Computed Tomography (CT) allows detecting different
aspects of small bowel pathology in course of
mechanical obstruction, principally correlated to
circulatory disturbances, giving useful indications for a
surgical treatment

Amorico M

Donatiello S.

Manco G

Manenti A

Vezzelli E

English

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia

Article ID: WMC003459                                                                                                                ISSN 2046-1690Small Bowel Mechanical Occlusion and ComputedTomography Severity Indicators: What to Look forCorresponding Author:Dr. Antonio Manenti,Associate Professor, Department Surgery - ItalySubmitting Author:Dr. Antonio Manenti,Associate Professor, Department Surgery - ItalyOther Authors:Dr. Maria Grazia Amorico,Assistant Professor, Radiology - University Modena - ItalyDr. Gianrocco Manco,Surgical Registrar, University of Modena - ItalyDr. Elena Vezzelli,Resident in Radiology, Radiology - University Modena - ItalyDr. Salvatore Donatiello,Resident in Radiology, Radiology - University Modena - ItalyArticle ID: WMC003459Article Type: Original ArticlesSubmitted on:07-Jun-2012, 01:02:54 PM GMT    Published on: 08-Jun-2012, 02:15:03 PM GMTArticle URL: http://www.webmedcentral.com/article_view/3459Subject Categories:RADIOLOGY Keywords:Small Bowel Occlusion, Computed Tomography, Intestinal Wall PathologyHow to cite the article:Manenti A, Amorico M, Manco G, Vezzelli E, Donatiello S. Small Bowel MechanicalOcclusion and Computed Tomography Severity Indicators: What to Look for. WebmedCentral RADIOLOGY2012;3(6):WMC003459Copyright: This is an open-access article distributed under the terms of the Creative Commons AttributionLicense(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal author and source are credited.Source(s) of Funding:NoneCompeting Interests:NoneWebmedCentral Peer Reviewed: NoWebmedcentral > Original Articles Page 1 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMSmall Bowel Mechanical Occlusion and ComputedTomography Severity Indicators: What to Look forAuthor(s): Manenti A, Amorico M, Manco G, Vezzelli E, Donatiello SAbstractComputed Tomography (CT) allows detecting differentaspects of small bowel pathology in course ofmechanical obstruction, principally correlated tocirculatory disturbances, giving useful indications for asurgical treatment.IntroductionThe small bowel mechanical obstruction is a complexclinical situation , with different  clinical aspects, oftencorrelated to the grading of ileal loops pathology.Patients with intestinal occlusion, still constitute adifficult and vexing problem for the surgeon, in order toarrive to a precise diagnosis, and to an appropriatetherapeutic decision. The value of CT in the diagnosisof intestinal occlusion is universally admitted, oftenpermitting to determine the site and cause of theobstruction (1-8). Our aim was to extend the CT studyto detect morphological aspects of the ileal loopscorrelated to this pathology, and to severity of theobstruction.MethodsWe retrospectively reviewed 25 cases, 14 men and11women, aged between 23 and 74 years, observedin the years 2009-2011, with small bowel mechanicalocclusion, secondary to a fibrous band or mattedadhesions, excluding patients with pre-existinggastroenterologic diseases or per i tonealcarcinomatosis. In all a contrast enhanced CT wasperformed. We considered the following pre-definedmorpho log ica l  c r i te r ia ,  cor re la ted  w i thphysio-pathological conditions, in order to value theintrinsic severity of the obstruction, distinguishing 4classes :1. contrast-enhanced hyper-density of the ileal loops,corresponding to an early vasodilatation, necessary fortheir hyper-peristalsis (Illustration 1);2. evident dilatation of ileal loops, 3 times or more thannormal, corresponding to a muscular wal lde-compensation, and persisting endoluminalhypertension (Illustration 2);3. mural thickening of more3 mm, with preservedcontrast hyper-enhancement of the mucosa,corresponding to increased capillary permeability andsecondary mucosa oedema (Illustration 3); 4. attenuated contrast enhancement of the ileal loopsand mesenteric oedema, corresponding to animpending circulatory insufficiency (Illustration 4).Coronal reformatted images were helpful andcomplementary to axials to improve reader confidence(9-10).All the patients had a subsequent surgical procedure,whose results were considered the standard ofreference.ResultsIt is evident the gradual worsening, through theaforementioned four classes of the CT signs of ilealobstruction, towards a condition of insufficient vascularsupply. The following percentages were calculatedconsidering, for a single case, the most advancedsymptoms:Class 1= 9 cases (36%);Class 2 = 10 cases (40%);Class 3 = 4 cases (16%);Class 4 = 2 cases (8%).The feeble numeric percentage of cases found in class3 and 4 corresponded to the necessity of a previousemergency treatment, imposed by critical clinicalconditions. These results were compared with those ofa control group of combined large and small bowelobstruction, where no important signs of ileal loopspathology could be seen, except their dilatation.DiscussionIn case of small bowel mechanical occlusion, theassociation of different morpho-pathological signs in asingle case is common; usually the more advancedsign is the result of the progressive passage troughthe previous stages, indicating the worsening of thedisease. The morphological criteria distinguishing theafore mentioned Class 4 can further aggravatetowards a condition of absent contrast enhancement inWebmedcentral > Original Articles Page 2 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMthe i leal loops, secondary to their parietaloverdistension and to compression of the capillarynetwork. Impending severe ischemia and danger ofperforation follows, with the subsequent diagnosis ofacute secondary peritonitis. Our proposed correlationsbetween morphological and physio-pathologicalindicators of the severity of intestinal obstruction wereperformed with the guide of CT. Similar studies,always  based on signs of secondary vascularpathology, demonstrated the CT value in particularconditions, as intestinal volvulus, or whirl of one or twoileal loops (11-16). We extended this “vascularinterpretation” to different other CT signs, interestingthe small bowels loops proximally to the site of amechanical obstruction. The subsequent clinicalimplications are clear: fluid sequestration in the abdominal compartment, possible evolution towards acondition of severe ischemia with impending danger ofparietal pneumatosis, bacterial translocation,aeroportitis, and also small bowel perforation. Thevenous mesenteric congestion in course of ilealmechanical obstruction was just the subject of ourrecent report (17). Here we recall attention to thedifferent CT grades and aspects of intrinsic intestinalwall pathology, chiefly based on secondary vascularalterations, and usefully addressing to a promptdiagnosis. Nevertheless, in case of small bowelocclusion, we must always admit that the finaldiagnosis and surgical indication must consider all theclinical, laboratory and radiological signs. Thecondition of combined large and small gut occlusiondoes not induce so important and early pathologicalchanges in the small bowels, probably because of itsless acute onset and slower increasing distension.Conclusion(s)Contrast enhanced CT permits to demonstrate thedifferent, often progressive, graded stages of ilealbowel pathology in course of mechanical occlusion,giving important elements for an accurate diagnosis.The present study confirms the great value of CT indetecting important aspects of small bowel pathology,correctly examining their circulatory secondary lesions.Reference(s)1. Furukawa A., Yamasaki M., Furuichi K. et al. HelicalCT in the diagnosis of small bowel obstruction.Radiographics 2001;21:341-355.2. Maglinte D.D.T., Kelvin F.M., Sandrasegaran K. etal. Radiology of small bowel obstruction: contemporaryapproach and controversies. Abdom.Imaging2005;30:160-178.3. Qalbani A., Paushter D.,  Dachman A.H.Multidetector row CT of small bowel obstruction.Radiol.Clin.North Am. 2007; 45:499-512.4. Desser T.S., Gross M. Multidetector row computedt o m o g r a p h y  o f  s m a l l  b o w e lobstruction.Sem.UltrasoundCTMRI 2008; 29: 308-321.5. Aufort S., Charra L., Lesnik A.et al. Multidetector CTof bowel obstruction:the value of post-processing.Eur.Radiol. 2005; 15:2323-2329.6. Petrovic B., Nikalaidis P.,HammondN.A. et al.Identification of adhesions on CT in small bowelobstruction. Emerg.Radiol. 2006; 12:88-93.7. Silva A.C., Pimenta M., Guimaraes L.S. Smallbowel obstruction: what to look for. Radiographics2009; 29:423-439.8. Delabrousse ., Lubrano J., Jehl J. et al. Small bowelobstruction from adhesive bands and mattedadhesions: CT differentiation. AJR Am.J.Roentgenol.2009; 192:693-697.9. Filippone A., Cianci R., Storto M.L. Bowelobstruction: comparison between mutidetector-row CTaxial and coronal planes. Abdom. Imaging 2007; 32310-316.10. Hodel J., Zins M., Desmottes L. et al. Location ofthe transitional zone in CT of small-bowel obstruction:added value of  mult ip lanar reformat ions.Abdom.Imaging 2009; 34: 35-41.11. Duba J.B., Bhatt S., Dogra V. Utility of CT whirlsign in guiding management of small-bowelobstruction. AJR Am.J.Roentgenol. 2008;191:743-747.12. Mallo R.D., Salem L., Lalami T. et al. Computedtomography diagnosis of ischemia and completeobstruction in small bowel obstruction: a systematicreview. J.Gastrointest. Surg. 2005; 9: 690-694.13. Kim J.H., Ha H.K., Kim J.K. et al. Usefulness ofknown computed tomography and clinical criteria fordiagnosing strangulation in small-bowel obstruction:analysis of true and false interpretation groups incomputed tomography. World J.Surg. 2004; 28: 63-68.14. Jancelewicz T., Vu L.T., Shawo A.E. Predictingstrangulated small bowel obstruction: an old problemrevisited. J. Gastrointest. Surg. 2009;13:93-99.15. Catel L. Lefèvre F., Lauren V. et al. Small bowelobstruction from adhesions: which CT severity criteriato research? [in French] J.Radiol.2003; 84:27-31.16. SheedyS.P, Earnest F.IV, Fletcher J.G. et al. CT ofsmall-bowel ischemia associated with obstruction inemergency department patients : diagnosticperformance evaluation. Radiology 2006; 241:729-736.17. Manenti A., Amorico M., Manco G., et al. Venouscongestion in acute mechanical intestinal obstruction:Webmedcentral > Original Articles Page 3 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMa computed tomography guided study.WebmedCentralSURGERY  2012;3(5):WMC003411.Webmedcentral > Original Articles Page 4 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMIllustrationsIllustration 1Marked contrast hyper-enhancement of a jejunal loop, proximal to an occluding fibrous band.Enormous cyst of the left kidney upper pole.Illustration 2Ileal loops well dilated, with evident parietal contrast enhancement.Webmedcentral > Original Articles Page 5 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMIllustration 3Parietal thickening of small bowels with still preserved vascular network.Illustration 4Oedema of the mucosa of the ileal loops, with a reduced vascular network.Webmedcentral > Original Articles Page 6 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMReviewsReview 1Review Title: Small Bowel Mechanical Occlusion and Computed TomographySeverity IndicatorsPosted by Dr. Faycal Kharfi on 11 Nov 2012 06:22:10 PM GMTWhat are the main claims of the paper and how important are they?: Small Bowel Mechanical Occlusion and Computed Tomography Severity Indicators.No the claims are not novel:1. Mourad Boudiaf et al., CT Evaluation of Small Bowel Obstruction, RadioGraphics, May 2001, 21, 613-624.2. Tracy A. Jaffe et al., Small-Bowel Obstruction: Coronal Reformations from Isotropic Voxels at 16-SectionMulti-Detector Row CT, J. Radiology, 2006, 23, 8:1 135-1423. Ana Catarina Silva et al., Small Bowel Obstruction: What to Look For1 RadioGraphics March 1, 2009, 29:2423-439.4. Eric Delabrousse et al., Small-Bowel Obstruction from Adhesive Bands and Matted Adhesions: CTDifferentiation Am. J. Roentgenol. March 1, 2009, 192:3 693-697.YesYes relatively.If a protocol is provided, for example for a randomized controlled trial, are there any important deviationsfrom it? If so, have the authors explained adequately why the deviations occurred? The protocol (method) is a simple and standard one.Yes relativelyGiving more details on the investigation protocol and followed method.Giving more details on the investigation protocol and followed method.Rating: 5Comment: No commentsCompeting interests: NoInvited by the author to make a review on this article? : NoHave you previously published on this or a similar topic?: NoReferences: Experience and credentials in the specific area of science: RadiologyHow to cite: Anonymous.Small Bowel Mechanical Occlusion and Computed Tomography SeverityIndicators[Review of the article 'Small Bowel Mechanical Occlusion and Computed Tomography SeverityIndicators: What to Look for ' by ].WebmedCentral 1970;3(11):WMCRW002327Webmedcentral > Original Articles Page 7 of 8WMC003459 Downloaded from http://www.webmedcentral.com on 22-May-2014, 06:00:02 PMDisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview, contents posted on this web portal do not undergo any prepublication peer or editorial review. It iscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions beforesubmitting any information that requires obtaining a consent or approval from a third party. Authors should alsoensure not to submit any information which they do not have the copyright of or of which they have transferredthe copyrights to a third party.Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater tothe needs of an individual patient. The web portal or any content(s) therein is neither designed to support, norreplace, the relationship that exists between a patient/site visitor and his/her physician. Your use of theWebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harmthat you may suffer or inflict on a third person by following the contents of this website.Webmedcentral > Original Articles Page 8 of 8

Small Bowel Mechanical Occlusion and Computed Tomography Severity Indicators: What to Look for

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Small Bowel Mechanical Occlusion and Computed Tomography Severity Indicators: What to Look for

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