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Intestinal Obstuction

Intestinal Obstuction. Hua-dan Xue 2008-11-30. Ileus (intestinal obstruction). Mechanical intestinal obstruction Simple obstruction ： occlusion/constriction of bowel lumen Strangulated obstruction ： impaired blood supply of obstructed segment Ileus (adynamic/non-obstructive)

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Intestinal Obstuction

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  1. Intestinal Obstuction Hua-dan Xue 2008-11-30

  2. Ileus (intestinal obstruction) • Mechanical intestinal obstruction • Simple obstruction：occlusion/constriction of bowel lumen • Strangulated obstruction：impaired blood supply of obstructed segment • Ileus (adynamic/non-obstructive) • Paralytic & spasm • Derangement impairing proper distal propulsion of intestinal contents Cautions to barium exam due to the possibility of obstruction aggravating

  3. Classification - location • Gastric outlet obstruction: • Only one/two air-fluid levels • Homogeneous mass displacing transverse colon • Duodenal obstruction: • Double-bubble sign; • Frequently normal due to absence of gas from vomiting

  4. Classification - location • Jejunal and ileal obstruction: • Candy cane: >3 loops+>3cm gas-fluid levels+>3~5 hours onset • Disparity in size between obstructed and normal loops • Little/no gas + stool in colon with complete mechanical obstruction after 12-24 hours • Stepladder appearance; string-of-bead; Cave: fluid-distended loops may lead one to overlook obstruction!!!

  5. Mechanical obstruction

  6. Classification - location • Colonic obstruction • Dilated colon only • Dilated small bowel (incompetent ileo-cecal valve) • Gas-fluid levels distal to hepatic flexure (fluid is normal in cecum and ascending colon) • Cecum most dilated portion (>10cm will be critical)

  7. Classification – location • Localized ileus • Causes: often associated with adjacent acute inflammatory process (acute pancreatitis, acute appendicitis, etc.) • Sentinel loop: loops near the local peritonitis • Closed-loop obstruction

  8. Closed-loop obstruction • Closed-loop obstruction • Fixation of bowel loop: • Coffee bean sign: gas filled loop • Pseudo-tumor: fluid-filled loop • U-shaped dilated bowel loop • Increasing intra-luminal fluid • Beak sign: point of obstruction • Whirl sign: twisting of bowel

  9. Closed-loop obstruction Large volvulus Beak sign

  10. Classification - etiology • 机械性肠梗阻 • 单纯性肠梗阻：肠管通畅性障碍 • 绞窄性肠梗阻：肠管通畅性障碍伴有血运障碍 • 动力性肠梗阻 • 麻痹性肠梗阻： • 痉挛性肠梗阻： • 血运性肠梗阻：肠系膜动脉血栓或栓塞所致 钡剂造影须慎重使用，钡剂吸收水分会加重梗阻

  11. 单纯性肠梗阻 • 阶梯状气液平 • 大跨度肠袢 • 鱼肋征

  12. 绞窄性肠梗阻Strangulated obstruction • Triad: • closed-loop obstruction of the involved segment (majority of cases) • Mechanical obstruction proximal to the involved segment • Venous congestion of the involved loop • Abdominal plain film : • signs for volvulus（肠扭转） or closed-loop obstruction + bowel thickening • CT has 63%~100% detection rate!!! • Poor/no enhancement of bowel wall • Mesenteric haziness due to edema

  13. 绞窄性肠梗阻 • 假肿瘤征： • 两端闭锁的绞锁肠段内充满大量液体，仰卧位呈肿块影，而站立位或侧卧位水平位片上则在该肿瘤块影上部见一短小的液面 • 咖啡豆征：闭襻 • 小跨度蜷曲肠襻：肠系膜增厚缩短 • 长液面征：张力低、血性液体 • 空回肠换位征：小肠扭转

  14. 肠扭转 • 小肠扭转：空回肠换位、花瓣样或香蕉样排列

  15. 麻痹性肠梗阻Ileus • Causes: • postoperative • intraabdominal inflammation • ischemic bowel disease • Large + small bowel ±gastric distension • Decreased small bowel distension in serial films • Delayed but free passage of contrast material

  16. Strangulated obstruction • Triad: • Closed-loop obstruction of the involved segment (majority of cases) • Mechanical obstruction proximal to the involved segment • Venous congestion of the involved loop • Abdominal plain film : • Signs for volvulus or closed-loop obstruction + bowel thickening • CT has 63%~100% detection rate!!! • Poor/no enhancement of bowel wall • Mesenteric haziness due to edema

  17. Comparison - Simple obstruction • Stepladder gas-fluid level • Large span loop • Fish-rib appearance

  18. Comparison - Strangulated obstruction • Pseudo-tumor • Coffee bean sign：closed loop • Small span loop：shortening of mesentery • Long gas-fluid level：low tension • Displacement of jejunum and ileum

  19. Volvulus • Small intestine volvulus： • displacement of ileum and jejunum, • banana-like flower-leaves-like form (representing the twisting bowel)

  20. Ileus (paralytic ) • Causes: • Postoperative • Intra-abdominal inflammation • Ischemic bowel disease • Large + small bowel ±gastric distension • Decreased small bowel distension in serial films • Delayed but free passage of contrast material

  21. Finding the reasons… • Post-operation • Infection • Intussusception • Thrombosis • Tumor (extrinsic and intrinsic bowel) • Congenital

  22. Intestinal obstruction • Modalities, Methods and indications 1、Plain abdominal film：acute perforation and obstruction of bowel 2、Barium enema：diagnose and therapy of obstructive disorders, e.g. intussusception, volvulus… 3、CT scan：all kinds of acute abdomen applicable. 4、B-us：solid organ trauma, peritoneal fluid collection, localized abscess, calculi & obstruction, intussusception, acute imflammation.

  23. references • Review manual • Primer of radiology

  24. The end

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