abdominal plain films
Post on 10-Jul-2016
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SBO vs Ileus/ partial SBO KUB
Heidi Ramos, PGY-2
Oakwood Hospital Radiology
Normal
• Normal Gas in Bowel – Always in stomach
– Two or three loops small bowel (<2.5cm)
– Almost always in rectum/ sigmoid (<6cm) (c<9cm)
• Normal Air Fluid Levels – Always in stomach
– Two or three in small bowel
– Never in colon
Small Bowel Obstruction
• X-ray findings:
– Bowel proximal to point of obstruction dilates – Swallowed air and continuous secreted fluid/ mucus
• Dilated sb >2.5 to 3 cm
• Air-fluid levels (think step ladder from left to right )
• Vomiting will release some proximal dilatation
– Bowel distal to point of obstruction collapses – Empties over time until collapse
• Absence/ paucity of gas in distal colon
Small Bowel Obstruction
• CT findings:
– Proximal
• Dilated, air/fluid filled loops
– Distal
• Collapsed bowel
– “Small Bowel Feces Sign”
• Air mixes with stagnant food bolus
Small Bowel Obstruction vs Ileus/ partial Small Bowel Obstruction
SBO Ileus
Etiology Prior surgery (weeks to yrs) Recent (hrs) post op
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent +/-
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
Ileus/ partial SBO
• Localized ileus
– Sentinel loop (s)
• One/two persistently dilated loops
• Gas in sigmoid/ rectum
• Generalized adynamic ileus
– Persistently dilated small and large bowel loops
– Post op inpatient (not an ER/ outpatient)
• Small bowel obstruction
– SB 5cm
– No distal gas
– Evidence of prior sx (sutures)
Small Bowel Obstruction
Paralytic/ Diffuse Ileus
• Post op Ileus – Evidence of surgical wound
– Air in distal colon
– Evidence of recent surgery
Small Bowel Ileus
• Focal Ileus
• Sentinel loop
– Patient with known acute pancreatitis
Obstruction (partial)
• Large Bowel Obstruction – Colon dilated to distal
descending
– Soft tissue density likely colon mass causing partial obstruction
– Not complete obstruction (air still in rectum)
Large Bowel Obstruction
• Sigmoid volvulus LBO
– “Coffee bean”
– Fixed point in left iliac fossa
– Bird’s Beak on BE
Large Bowel Obstruction
• Cecal volvulus LBO
– Massively dilated cecum
• Displaces small bowel
• SB now in RLQ (valvulae conniventes)
Bowel Inflammation
• Mucosal edema
– Distance between loops of bowel increased
– Haustral folds are very thick
• “thumbprinting”
Ulcerative Colitis vs. C. diff Pseudomembranous Colitis
• Toxic Megacolon – Dilated colon + Mucosal
Edema + Mucosal islands
Obstruction
• SBO
– SB dilated:
• Yes
– LB dilated:
• No
– Rectal air:
• No
– Other clues:
• Evidence sx
Gallstone Ileus
• SBO
– SB dilated:
• Yes
– LB dilated:
• No
– Rectal air:
• No
– Other clues:
• Round calcific density in RLQ/ TI
Rigler’s triad: Biliary gas SBO Gallstone
Obstruction
• SBO – SB dilated:
• Yes
– LB dilated: • No
– Rectal air: • No
– Other clues: • Air-fluid levels
– Too many/ stepladder
Small Bowel Obstruction
• Spot the transition point.
Focal Ileus
• Ileus – SB dilated:
• Yes, focal loop
– LB dilated: • No
– Rectal air: • Yes
– Other clues: • RLQ tenderness
– Acute appendicitis
Paralytic ileus
• SBO
– SB dilated:
• Yes
– LB dilated:
• Yes
– Rectal air:
• Yes
– Other clues:
• Inpatient / Recent Postop
F/u studies recovery time: Small intestine: 0-24h Stomach: 24-48h Colon: 48-72h
Large Bowel Obstruction
• Sigmoid volvulus: – Bird’s beak on BE
• Abrupt cut off
Large Bowel Obstruction
• LBO:
– Obstructing intraluminal mass
– “Apple Core” on plain film and BE
Obstructive Uropathy
• Uterine fibroid
– Degenerating (ca)
– Ureteral stent demonstrates not calcified bladder wall
• Tricked you: – This one’s GU
not GI!
Small Bowel Obstruction
• Spot the transition point.
Gastric Volvulus
• Last thing we think to volvuse
– Yes, if we use it in Radiology then it’s a word.
• Organoaxial makes a C shape.
• Mesoaxial twist to an 8 shape.
Gastric volvulus
• Presentation:
– Triad of Borchardt
• Severe sudden epigastric pain
• Intractable retching without vomiting
• Inability to pass NG tube
Gastric Volvulus
• Herniation of bowel into chest cavity.
• Note: two gastric air bubbles
• Need f/u Upper GI fluoroscopy study vs. CT ab/pelv WITH contrast to exclude other differentials such large abscess or esophageal diverticulum.
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