Imaging, 22 (2013), 55265914

GASTROINTESTINAL IMAGING

Post-surgical imaging of the intestines

A SLATER,

MRCP, FRCR

Radiology Department, John Radcliffe Hospital, Oxford, UK

Summary
CT is the most useful modality in patients who become ill immediately post-

operatively.
Free gas can normally be seen on CT up to 7 days after a laparoscopy or 4 weeks

after laparotomy.
MRI is useful for identifying fistulae and anastomotic leaks within the pelvis as the

structures do not move with respiration.

In patients with known adhesional disease, oral Grastrografin (diatrizoate

meglumine; Schering AG, Berlin, Germany) followed by an abdominal X-ray is

useful in selecting patients who can be managed conservatively.

doi: 10.1259/imaging/
55265914
2013 The British Institute of
Radiology

Cite this article as: Slater A. Post-surgical imaging of the intestines. Imaging 2013;22:55265914.

Abstract. Imaging has a vital role in the optimal

management of the post-operative patient. Careful selection of
modality and attention to detail of the technique according to
the clinical question being asked will result in increased
diagnostic accuracy and confidence. Accurate information
about what surgery has been performed should be obtained
before imaging is performed.

or ileus. This will be discussed later, but plain films

generally are difficult to interpret in this context.
An erect chest X-ray may show aspiration or pneumonia. The presence of free gas under the diaphragm is
difficult to interpret after surgery, and this is discussed in
the section on anastomotic leaks below.

Ultrasound
Imaging of the post-operative abdomen is a common
indication. Usually specific diagnoses are being considered, but often a patient will just be non-specifically unwell, and so the reporting radiologist must be familiar
with the common post-operative complications. Familiarity with the commonly performed surgical procedures
is also essential. It is extremely useful to have highquality information on the type of surgery that has been
performed, especially if this deviates significantly from
standard procedures. Often junior doctors are asked to
communicate the need for post-operative imaging to the
radiology department. All too often they do not have
access to this information, and imaging should not be
performed for this indication without accurate knowledge of what procedure has been performed.

Imaging modalities
Plain films
The plain abdominal film is generally only used to
determine the presence of mechanical bowel obstruction

This is of limited use post operatively. The presence of

intestinal obstruction may be surmised if hyperdynamic
distended bowel loops are seen, but usually bowel loops
that are distended from mechanical obstruction will
rapidly become paralytic and appear identical to an
ileus.
The presence of ascites is easy to diagnose on ultrasound, but its meaning is often difficult to interpret. Postoperative fluid collections such as abscess or haematomata
can be seen on ultrasound, but this modality is much less
sensitive than CT or MRI. This is due to the field of view
of ultrasound being limited by overlying dressings, free
peritoneal gas and gas within bowel loops. This is especially a problem if there is a post-operative ileus and there
are many gas-filled distended bowel loops present. Even
if an abscess is seen on ultrasound, it is difficult to be
certain that this is the only one. Conversely, abnormally
dilated bowel loops may be mistaken for abscesses on
ultrasound, and this mistake is easier to make than with
other modalities. Ultrasound is useful in specifically looking
for a subphrenic post-operative collection in someone who
is hiccuping.

CT
Address correspondence to: Dr Andrew Slater, Radiology Department, John Radcliffe Hospital, Headley Way, Oxford OX3
0LY, UK. E-mail: andrew.slater@orh.nhs.uk

imaging.birjournals.org

This is by far the most useful modality for imaging postoperative abdominal complications. Specific indications
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will be discussed below, but this is generally the most

accurate test for anastomotic leaks, fluid collections and
bowel ischaemia. Intravenous contrast would normally be
used unless there is a contraindication, and oral contrast is
often very useful to differentiate abscess from bowel and
to show anastomotic leaks. Rectal contrast is very useful
for demonstrating anastomotic leaks beyond the splenic
flexure of the colon.

MRI
This modality is of great use in the pelvis, owing to the
limited movement of the pelvic structures. Post-operative
leaks from rectal anastomoses and pelvic fluid collections
are often well seen using MRI. Its use elsewhere in the
abdomen is limited owing to movement artefact, and
generally CT is used instead. In very young patients, in
whom it is desirable to avoid radiation, MRI can be used
to look for large post-operative fluid collections.

Figure 2. Sagittal CT image showing fine curvilinear highattenuation material representing a stapled anastomosis
(arrow).

Fluoroscopy
Fluoroscopic X-ray imaging in combination with
endoluminal contrast is frequently used to identify postoperative complications, especially an anastomotic leak,
and to differentiate mechanical obstruction from ileus. Its
use will be discussed under these headings. In almost all
cases barium is contraindicated if there is any chance of
an anastomotic leak or bowel perforation, and an iodinated water-soluble contrast agent should be used instead.

Normal post-operative appearances of the

small bowel
Anastomoses
An anastomosis is a surgical joining of two hollow
organs. In the following text this will refer to the intestines, with biliary anastomoses being referred to in a different section. Hand-sewn anastomoses can be impossible

to visualise post-operatively, unless there is distortion of

the fold pattern or an obvious anatomical abnormality
such as an end-to-side anastomosis (Figure 1). Stapled
anastomoses are seen on fluoroscopy and CT as a line or
ring of fine curvilinear pieces of metal (Figure 2). On MRI
they will produce a signal void, so can be difficult to
perceive. Some end-to-side anastomoses have quite
a large blind-ending pouch on the side part of bowel.
Care is needed to ensure that this is not erroneously diagnosed as an anastomotic leak.

Strictureplasties
A strictureplasty is a surgical procedure usually used
in Crohns disease. It involves refashioning a stricture
to widen the lumen, while avoiding the loss of length of
small bowel that would occur if the stricture was
simply resected. Thus the result of the procedure may
not be visible on subsequent imaging, or there may be
a distorted segment, sometimes with an isolated surgical clip next to the intestine. A variant of this, the
Michelassi strictureplasty, involves a long side-to-side
anastomosis of two strictured segments of small bowel.
The intention is to relieve obstruction without loss of
surface area of small bowel, although length will be
reduced.

Roux-en-Y anastomosis

Figure 1. Barium follow-through examination of the small

bowel. An end-to-side ileo-colic anastomosis is seen (long
arrow) with a redundant side branch of colon (short arrow).
This is a hand-sewn anastomosis, so suture material is not
identified.
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This is where an end of small bowel is anastomosed

onto the side of another loop of small bowel, thus producing a Y configuration. It is named after the Swiss
surgeon who first described it. It is performed in bariatric surgery and in surgery to the distal stomach or
duodenum. A limb bringing bile and pancreatic secretions is joined on to the small bowel that is carrying oral
intake. Owing to the direction of peristalsis oral contrast
will not usually pass into the Roux loop that is carrying
bile, and so this will not be normally visualised on
fluoroscopic studies. Even the site of the anastomosis
can be difficult to see.
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Post-surgical imaging of the intestines

Figure 3. Oral water-soluble contrast examination of the

upper gastrointestinal tract in a patient who has had an
oesophagectomy and formation of a gastric pull-through.
The oesophagogastric anastomosis is seen (long arrow), as is
a leak of contrast outside the lumen (short arrow). There is
a nasogastric tube in situ, seen in outline.

Post-operative complications
Anastomotic leak
An anastomosis is a surgical joining of two hollow
organs. Failure of an anastomosis is usually due to ischaemia of the tissue at the join. This is especially
a problem for a gastric pull-through after an oesophagectomy where the arterial supply to the stomach has
been interfered with, and the anastomosis may be in the
superior mediastinum, a long way from the arterial origin
at the coeliac axis. Anastomotic leaks are also relatively
common in the rectum owing to the difficulties of surgery
deep within the pelvis. The consequences of an anastomotic leak depend upon the nature of the leaking luminal
contents, and where these contents are leaking into. A

Figure 4. A water-soluble contrast enema in a patient who

has had a colorectal anastomosis. A small, localised leak is
seen from the anastomosis (arrow). This was successfully
managed conservatively.

imaging.birjournals.org

Figure 5. A CT performed without luminal contrast. There

has been a colonic resection and there is a leak from the end
of the long rectosigmoid remnant. A discontinuity in the
staples can be clearly seen with a small amount of free gas
next to this (arrow).

leaking anastomosis from a gastric pull-through after an

oeosphagectomy can be very serious, as saliva, gastric
secretions and food pass into the mediastinum (Figure 3).
Conversely a leak from a low rectal anastomosis into
a contained cavity in the presacral may be relatively
minor, especially if there is a covering stoma that diverts
the faecal stream (Figure 4). Occasionally complete dehiscence of an anastomosis is seen with separation of the
joined organs, but much more common is a small leak,
which can be easy to miss on imaging if careful attention
is not paid to technique.
End-to-side intestinal anastomoses can produce a redundant side branch of bowel (sometimes called a dog
ear) that can be mistaken for a leak.
Anastomotic leaks can be detected directly by contrast
that is seen to pass out of the lumen on CT or fluoroscopy.
Alternatively a leak may be seen directly as a discontinuity
in the anastomotic ring on CT or MR (Figure 5). Indirect
detection of anastomotic leaks is via the presence of free
peritoneal gas, or gas and fluid collections.
For any gastric or small bowel surgery, positive oral
contrast with a dilute iodinated contrast is very helpful in
CT scanning. For oesophageal surgery, positive oral
contrast should include a cupful swallowed just before
the scan. Some practitioners would also advocate the
patient holding a mouthful of contrast and swallowing it
when the scanner asks them to breathe in.
For surgery to the right colon oral contrast should be
used for CT scans, for at least 40 min. Peristalsis may be
slow in sick post-operative patients, and it may be justified to repeat a CT after a delay of a further 1 h or more to
wait for contrast to reach the anastomosis. For surgery to
the left colon and rectum, rectal contrast should be used.
This can be inserted via a 12-French Foley catheter.
Smaller catheters will be of adequate calibre, but often do
not have enough stiffness to pass through the anal canal
easily. If there has been surgery to the anus or anorectal
junction, it may be preferable to ask someone from the
surgical team to insert the tube, although the chances of
complications from such a soft tube are extremely remote.
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Figure 6. (a) Axial T2 weighted fat-saturated MRI of a small

bowel pouch in the pelvis. A high signal track (short arrow)
extends posteriorly from the pouch (long arrow), indicating
an anastomotic leak. (b) Same case as (a) on a water-soluble
contrast enema. The leak is again clearly demonstrated
(arrow).

150 ml of dilute iodinated contrast is used, or to the limits

of the patients tolerance.
MRI can be used for detection of anorectal leaks owing
to the limited movement of the pelvic structures. Luminal
contrast is usually not used due to the high inherent soft
tissue contrast of MRI. The integrity of the anastomosis
can be directly assessed, and gas and fluid collections are
easily identified (Figure 6). The downsides of MRI are
that there is limited availability out of hours, it is difficult
for patients who require monitoring and if a fluid collection is identified, one cannot proceed directly to imageguided drainage.
Fluoroscopy with contrast is generally only used for
anorectal, sigmoid anastomosis or oesophagogastric
anastomoses. Fluoroscopy has the advantage over CT
that several images can be acquired over time, and in
different positions; an anastomotic leak may only be
revealed when a patient turns into a specific position. For
lower tract surgery, a Foley catheter is used in the anus.
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The balloon should not be blown up unless anal laxity

means that contrast cannot be kept in the rectum. Blowing up the balloon may damage a low anastomosis, or
may cover the opening to a leak, meaning that it is not
diagnosed.
CT and fluoroscopy are probably equal in detecting
oesophageal anastomosis leaks. Fluoroscopy has the advantage that images can be acquired with the patient in
different positions. CT has the advantage of being able to
examine the anastomosis directly for integrity, and that
the gas and fluid collections associated with a leak can be
detected. Usually barium contrast agents are contraindicated if there is any chance of an anastomotic leak or
a bowel perforation. However, if the initial water-soluble
contrast agent examination is normal, there is some evidence that repeating the examination with barium will
increase the sensitivity of the examination for small
oesophageal anastomotic leaks. A small amount of barium in the mediastinum seems to be well tolerated, unlike
barium in the peritoneum, which requires surgical washout [1].
There are several published studies looking at the accuracy of imaging in detecting anastomotic leaks, but
most are small and retrospective. Doeksen et al [2] looked
at 91 patients that had radiological evaluation for a possible anastomotic leak after colorectal surgery. The reference standard was consensus of clinical/surgical
findings. The imaging used was heterogeneous, rather
than a single standardised test. They calculated a sensitivity of 65% and a negative predictive value of 73%.
These percentages seem to be lower in the early postoperative period (,7 days) and in proximal anastomoses.
No complications of rectally administered contrast were
observed. Nicksa et al [3] retrospectively studied 36
patients who were re-operated for colorectal anastomotic
leakage, and found false-negatives in 3/18 contrast enemas (17%) and 14/27 CT scans (52%), implying that
contrast enemas are more accurate. DuBrow et al [4] described 16 patients with a clinical anastomotic leakage,
and reported that four imaging studies (25%) were initially misinterpreted. Akyol et al [5] studied 233 patients
who underwent left-sided colonic or colorectal anastomoses. Water-soluble contrast enema was routinely used
in the early post-operative period. Compared with subsequent clinical outcome, there was a false-negative rate
of 22% (11 of 51 patients with anastomotic leakage).
Lim et al [6] looked at outcomes from 23 low rectal
leaks after surgery. An extraluminal cavity or an anastomotic stricture on contrast enema predicted poor healing. Over a median period of 17 months, all subclinical
leaks healed on conservative management with serial
examination with water-soluble contrast enema. Only 4
out of 13 clinical leaks healed. They commented that
healing on water-soluble contrast enemas began early,
but was slow to complete.
Indirect detection of anastomotic leaks may be by the
presence of peritoneal gas, or gas and fluid collections.
Clearly free gas is a normal finding after laparotomy, but
for how long is it acceptable to see free gas within the
peritoneum after laparotomy? Power et al [7] reported
free air as a normal finding 12 days after laparotomy,
and loculated air as a normal finding for up to 26 days.
Cho and Baker [8] agreed, reporting that a post-operative
pneumoperitoneum could last for up to 4 weeks. An
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Post-surgical imaging of the intestines

increase in the amount of, rather than the presence of, free
air was found to be significant. Laparoscopy generally
involves the introduction of a smaller amount of gas, and
usually this is carbon dioxide, which is absorbed faster
than air. Millitz et al [9] studied patients following laparoscopic cholecystectomy, and stated that there should be
no free gas at 7 days. Nielsen et al [10] reported that postoperative pneumoperitoneum was resolved in most
cases following laparoscopic cholecystectomy in 2 days.
There are several types of fluid collections associated
with anastomotic leaks. These are listed as follows, with
those that are most likely to be infected or represent fluid
from a leak first, and those least likely last:

walled collection, gas and fluid

walled collection, fluid only
localised ascites
ascites with peritoneal enhancement
ascites without peritoneal enhancement.

Fistula
Where does fistula connect to?
A fistula is an abnormal communication between two
epithelialised surfaces; in the context of previous intestinal
surgery, this is usually between large or small bowel and
skin. This is a serious complication of intestinal surgery.
They usually occur on the anterior abdominal wall, but
perineal, gluteal or lumbar fistulae may also occur. They
may occur as a result of the direct effects of Crohns disease, although this would not usually be in the immediate
post-operative period, as it is assumed that active areas of
disease would have been resected. Fistulae may occur
from a leaking anastomosis, or from bowel that has been
punctured inadvertently at surgery, possibly without
realising it. If there is obstruction in the bowel this can
trigger the formation of a fistula, and sustain its existence
owing to increased intraluminal pressure.

For abdominal wall fistulae, CT is usually the first-line

investigation since it can provide a great deal of information about the site of the fistula and any associated
abscesses, and the presence of bowel obstruction can be
inferred from dilated bowel loops. Oral contrast is of
great benefit in delineating the fistula. If oral contrast
does not reach the fistula at the time of the CT, consideration can be given to delayed imaging or fluoroscopic
fistulography. The latter describes introducing watersoluble iodinated contrast into the fistula. A Foley catheter of size appropriate to the hole is gently introduced
into the fistula and water-soluble contrast is gently
injected (Figure 7). If the catheter persistently falls out of
the fistula, or contrast pours back out onto the skin, the
balloon on the Foley can be gently inflated to occlude the
lumen. Fistulography is most useful if performed after
CT, as the comprehensive anatomical information from
the CT can be combined with the dynamic fluoroscopic
images. Clearly, contrast can also be introduced into the
fistula immediately before a CT is performed (CT fistulography). Often patients with complex fistulae after
an abdominal catastrophe are transferred to specialist
institutions for management, and it is mandatory to attempt to obtain old imaging. Often this will obviate the
need for extensive repeat imaging.
MRI is usually the first-line imaging for pelvic fistulae.
The excellent contrast resolution will usually enable
a fistula to be diagnosed without intraluminal contrast.
Fistulae will be seen as abnormal tracks of high signal on
T2 extending from the bowel lumen to a different organ
or skin (Figure 8).

Is there distal obstruction?

Management of a fistula is usually conservative, but is
dependent upon good nursing care and nutrition. Lowoutput fistulae (,500 ml output per day) are expected to
close spontaneously assuming that there is not distal obstruction or active Crohns disease. As the bowel distal to
a fistula is usually collapsed, it is often necessary to perform a contrast study to rule out mechanical obstruction. It

Figure 7. A fluoroscopic fistulogram. A Foley catheter has

been placed into the efferent limb of an enterocutaneous
fistula. The balloon has been inflated in this case (long
arrow). Water-soluble contrast has filled the small bowel.
This distal small bowel is dilated down to the level of a kink,
representing an adhesion (short arrow).

imaging.birjournals.org

Figure 8. Sagittal T2 weighted MRI of the pelvis in a patient

who has had formation of a pelvis small bowel pouch. A Yshaped high-signal fistula track is seen (arrow) extending
from the pouchanal anastomosis to the skin and to the
urethra.

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can take more than one attempt to identify the distal limb
of bowel supplying the fistula. Generally for small bowel
fistulae, it is desirable to image from the small bowel all
the way to the colon.

Length of bowel for feeding

For patients with fistulae high in the small bowel,
a feeding tube can be inserted into the fistula to provide
nutrition. This is useful to avoid long-term use of total
parenteral nutrition (TPN) via central veins, which has
many complications. The TPN team will make this decision based upon the length of small bowel distal to the
fistula after exclusion of distal obstruction. The length can
be determined by CT, or by fluoroscopic fistulography as
described above. It is usually said that 1 m of small bowel
is needed to avoid TPN [11].
Post-operative abdominopelvic abscesses
Ultrasound is reasonably good at detecting abdominal
abscesses. If an abscess contains a lot of gas, it can be
difficult to identify its true nature, rather than free gas, or
gas in a distended viscus. It can be difficult to distinguish
an abscess from distended bowel, or bowel that is abnormal after surgery. Ultrasound may miss deep pelvic
abscesses or abscesses hidden behind normal gascontaining bowel. In general CT is much more useful
for detecting abscesses in the post-operative patient, although ultrasound should still be attempted first in
young, slim patients. This author would never attempt to
drain an abscess under ultrasound guidance without
having first having seen CT images; this is first to confirm
the presence of an abscess and to ensure a safe puncture
track, and second to ensure there are no other, larger
abscesses than may be occult on ultrasound. Ultrasound
guidance can be safely used for collections that are peripheral, abdominal, large and have little gas.
As described above, MRI is good at detecting pelvic
abscesses, although one cannot proceed directly to
drainage. CT is the best examination for detecting
abdominopelvic abscesses (Figure 9). It is fast, robust and
can easily be performed on unstable patients. The

Figure 10. Coronal CT after laparoscopic surgery. There is

a large right-sided intra-abdominal haematoma, which
extends through the right-sided laparoscopy port site (short
arrow). In addition small bowel has herniated through the
left-sided port site (long arrow).

radiologist may proceed directly to image-guided drainage if desired.

Pitfalls include haematomata, which are common postoperatively. These will usually have high-attenuation
material within them on CT (.30 HU). This will be high
attenuation even on scans performed without intravenous contrast (Figure 10). However, blood in the
peritoneal cavity will be diluted and the high attenuation
may only be apparent in a dependent pool (e.g. in the
pelvis). With time, haematomata will become lower
attenuation (around 10 HU or lower) and have an enhancing wall. Clearly these are very difficult to distinguish from abscesses, and a judgement must be made
using clinical factors to guide.
Odd-looking bowel can also cause confusion after
surgery; it may be dilated owing to ileus, mechanical
obstruction or the effects of surgery. Small bowel strictureplasties or Roux-en-Y anastomoses can produce segments of dilated small bowel that can superficially
resemble an abscess. Positive oral contrast will help to
distinguish bowel lumen from abscess. If oral contrast is
slow to move through the post-operative bowel, a repeat
CT after an interval of 1 h or more may be justified. Close
examination of the course of the intestines using thin
slices and multiplanar reformats will usually reveal the
answer. Power et al [7] compared abscesses post
anastomotic leak with abscesses from other causes. The
only distinguishing feature was perianastomotic fluid
containing gas, but this was not specific and no cases
showed leak of contrast.
Percutaneous drainage of fluid collections using image
guidance can be attempted once detected. This is done
using a Seldinger technique. Complications of this procedure include:

Figure 9. Axial CT showing two large pelvic fluid collections

haemorrhage
bowel perforation
fistula (this is generally a late complication of bowel

(arrows). The contents are of low attenuation with enhancing walls. Aspiration demonstrated frank pus.

introduction of infection

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perforation)

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failure

of treatment of sepsis due to catheter

displacement
communication with gastrointestinal tract or biliary
system
wrong antibiotics.
Singh et al [12] examined patients who had undergone percutaneous abscess drainage for diverticulitis and found that 38% developed fistulae. Only 2
(13%) were enterocutaneous; others were colovesical (3)
and colovaginal (1). They reported that the mean duration of drainage was 8 days and the long-term stoma
rate 13%.
Buckley et al [13] reported a postal survey of UK
practice. 70% reported that radiology took no further part
in management after catheter placement, in contradistinction to the United States, where it is standard practice
for radiologists to manage drains and undertake ward
rounds. This may be influenced by the different methods
of payment for these radiologists. In the same paper,
Buckley et al also studied 63 drains in 45 patients over
7 months at their UK institution. There were two major
complications, one immediate septic shock and one
bowel perforation leading to an enterocutaneous fistula.
In a review of the literature, they found that there was no
hard evidence to support flushing or irrigation of drains.
Percutaneous drainage of fluid collections is usually
through the anterior abdominal wall. Care must be taken
to avoid puncturing the intestines, or damaging the inferior epigastric artery. The transgluteal approach may be
used for deep pelvic collections. This is performed under
CT guidance with the patient prone. It was first described
by Butch et al [14]. The preferred course is below the
sacrospinous ligament, as close to the sacrum as possible
(Figure 11). This route has specific complications of sciatic
nerve injury and formation of a gluteal abscess from
tracking. It can be painful despite local anaesthesia, especially if a transpiriformis approach is used. Endocavitatory drainage (vagina or rectum) is reserved for deep
pelvic collections with no clear percutaneous route. It is
ultrasound guided, using an endocavitatory probe and
a needle guide.

Mechanical obstruction
Post-operative ileus and differentiation from mechanical obstruction
This refers to poor peristalsis after surgery, which can
occur for a variety of causes, or be idiopathic. It has
a benign course and is managed conservatively, but differential from mechanical bowel obstruction can be difficult. Its diagnosis relies upon excluding mechanical
obstruction. In both ileus and mechanical obstruction,
dilated gas-filled loops of small bowel with diameters
greater than 3.5 cm for proximal small bowel and 2.5 cm
for ileum may be seen on plain radiographs. Small bowel
has bowel wall folds that extend across the whole bowel
wall, in contrast to large bowel. If the bowel loops are
predominantly fluid filled then they may not be visible
on radiographs. If there is mechanical obstruction then
there will be a transition point between dilated and
collapsed bowel (Figure 12). If there is no apparent abnormality at this point on CT or MRI, then the cause is
assumed to be adhesional. Dilated, fluid bowel loops
with vigorous but non-effective peristalsis (to-and-fro
motion of contents) may be seen in mechanical obstruction on ultrasound. However, if obstruction is established, then the bowel may become atonic. The small
bowel faeces sign indicates luminal contents that have
a speckled appearance like large bowel contents
(Figure 12). When associated with small bowel dilatation
this is very specific for mechanical small bowel obstruction [15].
Barium fluoroscopy should generally be avoided in the
emergency investigation of high-grade bowel obstruction, since barium may take a very long time to reach the
level of obstruction, the patient is likely to vomit a significant amount of it and dilution by fluid within the
lumen will limit interpretation. In cases where the diagnosis of adhesional small bowel obstruction is strongly
suspected from plain films/CT, but it is unclear whether

Figure 12. Coronal CT showing dilated proximal small bowel.

Figure 11. Prone axial CT image from a patient with a pelvic
fluid collection. A needle is seen approaching the collection
posteriorly, adjacent to the sacrum.

imaging.birjournals.org

A transition point from dilated to collapsed small bowel is

indicated at the long arrow, where there is a 180 kink. The
dilated small bowel just proximal to this shows the small
bowel faeces sign (short arrow). At laparotomy this case was
found to be an adhesion.

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Figure 13. A radiograph taken 4 h after drinking 100 ml oral

Figure 15. Oral barium fluoroscopic study of the small

diatrizoate meglumine (Gastrografin; Schering AG, Berlin,

Germany). This patient has had a colectomy and ileo-rectal
anastomosis, and small bowel adhesions were suspected.
However, at 4 h contrast has reached the rectum (arrow).

bowel. There is an end-to-end ileo-colic anastomosis with

a stricture (arrow).

conservative management will be successful, a modified

technique is described as follows: the patient drinks
100 ml diatrizoate meglumine (Gastrografin; Schering AG,
Berlin, Germany) and plain abdominal films are taken at
1 h and 4 h. If contrast has not reached the colon at 4 h,
then this suggests high-grade small bowel obstruction
requiring surgical management (Figure 13) [16]. Gastrografin has a very high osmolarity and will draw fluid into
the bowel, which may have a therapeutic effect in lowgrade adhesional disease.

Adhesions
Adhesions are scar tissue forming on and around the
bowel after surgery. They can be asymptomatic or can
cause bowel obstruction to varying degrees. At imaging

they can be seen as a change in direction of the small

bowel together with luminal narrowing (Figure 12). This
is most obvious on fluoroscopic imaging when compression using a paddle can show immobility of this part
of the bowel. If the degree of obstruction is such that the
proximal bowel is dilated, then this will make the adhesion much more obvious. A cine sequence on MRI of
the small bowel is very helpful at identifying adhesions,
as their fixity and absent peristalsis becomes more
obvious.

Internal hernia
Internal hernias as post-operative complications occur
when a defect has been left in the mesentery after intestinal surgery. Bowel can pass through this defect, and
become obstructed or strangulated as with any other
hernia. Their identification in imaging relies upon a history of previous bowel surgery and showing a loop of

Figure 14. Internal hernia after gastric bypass surgery. The

margins of a defect in the small bowel mesentery are shown
by the thin arrows. A large segment of small bowel has
passed through this hole, and its mesentery is engorged
(thick arrow). The proximal small bowel is dilated, indicating
bowel obstruction.

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Figure 16. Rectal water-soluble contrast enema in a patient

who has had a colorectal anastomosis. A stricture is seen at
the site of the anastomosis (arrow).
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Post-surgical imaging of the intestines

small bowel held at a fixed point that does not correspond to the normal hernia orifices (Figure 14).

Anastomotic stricture
Strictures frequently form at an anastomosis, usually
due to ischaemia causing scarring weeks to months after
the operation. An anastomosis that has leaked is prone to
stricture formation if the leak has been treated conservatively and has not been revised (Figures 15 and 16).
Hernia to port site or incision
Small bowel may form a hernia through the abdominal
wall scar with conventional laparotomy or laparoscopy.
CT or MRI can makes this diagnosis with ease
(Figure 10). It is more difficult with fluoroscopy and
usually requires careful use of oblique and lateral views.

References
1. Upponi S, Ganeshan A, DCosta H, Betts M, Maynard N,
Bungay H, et al. Radiological detection of postoesophagectomy anastomotic leak: a comparison between
multidetector CT and fluoroscopy. Br J Radiol 2008;81:5458.

2. Doeksen A, Tanis PJ, Wust

AF, Vrouenraets BC, van
Lanschot JJ, van Tets WF. Radiological evaluation of colorectal anastomoses. Int J Colorectal Dis 2008;23:8638.
3. Nicksa GA, Dring RV, Johnson KH, Sardella WV, Vignati
PV, Cohen JL. Anastomotic leaks: what is the best diagnostic imaging study? Dis Colon Rectum 2007;50:
197203.
4. DuBrow RA, David CL, Curley SA. Anastomotic leaks after
low anterior resection for rectal carcinoma: evaluation with
CT and barium enema. AJR Am J Roentgenol 1995;165:
56771.
5. Akyol AM, McGregor JR, Galloway DJ, George WD. Early
postoperative contrast radiology in the assessment of

imaging.birjournals.org

6.

7.

8.
9.

10.

11.
12.

13.

14.

15.

16.

colorectal anastomotic integrity. Int J Colorectal Dis 1992;7:

1413.
Lim M, Akhtar S, Sasapu K, Harris K, Burke D, Sagar P,
et al. Clinical and subclinical leaks after low colorectal
anastomosis: a clinical and radiologic study. Dis Colon
Rectum 2006;49:161119.
Power N, Atri M, Ryan S, Haddad R, Smith A. CT assessment of anastomotic bowel leak. Clin Radiol 2007;62:
3742.
Cho KC, Baker SK. Pneumoperitoneum: diagnosis and significance. Radiol Clin North Am 1994;32:82944.
Millitz K, Moote DJ, Sparrow RK, Girotti MJ, Holliday RL,
McLarty TD. Pneumoperitoneum after laparoscopic cholecystectomy: frequency and duration as seen on upright chest
radiographs. AJR Am J Roentgenol 1994;163:8379.
Nielsen KT, Lund L, Larsen LP, Knudsen P. Duration of
postoperative pneumoperitoneum. Eur J Surg 1997;163:
5013.
Davidson J, Plumb A, Burnett H. Adult intestinal failure.
Clin Radiol 2010;65:395402.
Singh B, May K, Coltart I, Moore NR, Cunningham C. The
long-term results of percutaneous drainage of diverticular
abscess. Ann R Coll Surg Engl 2008;90:297301.
Buckley BT, Goodwin M, Boardman P, Uberoi R. Percutaneous abscess drainage in the UK: a national survey and
single centre study. Clin Radiol 2006;61:5564.
Butch RJ, Mueller PR, Ferrucci JT Jr, Wittenberg J, Simeone
JF, White EM, et al. Drainage of pelvic abscesses through the
greater sciatic foramen. Radiology 1986;158:48791.
Mayo-Smith WW, Wittenberg J, Bennett GL, Gervais DA,
Scott Gazelle G, Mueller PR. The CT small bowel faeces sign:
description and clinical significance. Clin Radiol 1995;50:
7657.
Joyce WP, Delaney PV, Gorey TF, Fitzpatrick JM. The value
of water-soluble contrast radiology in the management of
acute small bowel obstruction. Ann R Coll Surg Engl 1992;
74:4225.

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