all the patients who have been a part of this study making
my thesis possible.
I express my sincere and heartful gratitude to my guide
Dr.N,S.Mani.,MD.,DMRD for his guidance and support. My sincere thanks
also goes to Dr. S.Manohar MD., DMRD. (Head of the department)
My sincere thanks to Dr.T.Mukuntharajan.,DMRD., (Sr.Consultant),
Dr.N.Karunakaran.,
DMRD.,DNB.,(Consultant),
Dr.R.Ganesh.,DMRD.,
for helping me in
CONTENTS
S.NO.
TITLE
PAGE NO
1.
Introduction
2.
3.
Review of Literature
26
4.
38
5.
43
6.
Discussion
53
7.
Conclusion
59
Annexure
Bibliography
Proforma
Master chart
INTRODUCTION
Small Bowel Obstruction (SBO) is a common clinical condition, one
of the important causes
Objectives
1. Confirm the high grade Small Bowel Obstruction
2. To assess Cause, Site of Small Bowel Obstruction
3. To assess the Viability of Bowel loops
4. Correlation of CT findings with Intraoperative findings.
5. To assess the Sensitivity, Specificity, Accuracy of Spiral CT with
Intraoperative findings.
NORMAL ANATOMY
The small intestine is a convoluted tube, extending form the pylorus to
the ileocaecal valve, where it ends in the large intestine. It is about 7meters
long, and gradually diminishes in size from its commencement to its
termination. It is contained in the central and lower part of the abdominal
cavity. It is in relation, in front, with the greater omentum and abdominal
parieties, and is connected to the posterior abdominal wall by a fold of
peritoneum, the mesentery. The small intestine is divisible into three portions
: the duodenum, the jejunum, and the ileum.
Duodenum:
The duodenum has received its name from being about equal in length to
the breadth of twelve fingers (25cm). It is the shortest, the widest, and the
most fixed part of the small intestine, and has no mesentery, being only
partially covered by peritoneum. It is divided into 4 parts. i.e, superior,
descending, horizontal and ascending. As it unites with the jejunum it turns
abruptly forward, forming the duodeno-jejunal flexure.
The common bile duct and pancreatic duct together perforate the medial
side of 2nd part of duodenum, obliquely 7 to 10cm below the pylorus, the
accessory pancreatic duct sometimes pierces it about 2cm above and slightly
in front of these.
found than in the ileum, and are smaller and tend to assume a circular form.
By grasping the jejunum between the finger and thumb the circular folds
can be felt through the walls of the gut, these being absent in the lower part
of the ileum, it is possible in this way to distinguish the upper from the lower
part of the small intestine.
The ileum is narrow, thinner and less vascular than those of the jejunum.
It possesses but few circular folds, and they are small and disappear entirely
towards its lower end, but aggregated lymph nodules (peyer's patches) and
larger and more numerous. The jejunum for the most part occupies the,
umbilical and left iliac regions, while the ileum occupies chiefly the
umbilical, hypogastric, right iliac and pelvic regions. The terminal part of
the ileum usually lies in the pelvis, from which it ascends over the right
psoas and right iliac vessels; it ends in the right iliac fossa by opening into
the medial side of the commencement of the large intestine. The jejunum
and ileum are attached to the posterior abdominal wall by an extensive fold
of peritoneum, the mesentery, which allows the free motion, so that each coil
can accommodate itself to changes in form and position.
The root of the small bowel mesentery (SBM) is located in the central
portion of the abdomen, connecting the intraperitoneal structures and is
inosculations to the free border, where they also anastomose with other
branches running around the opposite surface of the gut. Form these vessels
numerous branches are given off, which submucous tissue. From this plexus
minute vessels pass to the glands and villi of the mucous membrane.
The veins have a similar course and arrangement to the arteries. The
lymphatics of the small intestine (lacteals) are arranged in two sets, those of
the mucous membrane and those of the muscular coat. The lymphatics of the
villi commence in these structures in the manner described above. They
form an intricate plexus in the mucous and submucous tissue, being joined
by the lymphatics from the lymph spaces at the bases of the solitary nodules,
and from this pass to larger vessels at the mesenteric border of the gut. The
lymphatics of muscular coat are situated to a great extent between the two
layers of muscular fibers, where they form a close plexus, throughout their
course they communicate freely with the lymphatics from the mucous
membrane, and empty themselves in the same manner as these into the
origins of the lacteal vessels at the attached border of the gut.
circular muscular fibers. This plexus lies in the submucous coat of the
intestine, it also contains ganglia from which nerve fibers pass to the
muscularis mucosa and to the mucous membrane. The nerve bundles of the
submucous plexus are finer than those of the myenteric plexus.
malignancy.
Masses, which suggest obturator hernia.
Check for symptoms commonly believed to be more diagnostic of
intestinal ischemia, including the following
Fever (temperature >100F )
Tachycardia (>100beats /min).
Peritoneal signs.
No reliable way exists to differentiate simple from early strangulated
obstruction on physical examination. Serial abdominal examinations are
important and may detect changes early.
A small bowel obstruction (SBO) is caused by a variety of pathologic
processes. They can be broadly classified into congenital and acquired
(Gore's classification)
Congenital causes of SBO
Duodenal atresia
Jejunal atresia
Ileal atresia/stenosis
Midgut volvulus
Meckels diverticulum
Inspissated meconium
Intrinsic lesions
Adhesions
Hernias
intestine
External
Adenocarcinoma
Inguinal
Carcinoid tumor
Femoral
Lymphoma
Obturator
Leiomysarcoma
Umbilical
Inflammatory conditions
Sciatic
Crohn's disease
Perineal
Tuberculosis.
Supravesical
Spigelian
Eosinophilic gastroenteritis
Lumbar
Radiation enteropathy
Incisional
Internal
Hematoma
Paraduodenal
Epiploic foramen
Thrombocytopenia
Diaphragmatic (traumatic)
Anticoagulants
Transomental
Henoch-schonlein purpura.
Transmesenteric
Insussusception
Masses
Polyps, lipoma
Tumor
Lymphoma
Duplication
Peritoneal metastasis
Carcinoid
Desmoid
Intraluminal causes
Gall stone
Bezoar
Inflammations / Abscess
Foreign body
Diverticulitis
Ascariasis
Appendicitis
Pelvic inflammatory disease
Crohn's disease
Hematoma
Aneurysm
Endometriosis
PATHOPHYSIOLOGY
Early in the course of an obstruction, intestinal motility and contractile
activity increase in an effort to propel luminal contents past the obstructing
point. The increase in peristalsis that occur early in the course of bowel
obstruction is present both above and below the point of obstruction, thus
accounting for the diarrhea that may accompany partial or even complete
small bowel obstruction in the early period.
Obstruction of the small bowel leads to proximal dilatation of the
intestine due to accumulation of gastrointestinal secretions and swallowed
air. This bowel dilatation, stimulates increased cell secretory activity
resulting in more fluid accumulations, leading to increased peristalsis both
above and below the obstruction with fragment loose stools and flatus early
in its course.
Increased small bowel distension leads to increased intraluminal
pressures. This can cause compression of mucosal lymphatics leading to
bowel wall lymphedema. Later in the course of obstruction, the intestine
becomes fatigued and dilated, with contractions becoming less frequent and
less intense.
As the bowel dilates, water and electrolytes accumulate both
intraluminally and in the bowel wall itself. This massive third -space fluid
loss accounts for the dehydration and hypovolemia. The metabolic effects of
fluid loss depend on the site and duration of the obstruction. With a proximal
obstruction,
dehydration
may
be
accompanied
by
hypochloremia,
10
per ml
been reported. In one small study, the sensitivity of plain radiographs was
reported as 75% and specificity was
Lappas et al9 proposed that two findings were more predictive of a higher
grade of complete SBO: present of air-fluid differentiation height in the
same small- bowel loop and presence of a mean level width greater than
25mm. The study found that when the two findings are present, the
obstruction is most likely high grade or complete. When both are absent, the
authors proposed that a low grade (partial) SBO is likely or nonexistent.
* Fixed, dilated U or C shaped bowel loops may suggest closed loop
obstruction.
* Small amounts of air trapped between the plicae circularis in an
upright films produce a " string of beads or pearls" appearance (most
specific sign). Multiple Air- Fluid levels, Step ladder configuration, Gasless
abdomen are the other specific signs.
Ultrasonography
Ultrasonography is less costly and less invasive than CT scanning.
It may reliably exclude SBO in as may as 89% of patients.
Specificity is reportedly 100%.
Enteroclysis
Enteroclysis is valuable in detecting the present of obstruction and in
differentiating partial from complete blockage.
This study is useful when plain radiographic findings are normal in
REVIEW OF LITERATURE
There are several studies have been published in evaluating the role of CT in
detecting the site and cause of high grade small bowel obstruction.Computed
Tomography has emerged as a premier modality and has a tremendous
impact in the evaluation and management of high grade small bowel
obstruction.A brief review of literature will be discussed below.
Omair Shakil et al 14 retrospectively studied the spiral CT in cases of
small bowel obstruction over a period of 5 years in adult Pakistani
population, who underwent
David Frager et al
15
the diagnosis and determining the degree, cause of small bowel obstruction
as compared with traditional clinical-radiographic assessment. A total of 90
examinations were evaluated over a period of 11 months. On the basis of the
combined clinical-radiographic findings, the diagnosis was complete
obstruction in 21 of 46 cases with sensitivity, 46%. When CT was used, the
diagnosis was established in all 46 cases with sensitivity 100%. In the 25
cases in which the traditional assessment failed, the early CT able to identify
complete obstruction, so that reduces delay in surgery. On the basis of the
combined clinical-radiographic findings, partial obstruction of the small
bowel was diagnosed in 6 of 20 cases with sensitivity of 30% , whereas all
cases were detected with CT. Thus this study concluded that CT is highly
sensitive and superior to combined clinic-radiographic findings.
Marc Zalcman et al
16
reduced or if at least two of the other signs were noticed, are the criteria for
ischemia on spiral CT. Intraoperatively ischemic bowel loops were noted in
24 cases. CT correctly identified ischemia in 23 cases ,with sensitivity of
96%, 9 false positives with specificity of 93% &The negative predictive
value of CT was 99%.Coming to individual parameters, reduced
enhancement of the bowel wall had a sensitivity of 48% and specificity of
100%, mural thickening had a sensitivity of 38% and specificity of 78%,
mesenteric fluid had a sensitivity of 88% and specificity of 90%, congestion
of mesenteric veins had a sensitivity of 58% and specificity of 79%, and
ascites had a sensitivity of 75% and specificity of 76%.This study highlights
the role of spiral CT in diagnosing ischemia in cases of small bowel
obstruction.
Alec J. Megibow and his colleagues2 retrospectively evaluated the
role of spiral CT in intestinal obstruction (included large bowel also in his
study) over a period of 2 years. A total of 167 cases were studied, in this 84
cases referred as intestinal obstruction, remaining 83 cases are control group.
CT evaluation done by two radiologists, who un aware of patient history,
confirmation of bowel obstruction by intraoperative findings ,clinical course
and barium studies and the results were analyzed .Among 84 cases, which
referred as intestinal obstruction, 64 cases only having intestinal obstruction
17
and vascular
18
predictive value was 79%, and negative predictive value was 95%.This
study showed spiral CT help in accurate diagnosis of bowel ischemia in
cases of small bowel obstruction. Exploratory laparotomy should be done,
when disparity between equivocal CT findings and a deteriorating clinical
condition.
Scaglione M et al
19
intestine closed loop obstruction over a period of 3 years. All these cases are
operated, with in a period of 6 hours after doing spiral CT. These 120 cases
of closed loop obstruction were evaluated for bowel ischemia and results
were analyzed. CT signs taken into consideration for diagnosing ischemia
were: submucosal edema, increased, reduced, or no enhancement of the loop
walls, edema of the mesenteric vessels, fluid within the loops or in the
intraperitoneal spaces. 120 cases were thoroughly evaluated, Spiral CT
diagnosed ischemia in 26 cases, but in reality there are 51 cases showed nonviable bowel loops intraoperatively. In this study of 120 cases they missed
bowel ischemia in 25 cases preoperatively. In
negative predictive value of 73%. Thus he concluded that even though Spiral
CT had good positive predictive value for diagnosing bowel ischemia ,
depending up on CT we cant say confidently, which dont show bowel
ischemia on CT ,cant be viable in reality, there is a chance of missing
ischemia on CT. So if any change in trophic status of bowel loops or its
mesentery may imply ischemic changes, and need for emergency
laparotomy.
Catel L et al 20 retrospectively reviewed 43 cases of Adhesive small
bowel obstruction for evaluation of bowel ischemia. All cases were
evaluated by three experienced radiologists. Signs for complicated small
bowel obstruction in this study were reduced enhancement of the small
bowel wall, mural thickening, congestion of small mesenteric veins, and
ascites. In this study 15 patients had ischemic signs on CT, 28 patients does
not have. Coming to individual parameters in diagnosing bowel ischemia a
sensitivity of 57% and a specificity of 100% noted with reduced bowel wall
enhancement and sensitivity of 35% and a specificity of 100% noted with
bowel wall thickness greater than 3 mm, and sensitivity of 35% and a
specificity of 93%noted if bowel wall thickness less than 1 mm taken as
criteria. In this study ascites and congestion of small mesenteric veins were
not much useful in diagnosing bowel ischemia. If u consider bowel-wall
21
19 cases of
Michael H. Fuchsjager et al
22
cause of obstruction. Thus he concluded that role of Small bowel feces sign,
in identification of site and cause of obstruction.
Dawn E. Lazarus et al
24
this sign more frequently associated with moderate, severe SBO than mild
SBO.
Usually adhesions as a cause of small-bowel obstruction (SBO) is
diagnosis of exclusion. Bojan Petrovic et al
25
retrospectively studied CT
scans of 142 patients with surgically proven SBO due to adhesions .This
study mainly to evaluate the findings suggestive of an extra luminal band
can be used in diagnosis of adhesive SBO. An extraluminal band was
suggested if any change in the conformation at the transition zone. In 142
patients, the study identified 73 cases having bands, in that 73 cases,
adhesions as cause of obstruction in 52 cases with a positive predictive value
of 71% and a p value of 0.008. This study demonstrated extraluminal band
was sensitivity of 61% and specificity of 63% in diagnosing SBO due to
adhesions. So this study summarized the role of bands in helping the
diagnosis of adhesions in cases of small bowel obstruction.
Diego A. Aguirre et al4 summarizes the role of multidetector CT in
diagnosis of abdominal hernias in problematic situations like scarred tissues,
severe abdominal pain, and obesity. In obese cases, it demonstrates the
location, shape, size and content of abdominal hernias. With 3D imaging and
multiplanar reformations, CT much more helpful in these cases. MDCT
help in identification of signs of strangulation .This study highlights the
26
Exclusion criteria:
Patient in early post operative period, generalized septicemia,
electrolyte disturbances i.e., hypokalemia and history of trauma were
excluded from study.
CT protocols:
All patients were scanned with GE optima 660- 64 slice multidetector
CT scanner. Initially, plain helical acquisition from the dome of diaphragm
to the inferior edge of the ischium was taken.
Depending up on the plain CT findings ,oral contrast was given to the
patients. All the patients were not administered oral contrast because most of
the patients had severe vomiting and more importantly positive contrast in
the bowel can obscure the etiology of the obstruction & enhancement of the
mucosa of the bowel lumen. The inherent fluid in the dilated bowel acts as a
contrast in most cases of high grade Small bowel Obstruction. Oral contrast
if given, it was given in the form of 30 ml of Gastroscan+ M
(Diatrizoatemeglumine and Diatrizoate sodium solution-370 mg /ml iodine)
mixed in 1200 to 1500 ml of mineral water or flavoured drinks and
administered orally over a period of 45-60 minutes. Around 150-200 ml of
oral contrast is administered just before the I.V.( Intravenous)contrast study
as a table dose. We advocated oral contrast only in few patients who had
The CT criteria
Bowel Dilatation-Small bowel with a caliber greater than 2.5 cm
is considered dilated.
High grade obstruction is greater than 50% difference in caliber
of proximal dilated small bowel and collapsed distal small bowel.
Bowel wall thickening because of difficulties related to the
precision of this measurement, we have elected to use the 3mm
threshold suggested by Bartnicke.28
Delayed wall enhancement29 of the involved loop compared to
the homogenous enhancement of adjacent normal bowel.
Congestion of small mesenteric veins30,31 characterized by
enlargement of small serpentine vessels in the mesenteric fat.
Peritoneal fluid32,33
Bowel wall pneumatosis34 (intramural air) characterized by gas
bubbles within the bowel wall.
Statistical tools
The information collected regarding all the selected cases were
recorded in a master chart. Data analysis was done with the help of computer
using epidemiological information package (EPI 2002). Using this software,
Specificity
Accuracy
No.
<10 years
2.4
10-20 years
1.2
20-30 years
11
13.3
30-40 years
13
15.7
40-50 years
18
21.7
50-60 years
23
27.6
15
18.1
Total
83
100
0.17years
MeanSD
- 46.2415.61
79years
We evaluated of about 83 cases , most of them fall under the age group
between 50-60 years (27.6%), second most commonest age group is 4050 years (21.7%). The mean is around 46.24 15.61 years.
Table 2
Sex distribution
Frequency and percentage wise distribution of cases according to their
sex
Sex
No.
Male
37
44.6
Female
46
55.4
Total
83
100
Table 3
Frequency and percentage wise distribution of cases according to their
CT level of obstruction
CT-level
No
Proximal Jejunum
7.2
Distal jejunum
9.6
Proximal ileum
18
21.7
Distal ileum
50
60.2
1.2
Total
83
100
Table 4
Frequency and percentage wise distribution of cases according to their
surgical level of obstruction
Surgical -level
No
Proximal Jejunum
6.0
Distal jejunum
11
13.3
Proximal ileum
18
21.7
Distal ileum
49
59.0
Total
83
100
Table 5
Association between surgical and CT level of obstruction
Surgical_level
Proximal Distal
Proximal distal
Total p-value
CT-Level
jejunum
jejunum ileum
ileum
Proximal
Distal jejunum
Proximal ileum
17
18
Distal ileum
48
50
clearly 0
11
18
49
83
jejunum
Not
p<0.001*
made out
Total
Table 6
Frequency and percentage wise distribution of cases according to their
causes (surgical findings)
Causes
No
Adhesions
32
38.5
Stricture
14
16.8
24
28.9
Intussusception
1.2
1.2
Tumors
9.6
Radiation enteropathy
1.2
Meckels diverticulum
1.2
Foreign body
1.2
Total
83
100
In 83 cases, Adhesions (38.5%) are the most common cause of SBO. The
other causes are (in the descending order of frequency ) Closed loop
obstruction (28.9%), Stricture(16.8%), Neoplasms(9.6%).
Table 7
Frequency and percentage wise distribution of cases according to their
CT- ISCHAMIC Parameter of bowel wall enhancement
Bowel wall enhancement No
Present
76
91.6
Absent
8.4
Total
83
100
Table-8
Frequency and percentage wise distribution of cases according to their
bowel viability
Viability
No
Present
75
90.4
Absent
9.6
Total
83
100
CTFinding
Surgical finding
Gangrene p-value
Viable
f
Viable
74
89.2 2
2.4 p<0.001
Gangrene
1.2
7.2
Table 10
Frequency and percentage wise distribution of cases according to their
confirmation of CT finding by surgical finding:
CT- Finding
Level
78
93.9
6.1
Cause
77
92.8
7.2
Viability
80
96.4
3.6
DISCUSSION
Experience accumulated mainly in the past decade showing that CT
is a valuable diagnostic tool in cases of small bowel obstruction ,in its
diagnosis and evaluation of etiology.35,36,37 In our current study we want to
evaluate cases of small bowel obstruction , answering
the
following
diagnosis
is
stricture, but
pre-
various extrinsic,
with
value
of
85.7%.
similar
prospective
study
by
CONCLUSION
Helical CT is useful imaging modality to characterize the cause, site
and possible complications of small bowel obstruction .Reformatting
helical CT scans in multiple planes provides a new perspective for the
evaluation of small bowel obstruction and may be useful in defining and
characterizing obstruction. However, in most patients, the multiplanar
reconstructions simply confirm and complement the information revealed on
axial source images. Helical CT is a highly sensitive method to diagnose or
rule out intestinal ischemia in the context of acute small- bowel obstruction.
CT can also demonstrate findings that indicate the presence of closed loop
obstruction or strangulation, both of which necessitate emergency
exploratory laparotomy.
In our study population we found out that Helical CT has good
accuracy in determining the level, cause of obstruction, viability of bowel
loops ,and also absence of bowel wall enhancement is the most important
specific parameter to diagnose ischemic changes. Historically acute Small
bowel obstruction was surgically operated relatively early, because of
difficulty of identification severity, strangulation on clinical and
conventional imaging grounds. Today with improved diagnostic modalities
and
resolution, some
obstructions can
resolve
with conservative
23
25
18
20
15
No.
15
11
13
10
5
0
<10
years
10-20
years
20-30
years
30-40
years
40-50
years
Age in years
50-60
60
years
60 and
above
No.
50
45
40
35
30
25
20
15
10
5
0
46
37
Male
Female
Sex
50
50
45
40
35
No.
30
25
18
20
15
10
8
6
5
0
Proximal
jejunum
Distal
Jejunum
Proximal
ileum
Distal
ileum
Not clearly
madeout
49
50
45
40
frequency
35
30
25
18
20
11
15
10
5
0
Proximal
jejunum
Distal ileum
Adhesions
Stricture
111
11
Tumors
Radiation enteopathy
32
Meckel's diverticulum
Foreign body
24
14
80
76
70
No.
60
50
40
30
20
10
0
Present
Absent
75
80
70
60
No.
50
40
30
20
10
0
Present
Absent
80
74
Viable
Gangrene
60
40
20
0
Viable
Gangrene
Surgical findings
Chart No .8 -Bowel
Bowel viability -comparison
comparison of CT and surgical findings .
78
80
77
80
Same as CT
70
Not
confirmation
with CT
No.
60
50
40
30
20
5
10
0
Level
Cause
Viability
Parameters
Image 2
Image 3
IMAGES 4 A& B: 40 Year old gentle man , case of Ca. rectum post abdominoperineal resection(APR) , presented with small
bowel obstruction because of adhesions ( Arrow pointing to the
adhesions of bowel loops to pelvic side walls)
Image 4a
Image 4b
Image 5a
Image 5b
Image 6a
Image 6b
Image 7a
Image 7b
Image 8a
Image 8b
Image 8c
IMAGES 9a , 9b & 9c 28 year old gentle man presented with
small bowel obstruction showing Left femoral hernia with dilated
bowel loops (Image 9c showing bowel loops in femoral triangle)
Image 9a
Image 9b
Image 9c
IMAGES 10a & 10b - 47 year old woman presented with small
bowel obstruction showing Stricture as cause ( arrows pointing to
stricture)
Image 10a
Image 10b
IMAGES 11a & 11b - 69 year old male patients presented with
small bowel obstruction showing Stricture as cause ( arrows
pointing to stricture)
Image-11a
Image-11b
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37.Savvas Nicolaou, Brian Kai, Stephen Ho et al. Imaging of Acute
Small-Bowel Obstruction. AJR 2005;185:10361044.
May-
Jun;9(5):690-4.
50.Balthazar EJ, Liebeskind ME, Macari M. Intestinal ischemia in
patients in whom small bowel obstruction is suspected: evaluation of
accuracy
limitations,
and
clinical
implications
of
CT
in
PROFORMA
NAME
AGE/SEX :
DATE
HOSP.NO :
ADDRESS :
COMPLAINTS & H/O PRESENT ILLNESS
CO-MORBID FACTORS
HELICAL CT FINDINGS
Bowel dilatation
Level of SBO
Cause of SBO
Parameters for Associated Ischemia
RECOMMENDATIONS
1. Helical CT should be the first imaging modality of choice in any case
of acute small bowel obstruction .
2. Always use I.V.Contrast studies to rule out bowel ischemia
3. If there is a disparity between CT findings and clinical situation,
deterioration of clinical condition always go for exploratory
laparotomy
4. Try to reduce radiation dosage to patient, by using new techniques&
different softwares.Try to get adequate information at a lower dose of
exposure.
5. Training doctors &CT technicians in management of contrast induced
side effects & emergencies.