CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:130 –139
CLINICAL IMAGING
Small-Bowel Obstruction: State-of-the-Art Imaging and Its Role in Clinical
Management
DEAN D. T. MAGLINTE,* THOMAS J. HOWARD,‡ KEITH D. LILLEMOE,‡ KUMAR SANDRASEGARAN,* and
DOUGLAS K. REX§
*Department of Radiology, ‡Division of General Surgery, and the §Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
Small-bowel obstruction (SBO) is a common clinical con-
dition with signs and symptoms similar to other acute
abdominal disorders. The radiologic investigation of pa-
tients with SBO as well as the indications and timing of
surgical intervention have changed over the past 2 decades.
This review focuses on modern imaging techniques and
their role in both the diagnosis and treatment of patients
with SBO.
S mall-bowel obstruction (SBO) remains a difficult clinical
entity to accurately diagnose and treat.1,2 Advances in ab-
dominal imaging coupled with the development of more ver-
satile nasointestinal tubes have led to innovative changes in
the evaluation and treatment of patients in whom SBO is
suspected.3 Although controversies remain in both the diagno-
sis and treatment of patients with SBO, radiologic imaging
remains a cornerstone in guiding clinical decision making.3–7
This review article focuses on advanced radiologic methods of
examination and their use in both the diagnosis and treatment
of patients with SBO.
Clinical Overview
The etiology of SBO has shifted over the past 5 decades
from predominately hernias to adhesions, Crohn’s disease, and
malignancy as the top 3 causes of SBO in Western society.8 –11
Hernias still represent the predominant cause of SBO in some
developing countries. Crohn’s disease just recently has been
recognized as a leading cause of SBO in the surgical literature,
a fact long suspected by many radiologists and gastroenterolo-
gists.10,11
Patients with SBO present clinically with abdominal pain,
distension, nausea, and vomiting. These signs and symptoms
mimic other intra-abdominal emergencies from which SBO
must be distinguished.4,5,8,12–16 Physical examination often re-
veals mild to moderate dehydration, tachycardia, abdominal
distension with tympany to percussion, and high-pitched tin-
kling or rushing bowel sounds. Mild abdominal tenderness is
common, but localized tenderness or peritoneal signs are indic-
ative of intestinal compromise and these patients are best
treated by emergent surgery. Laboratory investigations reveal a
mild to moderate leukocytosis, electrolyte level abnormalities,
and an increased blood urea nitrogen\creatinine ratio, and
occasionally increased amylase levels, which can mimic acute
pancreatitis.
In patients with suspected SBO, radiographic imaging plays
a central role in confirming the diagnosis and based on these
findings; in helping to choose the appropriate therapy. Simple
mechanical SBO can be treated safely using a trial of medical
management that includes nasoenteric decompression, intrave-
nous fluid hydration, and serial abdominal radiography. His-
torical data in patients with surgically proven strangulation
showed that the preoperative diagnosis based on clinical and
laboratory data, abdominal plain films, and monoslice comput-
erized tomography (CT) scanning is reliable in only 15% to 50%
of patients.15,17–19 Based on these reports, there have been ad-
vocates for early surgical management in all patients with SBO
because of the uncertainty in diagnosing strangulation and the
high complication rate associated with delayed surgical inter-
vention in this setting.10,20,21 Despite these concerns, current
mortality rates for patients with SBO is only 1% to 2%, suggest-
ing that the vast majority of patients do not have strangulated
obstruction and the risks associated with nonsurgical manage-
ment are acceptable provided immediate surgery is available if a
patient fails to improve or develops signs and symptoms of
intestinal compromise.22–27 Recent literature has shown that
even patients with high-grade mechanical SBO can resolve
spontaneously with nonsurgical management using nasointes-
tinal decompression, further supporting an even-handed ap-
proach to this complex problem.28 –31
Radiologic Investigations
Plan Film Examination (Abdominal
Radiography)
In SBO, abdominal radiographs are diagnostic in only
50% to 60% of cases.1,2,32 A critical analysis of plain film findings
shows a sensitivity of only 66% in proven cases of SBO, and in
21% of these patients their plain films were reportedly nor-
mal.1,32,33 In patients, identified as having abnormal but non-
specific plain film findings, 13% had low-grade and 9% had
high-grade obstructions, findings that have been confirmed in a
recent investigation.34 Despite these limitations, plain film ra-
diographs remain the initial imaging study in almost all pa-
tients with suspected SBO.2,33 Abdominal radiography has a low
Abbreviations used in this paper: CT, computerized tomography; MR,
magnetic resonance; SBO, small-bowel obstruction.
© 2008 by the AGA Institute
1542-3565/08/$34.00
doi:10.1016/j.cgh.2007.11.025