Fecal impaction: a cause of isolated small bowel dilatation on abdominal radiographs.

OBJECTIVE: The purpose of this study was to assess the frequency of isolated small bowel dilatation on abdominal radiographs in patients with colonic fecal impaction and also to elucidate the cause of this finding. METHODS: A computerized search of radiology files revealed 515 patients with colonic fecal impaction on abdominal radiographs. The radiologic reports described isolated small bowel dilatation not related to other known causes of ileus or obstruction in 18 (3.5%) of the 515 patients. The films were reviewed to determine the distribution of fecal impaction and the degree and extent of small bowel dilatation. In 16 cases, medical records were reviewed to determine the clinical presentation, treatment, and course. Finally, follow-up radiographs were reviewed in four cases to determine the response to treatment of the impaction. RESULTS: All 16 patients with available medical records had abdominal symptoms. The average diameter of the dilated small bowel on abdominal radiographs was 3.7 cm. Fourteen patients (78%) had a diffuse colonic fecal impaction (nine) or a predominantly right-sided fecal impaction (five) that involved the cecum, and the remaining four (22%) had a left-sided colonic fecal impaction. All 12 patients with clinical follow-up had resolution of symptoms and all four with follow-up radiographs had resolution of small bowel dilatation after treatment of the underlying impaction. CONCLUSION: Fecal impaction should be considered in the differential diagnosis of small bowel dilatation on abdominal radiographs, as treatment of the underlying impaction usually produces a dramatic clinical response with resolution of the small bowel dilatation on follow-up radiographs.     

The left lateral view in the plain-film assessment of abdominal distension.

Since the left lateral position facilitates the entry of air into the rectosigmoid, it has been employed in the plain-film evaluation of patients with abdominal distension. The value of this view is illustrated by examples of patients with (a) colonic ileus due to imipramine hydrochloride (Tofranil) or chlorpromazine, (b) partial mechanical obstruction due to diverticulitis, (c) involvement of the rectum by Hirschsprung's disease, and (d) sequential evaluation of a patient with clindamycin colitis. This simple maneuver is recommended for (a) evaluation of patients with plain-film evidence of low colonic obstruction, (b) problems of differential diagnosis between bowel obstruction and ileus, and (c) evaluation of patients with conditions affecting the rectosigmoid.     

Acute large-bowel pseudo-obstruction

The clinical and radiological features of acute large-bowel pseudo-obstruction occurring in 13 patients over a 7-year period are reviewed. Clinical features included atypical signs and symptoms of large-bowel obstruction and serious concomitant illness, including trauma in 10. The predominant radiological features were gross colonic dilatation, scant fluid levels, a gradual transition to collapsed bowel and a normal gas and faecal pattern in the rectum. Correct diagnosis was established by plain film and/or barium enema examination in the majority of cases (nine out of the 13). In the remaining four cases the diagnosis was made at laparotomy, although review of the radiographs suggested that the correct diagnosis could have been made pre-operatively in three. Instant barium enema is recommended in doubtful cases to rule out distal obstruction. Prompt recognition of the condition, with daily monitoring and conservative management, should eliminate unnecessary surgery and minimise the risk of caecal perforation.     

Colonic transit in spinal cord-injured patients

This report describes a study of transit time through the colon, as well as the caliber of the colon and distal small bowel, in 28 spinal cord-injured patients to see if there is a correlation between those findings and difficulty with bowel care and symptoms. In 15 of these 28 patients anorectal dynamic studies were also done. Each patient ingested 20 radiopaque markers, after which colon transit times were measured by multiple abdominal radiographs. The width of the ileum was measured and correlated with symptoms. The findings indicate that transit time was delayed in the left and rectosigmoid colon; four patients had a large and highly compliant rectum, whereas six had anorectal dyssynergia. All ten had difficulty with bowel care. The distal small bowel was dilated in ten patients, all of whom had symptoms and nine of whom had spinal cord lesions superior to T5.     

胆石性肠梗阻的CT诊断

目的:评价CT对胆石性肠梗阻的诊断价值。方法:回顾性分析5例经手术证实的胆石性肠梗阻患者的CT检查资料及临床表现。结果:所有病例CT表现均见肠腔内异位结石、肠梗阻、胆系积气及胆囊窝结构紊乱,1例显示腹腔游离积液,1例结石位于十二指肠降段,1例结石位于空肠,另3例结石位于回肠。结石呈圆形或椭圆形,直径2.5~5cm,梗阻以上肠管扩张,可见气液平,1例完全性肠梗阻病例梗阻以下肠管空虚。5例术前CT诊断准确率为100%。结论:胆石性肠梗阻有典型的CT表现,CT是胆石性肠梗阻的最佳方法。     

慢性HBV感染者剖宫产术后早期炎性肠梗阻相关因素分析

 目的 探讨慢性HBV感染者剖宫产术后早期炎性肠梗阻的相关因素及非手术治疗效果。方法 回顾性分析慢性HBV感染者剖宫产术后发生早期炎性肠梗阻8例临床资料,并选取慢性HBV感染者同期剖宫产40例作为对照,分析其相关因素及非手术治疗效果。结果 本组慢性HBV感染孕妇剖宫产术后肠梗阻发生率为1.4‰,采用非手术治疗后治愈;既往腹部手术史是慢性HBV感染者剖宫产术后早期炎性肠梗阻的单一危险因素,孕次、产次、孕周、胎儿体重、产后出血量、剖宫产手术时间、术后镇痛不增加肠梗阻的危险。结论 既往腹部手术史是慢性HBV感染者剖宫产术后早期炎性肠梗阻的危险因素,非手术治疗效果良好。     

Gastrointestinal complications of cytosine-arabinoside chemotherapy: findings on plain abdominal radiographs

We analyzed the findings on plain abdominal radiographs in 24 patients who had adverse gastrointestinal reactions after chemotherapy with cytosine-arabinoside (Ara-C) for treatment of acute leukemia or non-Hodgkin lymphoma. Ara-C was given with vincristine, VP 16-213, daunorubicin, amsacrine, adriamycin, or corticosteroids in various combinations and dosages. The abnormalities noted on plain abdominal radiographs included paralytic ileus (73%), cecal distension (38%), pneumatosis intestinalis (27%), thickened loops of small bowel (19%), and pneumoperitoneum (8%). One patient had small-bowel ileus simulating an obstruction. In 23%, death was directly related to gastrointestinal complications. Bowel wall erosions, necrosis, and transmural or submucosal hemorrhage were the main findings at autopsy. This experience suggests that plain abdominal radiographs are useful in the diagnosis of gastrointestinal complications associated with chemotherapy with Ara-C.     

结肠癌性肠梗阻的CT表现

目的确定肠梗阻的部位与病因，并讨论结肠癌的CT表现与检查方法。方法26例临床疑诊结肠癌患者包括手术病理证实的23例结肠癌和3例回盲区炎症术前均经全腹CT平扫，21例又经增强扫描，8例经多平面重建（MPR）检查。结果CT检查证实，结肠癌性肠梗阻表现为梗阻近端肠管扩张，梗阻远端肠管空虚，移行段（病变段）肠管不规则软组织肿块，肠壁增厚，肠腔不规则狭窄，局限性强化。典型者病变段肠管长轴切面可见类结肠造影表现：不规则狭窄肠管与正常肠管分界清楚，呈“肩样征”。26例中，术前3例结肠癌被漏诊，3例回盲区炎症被误诊为结肠癌，CT诊断结肠癌性梗阻的敏感性为87％，准确性为76％。结论全腹CT扫描，尤其MPR对判定结肠癌性梗阻部位与病因有较高的敏感性，并有助于术前临床分期。     

Prospective evaluation of ultrasound in distal ileal and colonic obstruction

AIM: To evaluate prospectively the usefulness of ultrasound in determining the site and cause of distal small bowel and colonic obstruction. MATERIALS AND METHODS: Ultrasound findings in 60 consecutive patients with suspected distal ileal or colonic obstruction were correlated with final surgical and radiological diagnoses. The diagnostic value of ultrasound was compared with plain abdominal radiography (AXR) for the presence and level of obstruction. RESULTS: Forty-five patients were confirmed to be obstructed. Ultrasound correctly identified obstruction in 44/45 and the cause in 36/45 (80%). Overall sensitivity of US for obstruction was 98% and specificity 80%, compared with 79% and 53% respectively for the AXR. CONCLUSION: Ultrasound is useful in determining the presence and cause of distal ileal and colonic obstruction.     

Gallstone ileus analysis of radiological findings in 27 patients

PURPOSE: We retrospectively compared the clinical value of plain abdominal film, abdominal sonography and abdominal CT in diagnosing gallstone ileus in 27 patients. MATERIAL AND METHODS: 27 patients (23 women and 4 men, age range 58-96 years; mean age 71.5 years) with surgically proven gallstone ileus were submitted to plain film, sonography and CT of the abdomen. Abdominal plain films were performed in 19 cases in upright position (postero-anterior projection), in eight cases in supine position. Abdominal US were performed with 3.5 and/or 7.5 MHz probes. CT was performed with a helical unit (slice thickness 4mm, reconstruction interval 4mm, pitch 1.5), after intravenous contrast agent (120 ml) infusion (3 ml/s, 55 s acquisition delay from bolus starting) and using a power injector. The following findings were searched on: pneumobilia, air in gallbladder, cholecysto-digestive fistula, extraluminal fluid, bowel loops dilatation, intestinal air-fluid levels, ectopic stones. RESULTS: Plain abdominal films showed the following findings: air-fluid levels (77.78% of cases), bowel loops dilatation (88.89%), site of obstruction (44.4%), pneumobilia (37.04%), air in gallbladder (3.70%), ectopic stone (33.33%). Abdominal sonography demonstrated bowel loops dilatation (44.44%), extraluminal fluid (14.81%), ectopic stones (14.81%), gallbladder abnormalities, (37.04%), pneumobilia (55.56%). CT findings retrospectively observed were: bowel loops dilatation (92.59%), air-fluid levels (37.04%), bilio-digestive fistula (14.81%), pneumobilia (88.89%), ectopic stone (81.48%), extraluminal fluid (22.22%). The Rigler's triad, that is pneumobilia, bowel mechanical obstruction and ectopic stone detection was observed 4 times with RX (14.81%), 3 times with US (11.11%) and 21 times with CT (77.78%). CONCLUSIONS: Air-fluid levels and bowel loop dilatation were the radiological findings more frequently observed in our series. Plain abdominal film allowed us mainly to identify signs of obstruction, US were more effective in disclosing biliary pathology, CT allowed us to correctly diagnose biliary ileus with much higher accuracy.     

The plain abdominal radiograph in acute gastrointestinal graft-vs.-host disease

The plain abdominal radiographs of 28 patients with acute gastrointestinal graft-vs.-host disease (GVHD) were examined to determine the plain radiographic findings associated with this disorder. These findings, in order of decreasing frequency, included air-fluid levels, bowel wall/mucosal fold thickening, gasless abdomen, bowel dilatation, pneumatosis intestinalis, and ascites. When a number of these findings are present, the plain abdominal radiographs may be sufficiently characteristic to suggest gastrointestinal GVHD. Differentiating acute gastrointestinal GVHD from small-bowel obstruction is often of major clinical importance. Fortunately, the bowel gas pattern in acute gastrointestinal GVHD rarely suggests obstruction and, thus, bowel obstruction can usually be excluded on the basis of plain radiographs alone.     

The relevance of free fluid between intestinal loops detected by sonography in the clinical assessment of small bowel obstruction in adults

INTRODUCTION: The main role of the radiologist in the management of patients with suspicion of small bowel obstruction is to help triage patients into those that need immediate surgical intervention from those that require medical therapy or delayed surgery. Ultrasound examination is usually considered not helpful in bowel obstruction because of air in the intestinal lumen that interferes the evaluation of the intestinal loops, however recently some Authors attested the increasing important role of sonography in the acute abdominal disease. Aim of our report is to demonstrate the value of free fluid detected by US in differentiating between low and high-grade small bowel obstruction. MATERIALS AND METHODS: The study is based on 742 consecutive patients who presented symptoms of the acute abdomen; all patients had undergone initial serial abdominal plain film and US examinations prior to any medical intervention. We reviewed the imaging findings of 150 cases in whom small bowel obstruction was clinically suspected and confirmed at surgery. We consider the following radiographic and US findings: dilatation of small bowel loops; bowel wall thickness; presence of air-fluid levels; thickness of valvulae conniventes; evidence of peristalsis; presence and echogenicity of extraluminal fluid. We looked at the value of extraluminal peritoneal fluid at US examination in differentiating low and high-grade small bowel obstruction based on the surgical outcome. RESULTS: In 46 patients altered peristaltic activity, thin bowel walls, fluid filled loops with hyperechoic spots in the bowel segment proximal to obstruction were noted at US, whereas radiographic features were: moderate dilatation of small bowel loops, with thin bowel wall and evidence of numerous and subtle valvulae conniventes; presence of air-fluid levels was also noted. In 70 other patients, US examination revealed all the findings described in the precedent cases and also the presence of free extraluminal fluid; abdominal plain film showed an increased dilatation of small bowel loops with moderate thickened wall and air-fluid levels. In 34 other patients US examination revealed the presence of thick-walled loops, hypoperistalsis and a larger amount of free extraluminal fluid. Radiographic findings in these patients were: horizontal featured and markedly dilated small bowel loops presenting parietal thickness, presence of intraluminal fluid stasis and evidence of thickened, sparse and incomplete valvulae conniventes. At surgery etiology of small bowel obstructions was various, but most of cases related to adhesions (70 cases). The presence of extraluminal fluid were confirmed at surgery in 104 patients. CONCLUSIONS: Our experience using sonography in suspicion of SBO (small bowel obstruction) suggests the usefulness of this imaging modality to differentiate a functional or obstructive ileus, demonstrating the evidence of intestinal peristalsis. Furthermore, the presence of a large amount of fluid between dilated small bowel loops suggests worsening mechanical small bowel obstruction, that requires not a medical therapy but immediate surgery.     

Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation

PURPOSE: To compare the diagnostic yield of abdominal radiography with that of computed tomography (CT) in adult patients presenting to the emergency department with nontraumatic abdominal pain. MATERIALS AND METHODS: Records of 1,000 consecutive patients presenting to the emergency department with acute abdominal pain from April to June 1998 were retrospectively reviewed. A total of 871 patients underwent abdominal radiography, and 188 underwent abdominal CT. The report interpretations of the abdominal radiographs and CT scans were divided into normal, nonspecific, and abnormal categories. Final discharge diagnoses were compared with the interpretations of the imaging examination results, and sensitivities and specificities of each modality were calculated and compared. RESULTS: Interpretation of abdominal radiographs was nonspecific in 588 (68%) of 871 patients, normal in 200 (23%), and abnormal in 83 (10%). The highest sensitivity of abdominal radiography was 90% for intraabdominal foreign body and 49% for bowel obstruction. Abdominal radiography had 0% sensitivity for appendicitis, pyelonephritis, pancreatitis, and diverticulitis. Sensitivities of abdominal CT were highest for bowel obstruction and urolithiasis at 75% and 68%, respectively. CONCLUSION: Abdominal radiographs are not sensitive in the evaluation of adult patients presenting to the emergency department with nontraumatic abdominal pain.     

Congenital anomalies of the small intestine, colon, and rectum.

Congenital anomalies of the gastrointestinal tract are a significant cause of morbidity in children and, less frequently, in adults. These abnormalities include developmental obstructive defects of the small intestine, anomalies of the colon, anomalies of rotation and fixation, anorectal anomalies, and intestinal duplications. Neonates with complete high intestinal obstruction do not usually require further radiologic evaluation following radiography, whereas those with complete low obstruction should undergo a contrast material enema examination. An upper gastrointestinal series must be performed in all patients with incomplete intestinal obstruction because management is different in each case. In low intestinal obstruction, ultrasonography (US) may help differentiate between small bowel obstruction and colonic obstruction. In addition, US can help correctly identify meconium ileus and meconium peritonitis and is useful in the diagnosis of enteric duplication cysts. In malrotation and anorectal anomalies, computed tomography (CT) and magnetic resonance (MR) imaging can provide superb anatomic detail and added diagnostic specificity. Intestinal duplications manifest as an abdominal mass at radiography, contrast enema examination, or US. At CT, most duplications manifest as smoothly rounded, fluid-filled cysts or tubular structures with thin, slightly enhancing walls. At MR imaging, the intracystic fluid has heterogeneous signal intensity on T1-weighted images and homogeneous high signal intensity on T2-weighted images. Familiarity with these gastrointestinal abnormalities is essential for correct diagnosis and appropriate management.     

Segmental dilatation of the small bowel: report of three cases and literature review

Segmental dilatation of the small bowel is a rare congenital abnormality that occurs mainly in children and produces significant nonspecific symptoms. The authors reviewed 33 cases reported in the literature and present three new cases in which the lesion was demonstrated on radiographs obtained before laparotomy. These cases showed the spectrum of symptoms and characteristic radiologic features of this condition in both plain abdominal radiographs and barium studies. Plain radiographs of the abdomen may show an isolated loop of bowel containing an air-fluid level. The characteristic finding in barium studies of the small bowel is a localized dilatation of the small bowel lumen with afferent and efferent loops. In the absence of a complication or coexistent cause of obstruction, the transit time of contrast medium through the small bowel is not delayed. The radiologic examination is useful in diagnosis, and the condition is cured with surgery.     

Small bowel obstruction: role and contribution of sonography

The purpose of this study was to determine whether sonography provides additional clinical information in patients suspected of small bowel (SB) obstruction. During a period of 30 months, in a prospective setting, we evaluated with sonography 123 patients suspected of SB obstruction. Sonographic examinations of the entire abdomen were performed with state-of-the-art, real-time, grey-scale equipment. Fourteen patients were labelled ’gassy' and no added information was provided following abdominal ultrasound. Sonography confirmed the SB obstruction in 82 cases with 5 false positives, resulting in a specificity of 82.1 %. Sonographic examinations were negative in 27 cases with 4 false negatives and a sensitivity of 95 %. The accuracy was 91.7 % when the ’gassy' patients were excluded and 81.3 % overall. The aetiology of the ileus was detected by sonography in 13 cases of paralytic ileus (54.1 %) and in 57 cases of mechanical ileus (71.4 %). It is concluded that ultrasound, which is a non-invasive, portable and even bedside imaging procedure, appears accurate in confirming a SB obstruction and in determining the aetiology of SB obstruction. Received: 22 March 1996; Revision received 30 December 1996; Accepted: 2 January 1997     

Radiological appearances of colonic ring staple anastomoses

The radiographic appearances of colonic staple ring anastomoses are presented. Staple ring disruption on plain abdominal radiographs in the early post-operative period suggests dehiscence of the bowel anastomosis and is an indication for urgent water-soluble contrast medium enema to confirm the diagnosis. Rectal stenosis can develop as a late complication of staple anastomosis and may be detected on barium enema.     

肠梗阻导管联合大承气汤治疗恶性肠梗阻的疗效观察

目的：观察肠梗阻导管联合大承气汤对恶性肠梗阻的疗效。方法2011年1月-2013年8月收治的恶性肠梗阻患者75例随机分成3组。各组在禁食水、反复清洁灌肠、抗感染、纠正水电解质和酸碱平衡紊乱、全胃肠外营养常规治疗基础上,对照Ⅰ组25例采用鼻导管治疗,对照Ⅱ组25例采用肠梗阻导管治疗,观察组25例采用大承气汤联合肠梗阻导管治疗。观察治疗3 d 和7 d 后,腹胀、腹痛例数,腹围缩小程度、累计胃肠减压量以及腹胀、腹痛缓解时间、恢复排气时间、气液平面消失时间、临床疗效。结果观察组治疗3 d 及治疗7 d 后,较两个对照组腹痛、腹胀例数均有明显减少（P ﹤0.05）,腹围缩小程度及胃肠累积减压量明显增加（P ﹤0.05）;观察组的腹胀、腹痛缓解时间、排气恢复时间及气液平消失时间均短于两个对照组（P ﹤0.05）;在治愈率及总有效率上,观察组明显高于两个对照组（P ﹤0.05）。治疗7 d 后,对照Ⅱ组的临床症状缓解率及总有效率均好于对照Ⅰ组（P ﹤0.05）。结论恶性肠梗阻患者用肠梗阻导管联合大承气汤后,可使肠道功能及早得到恢复,促进肠蠕动及毒素排出,缩短患者的住院时间,提高其生活质量,值得临床应用。     

Hyperirritable stomach as a cause of obstructive symptoms after sleeve gastrectomy: clinical and radiographic findings

PurposeTo characterize clinical and radiographic features of a hyperirritable stomach after sleeve gastrectomy.Materials/methodsRadiology reports revealed that 10/76 patients (13%) with obstructive symptoms after sleeve gastrectomy had a hyperirritable stomach.ResultsAll 10 patients presented with nausea, vomiting, and/or regurgitation. All 10 had emesis on barium studies in the absence of gastric outlet obstruction, gastroparesis, or small bowel obstruction/ileus. Five had extraintestinal causes of nausea/vomiting. Eight had improvement/resolution of symptoms on medical treatment.ConclusionIn 13% of patients with nausea/vomiting after sleeve gastrectomy, barium studies revealed a hyperirritable stomach, which likely is multifactorial and self-limited in most patients.     

Resolution of gallstone ileus with spontaneous evacuation of gallstone

Gallstone ileus (GSI) is a rare cause of small bowel obstruction (SBO). Even more extraordinary is the spontaneous evacuation of a gallstone, which has caused SBO. A 69-year-old gentleman presented with symptoms and signs of SBO. His plain abdominal X-ray revealed dilated loops of the small bowel and opacity in the region of the terminal ileum consistent with a diagnosis of GSI. Because of severe cardiorespiratory co-morbidities, the patient was treated conservatively and improved within 24 h. A CT scan revealed that the stone had passed into the rectum and was spontaneously evacuated. If the gallstone is <2.5 cm on CT scan, spontaneous evacuation is a real possibility and initial conservative treatment in a high-risk surgical patient is a consideration.