Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction

Chronic nausea and vomiting: a diagnostic approach

INTRODUCTION

Chronic nausea and vomiting (CNV) are commonly encountered symptoms in medical practice. CNV is the presenting symptom in a variety of gastrointestinal and non-gastrointestinal disorders. However, in a significant percentage of patients without an obvious underlying cause, CNV poses a significant diagnostic challenge to the evaluating physician.

AREAS COVERED

A comprehensive clinical history and physical examination form the foundation for further diagnostic work-up. In the present review, we discuss the diagnostic approach to CNV, highlighting the epidemiology, pathophysiology, causes, and modes of evaluation of this condition. Specific investigations, carefully guided by clinical assessment and tailored for each patient, would be more beneficial in diagnosing CNV than empirically performing a blanket of investigations.

EXPERT OPINION

Whilst CNV remains a historically challenging diagnostic and therapeutic dilemma, research into this topic is limited. Hence, there is a growing call for more research into diagnostic modalities for CNV. With scientific advancement and further research, it is hoped that easy-to-use, cheap, noninvasive novel diagnostic modalities for CNV will be available soon.

ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction

Small-bowel obstruction is a common cause of abdominal pain and accounts for a significant proportion of hospital admissions. Radiologic imaging plays the key role in the diagnosis and management of small-bowel obstruction as neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management. This document focuses on the imaging evaluation of the two most commonly encountered clinical scenarios related to small-bowel obstruction: the acute presentation and the more indolent, low-grade, or intermittent presentation. This document hopes to clarify the appropriate utilization of the many imaging procedures that are available and commonly employed in these clinical settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnostic utility of CT for small bowel obstruction: Systematic review and meta-analysis

BACKGROUND

To perform a systematic review and meta-analysis evaluating the diagnostic performance of computed tomography (CT) for small bowel obstruction (SBO), including diagnostic accuracy, ischemia, predicting surgical intervention, etiology and transition point.

METHODS

PubMed/MEDLINE and related databases were searched for research articles published from their inception through August 2018. Findings were pooled using bivariate random-effects and summary receiver operating characteristic curve models. Meta-regression and subgroup analyses were performed to evaluate whether publication year, patient age, enhanced CT, slice thickness and pathogenesis affected classification accuracy.

RESULTS

In total, 45 studies with a total of 4004 patients were included in the analysis. The pooled sensitivity and specificity of CT for SBO were 91% (95% confidence interval [CI]: 84%, 95%) and 89% (95% CI: 81%, 94%), respectively, and there were no differences in the subgroup analyses of age, publication year, enhanced CT and slice thickness. For ischemia, the pooled sensitivity and specificity was 82% (95% CI: 67%, 91%) and 92% (95% CI: 86%, 95%), respectively. No difference was found between enhanced and unenhanced CT based on subgroup analysis; however, high sensitivity was found in adhesive SBO compared with routine causes (96% vs. 78%, P = 0.03). The pooled sensitivity and specificity for predicting surgical intervention were 87% and 73%, respectively. The accuracy for etiology of adhesions, hernia and tumor was 95%, 70% and 82%, respectively. In addition, the pooled sensitivity and specificity for transition point was 92% and 77%, respectively.

CONCLUSIONS

CT has considerable accuracy in diagnosis of SBO, ischemia, predicting surgical intervention, etiology and transition point.

Detection of Transition Zone in Bowel Obstruction via Curved Multiplanar Reformations with Multidetector Computed Tomography

Objective

We conducted this study to determine the added value of curved multiplanar reformations (CMPR) and multiplanar reformations (MPR) of multidetector computed tomography (MDCT) scan in the visualization and localization of the zone of transition in patients with intestinal obstruction.

Materials and methods

A total of 100 patients with suspected bowel obstruction were evaluated in a retrospective cross-sectional study from September 2016 to September 2018 at Dr. Ziauddin University Hospital, Clifton Campus. All patients underwent multidetector computed tomography (CT) scans with oral and intravenous contrast before surgical exploration. CMPR and MPR were acquired at the time of examination in each patient in addition to routine axial images. The CT scans were analyzed by two independent, experienced radiologists skilled at detecting the zones of transition in patients with bowel obstruction using the axial images alone, followed by axial images along with MPR, and then MPR plus CMPR. Patient data were masked to the radiologists. The CT scan findings were compared with surgical findings to determine the accuracy of CMPR in detecting the zone of transition between distended and collapsed bowel loops. The added CMPR showed high accuracy in the diagnosis of intestinal obstruction with a remarkable advantage over the conventional axial images. Data analysis was done on IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Cohen’s kappa statistics were obtained to show the measure of agreement between the two readers. McNemar’s test was also applied to determine the homogeneity.

Results

Two radiologists, one with two years of experience and the other with five years of experience were 80% and 81% accurate, respectively, in identifying the zones of transition using axial images alone. Using axial images plus MPR, their accuracy was 88% and 92%, respectively. Using MPR plus CMPR, their accuracy was 96% and 98%, respectively. The accuracy of MPR plus CMPR views was significantly increased when compared to the accuracy using axial images alone. CT findings were compared to surgical findings in terms of diagnostic performance. The kappa value of 0.6 indicates moderate association and substantial agreement between two radiologists. McNemar’s test showed homogeneity in the number of valid cases.

Conclusion

CMPR is an important and accurate technique for evaluating intestinal obstruction in addition to MPR as it helps in better localization of the zone of transition and in determining the cause of obstruction. This insight provides guidance for the appropriate treatment.

Chronic nausea and vomiting: evaluation and treatment

Nausea is an uneasy feeling in the stomach while vomiting refers to the forceful expulsion of gastric contents. Chronic nausea and vomiting represent a diverse array of disorders defined by 4 weeks or more of symptoms. Chronic nausea and vomiting result from a variety of pathophysiological processes, involving gastrointestinal and non-gastrointestinal causes. The prevalence of chronic nausea and vomiting is unclear, although the epidemiology of specific conditions, such as gastroparesis and cyclic vomiting syndrome, is better understood. The economic impact of chronic nausea and vomiting and effects on quality of life are substantial. The initial diagnostic evaluation involves distinguishing gastrointestinal causes of chronic nausea and vomiting (e.g., gastroparesis, cyclic vomiting syndrome) from non-gastrointestinal causes (e.g., medications, vestibular, and neurologic disorders). After excluding anatomic, mechanical and biochemical causes of chronic nausea and vomiting, gastrointestinal causes can be grouped into two broad categories based on the finding of delayed, or normal, gastric emptying. Non-gastrointestinal disorders can also cause chronic nausea and vomiting. As a validated treatment algorithm for chronic nausea and vomiting does not exist, treatment should be based on a thoughtful discussion of benefits, side effects, and costs. The objective of this monograph is to review the evaluation and treatment of patients with chronic nausea and vomiting, emphasizing common gastrointestinal causes.

Surgeon attitudes and practice patterns in managing small bowel obstruction: a qualitative analysis

BACKGROUND

Historical training instructs surgeons to, "never let the sun set on a small bowel obstruction (SBO)" due to concern for bowel ischemia. However, the routine use of computed tomography scans for ruling out ischemia provides the opportunity for trial of nonoperative management, allowing time for resolution of adhesive SBO. In light of advances in practice, little is known about how surgeons manage these patients, in particular, whether there is consistency in the stated duration for safe nonoperative management.

METHODS

Using a case vignette (a patient with computed tomography scan diagnosed complete SBO without bowel ischemia), we interviewed a purposive sample of general surgeons practicing in Washington State to understand stated approaches to clinical management. Interview questions addressed typical practice, preferred timing of surgery, and approach. We conducted a content analysis to understand current practice and attitudes.

RESULTS

We interviewed 15 surgeons practicing across Washington State. Surgical practice patterns for patients with SBO varied widely. The period of time that surgeons were willing to manage patients nonoperatively ranged from 1-7 d. Interviews revealed insight into surgical decision-making, the importance of patient preferences, variation in practice, and evidence gaps. All surgeons acknowledged a lack of evidence to support appropriate management of patients with SBO.

CONCLUSIONS

Interviews with practicing surgeons highlight a changing paradigm away from routine early surgery for patients with adhesive SBO. However, there is lack of consensus in the appropriate duration of nonoperative management and practices vary considerably. These revealed attitudes inform the feasibility and design of future randomized studies of patients with adhesive SBO.

Operative versus non-operative management of adhesive small bowel obstruction: A systematic review and meta-analysis

OBJECTIVES

To investigate outcomes of operative and non-operative management of adhesive small bowel obstruction (SBO).

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of operative versus non-operative management of patients with adhesive SBO. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We found one RCT, two prospective and three retrospective observational studies, enrolling a total of 876 patients. The analyses showed that operative management of adhesive SBO was associated with a lower risk of future recurrence [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.38-0.76, P = 0.0005] but a higher risk of mortality [risk difference (RD) 0.03, 95% CI 0.01-0.06, P = 0.01] and complications (OR 5.39, 95% CI 2.97-9.78, P < 0.00001). There was no difference in need for surgical re-intervention rate (OR 0.72, 95% CI 0.35-1.47, P = 0.36) and length of stay [mean difference (MD) 5.07, 95% CI -2.36-12.49, P = 1.0] between operative and non-operative managements. The baseline suspicion of strangulation was a major confounding factor. When the baseline suspicion of strangulation was higher in the operative group, the risk of mortality (RD 0.04, 95% CI 0.02-0.07, P = 0.0006) and complications (OR 8.14, 95% CI 4.16-15.94, P = 0.00001) were higher in the operative group but the risk of recurrence was lower (OR 0.62, 95% CI 0.43-0.90, P = 0.01). When the baseline suspicion of strangulation was low in both groups, there was no difference in any of the outcomes except recurrence (OR 0.09, 95% CI 0.02-0.37, P = 0.0009) which was lower in the operative group.

CONCLUSIONS

The difference in baseline suspicion of strangulation between operative and non-operative groups is a major confounding factor in current literature. The benefit of surgical treatment should be balanced with the risks associated with surgery, patient's co-morbidities, and presence or absence of strangulation. Based on the best available evidence it could be argued that surgical intervention could be preserved for cases with high suspicion or evidence of bowel strangulation. The controversy still remains for optimum length of conservative management and timing of surgery (early or late) for cases with low baseline suspicion of strangulation. Randomised controlled trials are required to compare outcomes of early operation (<24 h) versus late operation (>24 h) and early operation versus conservative management in patients with low suspicion of strangulation.

Laparoscopy for Small Bowel Obstruction Caused by Single Adhesive Band

Background and Objectives:

There are still concerns about the comparative outcomes of operative treatment (OT) and conservative (nonsurgical) treatment (CT) for small bowel obstruction (SBO), especially that caused by single adhesive bands. We performed a retrospective study to compare surgical with nonsurgical outcomes.

Methods:

A total of 62 patients were enrolled. The OT group underwent laparoscopy (n = 16), and the CT group (n = 46) did not. We compared early and late outcomes between the 2 groups.

Results:

Times to first flatus, oral intake, and defecation after treatment were shorter in the OT group (P = .030, .033, and .024), and the recurrence rate was lower in the OT group than in the CT group (6.2% vs 32.6%; P = .038). Time from discharge to first recurrence was longer in the OT group than in the CT group (172 vs 104.6 ± 26.5 days, P = .027).

Conclusions:

SBO related to a single adhesive band is not effectively treated by CT. However, laparoscopic OT provides notable success if the surgery is performed early. Therefore, it should be the preferred treatment.

Atraumatic splenic rupture and ileal volvulus following cocaine abuse

We present the case of a 38-year-old male with an atraumatic splenic rupture, hemoperitoneum, and ileal volvulus following acute cocaine intoxication. Computed tomography showed a "whirl sign", a subcapsular splenic hematoma with suspected peripheral laceration, and diffuse hemoperitoneum. At laparotomy, the spleen was confirmed to be the source of bleeding and was removed. A nonreducible volvulus was found at the distal ileum, and this segment of small bowel was removed. The patient had an uneventful postoperative recovery.

Clinical outcome in acute small bowel obstruction after surgical or conservative management

BACKGROUND

Small bowel obstruction (SBO) is characterized by a high rate of recurrence. In the present study, we aimed to compare the outcomes of patients managed either by conservative treatment or surgical operation for an episode of SBO.

METHODS

The outcomes of all patients hospitalized at a single center for acute SBO between 2004 and 2007 were assessed. The occurrence of recurrent hospitalization, surgery, SBO symptoms at home, and mortality was determined.

RESULTS

Among 221 patients admitted with SBO, 136 underwent a surgical procedure (surgical group) and 85 were managed conservatively (conservative group). Baseline characteristics were similar between treatment groups. The median follow-up time (interquartile range) was 4.7 (3.7-5.8) years. Nineteen patients (14.0 %) of the surgical group were hospitalized for recurrent SBO versus 25 (29.4 %) of the conservative group [hazard ratio (HR), 0.5; 95 % CI, 0.3-0.9]. The need for a surgical management of a new SBO episode was similar between the two groups, ten patients (7.4 %) in the surgical group and six patients (7.1 %) in the conservative group (HR, 1.1; 95 % CI, 0.4-3.1). Five-year mortality from the date of hospital discharge was not significantly different between the two groups (age- and sex-adjusted HR, 1.1; 95 % CI, 0.6-2.1). A follow-up evaluation was obtained for 130 patients. Among them, 24 patients (34.8 %) of the surgical group and 35 patients (57.4 %) of the conservative group had recurrent SBO symptoms (odds ratio, 0.4; 95 % CI, 0.2-0.8).

CONCLUSIONS

The recurrence of SBO symptoms and new hospitalizations were significantly lower after surgical management of SBO compared with conservative treatment.

MDCT of Small Bowel Obstruction: How Reliable Are Oblique Reformatted Images in Localizing Point of Transition?

The goal of this study is to prospectively assess the additional value of oblique reformatted images for localizing POT, having surgery as a reference standard. Materials and Methods. 102 consecutive patients with suspected small bowel obstruction (SBO) underwent 64-slice multidetector row CT (MDCT) using surgical findings as reference standard. Two independent GI radiologists reviewed the CT scans to localize the exact POT by evaluating axial images (data set A) followed by axial, coronal, and oblique MPR images. CT findings were compared to surgical findings in terms of diagnostic performance. McNemar's test was used to detect any statistical difference in POT evaluation between datasets A and B. Kappa statistics were applied for measuring agreement between two readers. Results. There was a diagnostic improvement of 9.9% in the case of the less experienced radiologist in localizing POT by using oblique reformatted images. The more experienced radiologist showed diagnostic improvement by 12.9%.

Meaning of free intraperitoneal fluid in small-bowel obstruction: preliminary results using high-frequency microsonography in a rat model

OBJECTIVES

The aim of this study was to detect the onset, evolution, and meaning of extraluminal free fluid in a rat model of small-bowel obstruction using high-frequency microsonography.

METHODS

Small-bowel obstruction was surgically created in 8 rats divided into 2 groups of 4 rats each. All rats were examined by high-frequency microsonography to monitor the evolution of small-bowel obstruction and the abdominal sonographic findings. In group 2 rats, the obstruction was resolved 2 hours after surgery.

RESULTS

In all rats, free peritoneal fluid was detected just near the obstructed loop after 1 hour and in the hepatorenal recess after 2 hours. These features progressively increased in the following hours in group 1 rats. In group 2, the amount of free fluid decreased shortly after removing the obstruction.

CONCLUSIONS

Free fluid is an early finding in small-bowel obstruction, and the increase or decrease of its amount is correlated with the worsening or resolution of the obstruction.

Early MRI findings of small bowel obstruction: an experimental study in rats

PURPOSE

This study was undertaken to identify the early magnetic resonance imaging (MRI) findings of small bowel obstruction (SBO) and to analyse their evolution over time comparing them with histological findings.

MATERIALS AND METHODS

SBO was surgically induced in 10 rats divided into two groups monitored at predetermined time points until the 8th hour: group 1, macroscopically observed and group 2, investigated with 7-Tesla micro-MRI (7 T μ-MR). At the end of observation, the bowel was excised for histological analysis.

RESULTS

7 T μ-MRI T2-w sequences acquired 15 min after SBO, showed early evidence of bowel wall hyperintensity and a small amount of peritoneal free fluid. At 1 h, a hyperintensity of the loop proximal to the obstruction was found and, after 4 h, free fluid between the loops, bowel wall thickening and increased wall hyperintensity were also found. After 6 h hypotonic reflex ileus (only gas-filled dilated loops) was detected, which became paralytic ileus (dilation with air-fluid levels) after 8 h. The MRI findings were all confirmed at histological examination.

CONCLUSIONS

This study allows definition of the early MRI features of SBO (peritoneal free fluid and hyperintensity of the injured bowel) and their chronological evolution, also confirmed by histological examination. Our data suggest a potential role of MR imaging in the early diagnostic assessment and management of patients with SBO. The chance to achieve an early detection of bowel injury and to correlate the histological pattern with imaging findings could contribute to a finer and earlier diagnosis and a more effective treatment.

CT findings of small bowel strangulation: the importance of contrast enhancement

The purpose of this study is to illustrate computed tomography (CT) findings suggestive of small bowel strangulation. We have performed the precontrast and postcontrast CT with single and multidetector CT scanners and evaluated the bowel wall changes and mesentery changes and correlated them with the operative findings. The direct CT findings suggestive of small bowel strangulation included high-density bowel wall on precontrast scans; lack of, or diminished contrast enhancement of the involved bowel wall; localized mesenteric fluid accumulation (mesenteric congestion); and localized pneumatosis. The indirect CT signs included C- or U-shaped loops with mesenteric vessels converging toward the obstruction site, ascites, target sign, two adjacent collapsed round loops, and whirl sign. We particularly emphasize the importance of contrast enhancement of bowel mucosa for early diagnosis to differentiate strangulation from a mechanical obstruction without bowel ischemia, and also the importance to differentiate proximal secondary gas-filled dilated small bowel loops from distal primary involved fluid-filled small bowel loops because these two types of small bowel loops are present in the single peritoneal cavity. As early recognition of small bowel strangulation may help improve the patient outcome because the involved bowel loops can be preserved without resection, it is essential to become familiar with the CT signs suggested small bowel obstruction strangulation.

Clinicoradiological score for predicting the risk of strangulated small bowel obstruction

BACKGROUND

Intestinal ischaemia as a result of small bowel obstruction (SBO) requires prompt recognition and early intervention. A clinicoradiological score was sought to predict the risk of ischaemia in patients with SBO.

METHODS

A clinico-radiological protocol for the assessment of patients presenting with SBO was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict ischaemia requiring resection.

RESULTS

Of 233 consecutive patients with SBO, 138 required laparotomy of whom 45 underwent intestinal resection. In multivariable analysis, six variables correlated with small bowel resection and were given one point each towards the clinical score: history of pain lasting 4 days or more, guarding, C-reactive protein level at least 75 mg/l, leucocyte count 10 x 10(9)/l or greater, free intraperitoneal fluid volume at least 500 ml on computed tomography (CT) and reduction of CT small bowel wall contrast enhancement. The risk of intestinal ischaemia was 6 per cent in patients with a score of 1 or less, whereas 21 of 29 patients with a score of 3 or more underwent small bowel resection. A positive score of 3 or more had a sensitivity of 67.7 per cent and specificity 90.8 per cent; the area under the receiver operating characteristic curve was 0.87 (95 per cent confidence interval 0.79 to 0.95).

CONCLUSION

By combining clinical, laboratory and radiological parameters, the clinical score allowed early identification of strangulated SBO.

The relevance of transition zones on computed tomography in the management of small bowel obstruction

BACKGROUND

Frequently, radiologists emphasize radiographic transition zones (RTZs) on computed tomography (CT), which are areas of abrupt change from dilated to collapsed bowel, as pathognomonic for small-bowel obstruction (SBO) diagnosis and location. The relevance of RTZs to patient management remains unknown. The purpose of this study was to determine the surgical predictive value and intraoperative accuracy of RTZ.

METHODS

A retrospective review of 200 patients with SBO who underwent abdominal CT at a single institution from 2002 to 2007 was performed. Statistical analysis was conducted using an unpaired t test, a Chi-square test, and multivariate analysis.

RESULTS

Of the 200 patients with SBO, 150 (75%) had an RTZ. Seventy-five (38%) patients required operative intervention; 58 (39%) patients had RTZ and 17 (34%) patients did not have RTZ (P=NS). The presence of RTZ was not associated with increased probability of operative versus nonoperative management (odds ratio=1.19; 95% confidence interval [0.61-2.32]). The mean time to operative intervention was 3.6 days. Immediate operative intervention (<24 h) was equivalent in patients with versus without RTZ (57% vs 53%; P=NS) as was intervention for failed nonoperative management (43% vs 47%; P=NS). For patients who required operative intervention, RTZ correlated with intraoperative site of obstruction in only 31 (63%) patients.

CONCLUSION

The presence of RTZs does not increase the likelihood of operative intervention or identify patients who will fail nonoperative management. RTZ should, therefore, not be used as a major criterion influencing operative versus nonoperative management decisions in patients with SBO. For patients who required operative intervention, RTZ had a 63% correlation with intra-operative findings, which makes it a useful adjunct to pre-operative planning.

Value of multidetector CT in decision making regarding surgery in patients with small-bowel obstruction due to adhesion

The aim of this study was to evaluate the value of use of multidetector CT (MDCT) to predict the need for subsequent surgery in patients with small-bowel obstruction (SBO) due to adhesion. During a 3-year period, 128 patients with an SBO due to adhesion were enrolled in this prospective study. Initially, all patients were treated conservatively. Surgery was performed in patients who developed signs of strangulation or did not improve, despite a conservative treatment for at least 5 days. Of the 128 patients, 37 patients eventually underwent surgery. Two radiologists interpreted MDCT findings regarded as predictive indicators for subsequent surgery in consensus. The findings included degree of SBO, presence of transition zone, and an abnormal vascular course. These findings were statistically compared between the group operated on and the group not operated on. A higher degree of SBO, an abnormal vascular course, and the presence of transition zone were more frequently seen in the group of patients operated on (p < 0.001). Sensitivities, specificities, positive and negative predictive values, and risks for the use of MDCT to predict the need for surgery were 100%, 46.1%, 43%, 100%, and 1.9 (1.5 < or = 95% confidence interval (CI) < or = 2.2) for a high-grade obstruction; 100%, 23%, 34.5%, 100%, and 1.3 (1.2 < or = 95% CI < or = 1.5) for the presence of a transition zone; and 70.2%, 90.1%, 74.2%, 88.1%, and 7.1 (3.7 < or = 95% CI < or = 13.7) for the presence of an abnormal course of the mesenteric vessels, respectively. The presence of a high degree of SBO and an abnormal vascular course around transition zone are useful indicators on MDCT to predict the need for surgery in patients with an SBO due to adhesion.

Location of the transition zone in CT of small-bowel obstruction: added value of multiplanar reformations

PURPOSE

To assess the additional value of multiplanar reformations (MPR) in comparison with axial images alone for location of the transition zone in CT of mechanical small-bowel obstruction (SBO).

MATERIALS AND METHODS

Sixty-nine consecutive patients with mechanical SBO underwent 16-slice multi detector row CT (MDCT). The gold standard for the precise location of the transition zone was established by two experienced abdominal radiologists, unblinded to clinical and surgical reports, reviewing all CT examinations. On a workstation, two blinded readers independently located the transition zone using first axial slices alone and then 1 month later MPR (axial, coronal, sagittal and oblique views) according to a three-point confidence scale. Diagnostic accuracy and mean confidence score were evaluated for both the transverse and multiplanar data sets.

RESULTS

Accuracy of transition zone location for reader 1 and reader 2 was 86% and 84% with axial slices alone, and by using MPR 93% (significant: P = 0.03) and 90% (not significant: P = 0.08), respectively. Mean confidence score was significantly increased for both readers using MPR: 0.3 higher (P = 0.0001) and 0.37 higher (P = 0.0001) respectively.

CONCLUSION

MPR can increase both accuracy and confidence in the location of the transition zone in CT of SBO.

Predicting strangulated small bowel obstruction: an old problem revisited

BACKGROUND

Diagnosing intestinal strangulation complicating a small bowel obstruction (SBO) remains a considerable challenge. Despite decades of experience and numerous studies, no clinical indicators have been identified that reliably predict this life-threatening condition. Our goal was to determine which clinical indicators in patients with SBO can be used to independently predict the presence of strangulated intestine.

METHODS

Medical records were reviewed for 192 adult patients operated on for acute SBO over an 11-year period (1996-2006). Seventy-two preoperative clinical, laboratory, and radiologic findings at admission were examined. Data from patients with strangulated intestine were compared to data from patients without bowel compromise. Likelihood ratios were generated for each significant parameter in a multivariate logistic regression analysis.

RESULTS

Forty-four patients had bowel strangulation requiring bowel resection, and 148 had no strangulation. The most significant independent predictor of bowel strangulation was the computed tomography (CT) finding of reduced wall enhancement, with a sensitivity and specificity of 56% and 94% [likelihood ratio (LR) 9.3]. Elevated white blood cell (WBC) count and guarding were moderately predictive (LR 1.7 and 2.8).

CONCLUSION

Regression analysis of multiple preoperative criteria demonstrates that reduced wall enhancement on CT, peritoneal signs, and elevated WBC are the only variables independently predictive of bowel strangulation in patients with SBO.

Intestinal Obstruction and Ileus: Role of Computed Tomography Scan in Diagnosis and Management

A significant proportion of patients with intestinal obstruction will be evaluated with a CT scan of the abdomen. This study presents a group of 97 patients diagnosed with mechanical obstruction or ileus on CT scan over a 16-month period at a community based teaching hospital and follows the further management of these patients. Our study shows that 43.3 per cent of patients with mechanical obstruction, diagnosed by CT scan, eventually needed surgical treatment. On the other hand, even when CT indicates ileus, 20 per cent of these patients may still require surgical intervention.

Adhesion-related small bowel obstruction

Postoperative adhesions are the commonest cause of small bowel obstruction (SBO), a frequent surgical emergency. Adhesion obstruction is potentially lethal and a crucial aspect in management is to differentiate whether there is actual, or impending, small bowel ischaemia and therefore a need for emergency surgery. There are no completely accurate imaging or haematological techniques to exclude the requirement for surgery. Modern computerized tomography (CT) has been a significant advance in noninvasive assessment of SBO and may demonstrate the cause of the obstruction and suggest the presence of bowel ischaemia. It is important to note that adhesions may not be the cause of SBO in a patient who has had abdominal surgery. Recurrent cancer, an obstructive colon lesion in the presence of an incompetent ileocaecal valve, an occult hernia, small bowel arterial or venous ischaemia, amongst others may be the cause and CT may elucidate some of these causes and help plan management. Increasing utilization of laparoscopic surgery may reduce the extent and incidence of adhesions and laparoscopic adhesiolysis, in experienced hands, may be successful in managing acute obstruction or alternatively as a planned procedure when the obstruction has resolved. Adhesive SBO remains a common surgical emergency and there is no substitute for repeated examination by a surgeon, capable of performing a laparotomy, in the optimal management of these complex patients.

Bowel transition points: multiplicity and posterior location at CT are associated with small-bowel volvulus

PURPOSE

To retrospectively evaluate the sensitivity and specificity of the number and location of bowel transition points at computed tomography (CT) in the diagnosis of small-bowel volvulus, with surgical findings as the reference standard.

MATERIALS AND METHODS

This HIPAA-compliant study had institutional review board approval; informed consent was waived. One hundred adult patients who had undergone preoperative CT and who had surgically proved non-abdominal wall hernia small-bowel obstruction (n=68) or small-bowel volvulus (n=32) were retrospectively identified. The patients included 61 women and 39 men with a mean age of 57 years (range, 18-96 years). One reader, blinded to the diagnoses, recorded the number of transition points at CT, the anteroposterior location of each transition point relative to the anterior edge of the spine, and the presence or absence of a whirl sign. Statistical analyses were performed with the Fisher exact test, unpaired t tests, and multiple logistic regression.

RESULTS

The frequency of the finding of multiple transition points was significantly higher in patients with volvulus (19 [59%] of 32) than in patients without volvulus (11 [16%] of 68) (P<.001). Transition points associated with volvulus were less likely to be located more than 7 cm anterior to the spine (four [12%] of 32 patients) than were transition points not associated with volvulus (31 [46%] of 68 patients) (P<.005). The whirl sign was an additional significant independent predictor of volvulus (P<.05). When all three of these predictors were present, the specificity for small-bowel volvulus was 100%.

CONCLUSION

The presence of multiple transition points with a posterior location at CT in an adult with small-bowel obstruction is significantly associated with volvulus.

Early outcomes of surgery for small bowel obstruction: analysis of risk factors

OBJECTIVES

The study aimed to review the etiologies of patients who underwent surgery for small bowel obstruction (SBO) and to evaluate the risk factors affecting the early postoperative outcomes.

MATERIALS AND METHODS

A case series of 430 patients (252 men) with a mean age of 64.5 years, who underwent 437 operations for SBO, were retrospectively reviewed.

RESULTS

Peritoneal adhesions and hernia were the most common causes of SBO, contributing 42.3 and 26.8% of all cases, respectively. Strangulation occurred in 27.7% and caused nonviable bowel in 13.0% of obstructing episodes. Old age (age >/= 70 years), female patient, nonadhesive obstruction, and hernia were the independent significant factors associated with bowel strangulation. The 30-day mortality was 6.5%, and the median postoperative hospital stay was 8 days. Old age, the presence of premorbid pulmonary disease, and malignant obstruction were the independent factors associated with operative mortality. The overall complication rate was 35.5%, and old age was the only significant factor associated with postoperative complications.

CONCLUSIONS

Surgery for SBO is still associated with significant mortality and morbidity. As old age is significantly associated with an increased incidence of strangulation, operative mortality, and complications, this group of patients should be managed with extra cautions to avoid unfavorable outcome of surgery.

CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation

PURPOSE

To retrospectively evaluate the diagnostic performance of computed tomography (CT) for detection of small-bowel ischemia in emergency department patients with abdominal pain and to compare the prospective interpretation with a retrospective interpretation by using surgical or pathologic findings as the reference standard.

MATERIALS AND METHODS

The HIPAA-compliant study was approved by the institutional review board, and patients consented to research authorization. Sixty patients (61 examinations) (25 male, 35 female patients; median age, 67 years; range, 0.9-89.7 years) with acute abdominal pain underwent immediate abdominal and pelvic CT and subsequent surgery of the small bowel within 7 days of CT. Prospective radiologic reports were reviewed for diagnosis of small-bowel obstruction and ischemia. Two gastrointestinal radiologists performed blinded, independent, retrospective review of the CT studies with no clinical data other than presence of acute abdominal pain. The reviewers categorized CT signs of obstruction and ischemia and estimated diagnostic certainty. Discordant findings were resolved by consensus review by a third gastrointestinal radiologist. CT interpretations were compared with prospective interpretations and surgical or pathologic findings. Sensitivity and specificity estimates with confidence intervals were calculated. Fisher exact and chi2 tests were used to assess associations between CT signs and the diagnosis of ischemia; kappa statistics were used to estimate agreement between readers.

RESULTS

In 27 (44%) of 61 CT studies, small-bowel ischemia was surgically or pathologically confirmed. Sensitivity and specificity for the diagnosis of ischemia were, respectively, 14.8% and 94.1% for prospective interpretations, 29.6% and 91.2% for reader 1, 40.7% and 85.3% for reader 2, and 51.9% and 88.2% for the consensus review. Decreased segmental enhancement was the most specific sign for small-bowel ischemia (P = .001), and its recognition would have improved the diagnostic performance of all readers. There was a significant association of the small-bowel feces sign with the presence of small-bowel ischemia (P = .046).

CONCLUSION

Diagnostic performance assessment of CT for the diagnosis of small-bowel ischemia revealed poor prospective interpretation sensitivity.

ACR Appropriateness Criteria® on Suspected Small-Bowel Obstruction

With no one generally accepted approach to evaluate patients with suspected small-bowel obstruction (SBO), standard CT has emerged as the preeminent imaging modality and should be considered in the initial evaluation of patients with suspected high-grade SBO. Playing less significant roles in the diagnosis of acute SBO are barium enemas and the small-bowel examination.

[Surgical treatment of ileus. Differential diagnosis and therapeutic results]

Intestinal obstruction and ileus continue to represent a surgical challenge, regarding diagnosis and treatment. The decision when to operate is often difficult and should be based primarily on the clinical impression, although modern diagnostic tests are very helpful. Additionally, it is crucial to choose an operation that the patient can tolerate, as the spectrum of surgical interventions ranges from the taking-down of a single adhesion, that may be done laparoscopically, to sophisticated lysis of the intestine in patients with metastatic cancer in the peritoneal cavity, and simple diversion to extensive resections. These aspects are highly relevant, as good outcome can only be expected when the operation is performed correctly and optimal timing and appropriate choice of procedure are ensured.

Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images?

Feasibility of diagnosing small bowel obstruction on multidetector-row computed tomography (MDCT) using coronal reformations alone is evaluated. Three radiologists with subspecialty training in abdominal imaging reviewed abdominopelvic CT of 67 patients in consensus. Thirty-four patients had surgically proven small bowel obstruction. The remaining 33 patients had CT for other reasons and had no intestinal obstruction. The images were displayed in either axial or coronal planes and were reviewed on separate days . Each CT was evaluated for the presence of small bowel obstruction and its etiology when applicable. Thirty-three (100%) of 33 patients were correctly diagnosed not to have intestinal obstruction on coronal images. Thirty-four (100%) of 34 patients were correctly diagnosed to have small bowel obstruction on both forms of image display. There were five patients where the final surgical diagnosis for the etiology of small bowel obstruction did not agree with the interpretation of either the coronal or axial images; however, in all five patients, the interpretations of axial and coronal images were similar. In only one patient, the etiology of small bowel obstruction based on the coronal images did not agree with that of axial images and the surgical result; however, the site of small bowel obstruction was correctly diagnosed. There were approximately 20% fewer images in the coronal reformation data set, and the radiologists found review of these images to be easier for localizing the zone of transition in small bowel obstruction. Very high diagnostic accuracy can be achieved based on coronal reformations alone, and this form of image display may potentially be substituted for the conventional axial images. Since there are fewer images to review when the studies are displayed in coronal plane, this may positively impact radiologist workflow.

[Value of the small bowel feces sign at CT in adhesive small bowel obstruction]

PURPOSE

The purpose of this study is to describe the CT features of the small bowel feces sign and to determine its value as a positive criteria of non-severity in adhesive small bowel obstruction.

MATERIALS AND METHODS

We performed a retrospective study of adhesive small bowel obstructions diagnosed by CT from January 2001 to December 2002. All CT examinations featuring a small bowel feces sign were included. Clinical follow-up was available for all included patients.

RESULTS

Twenty patients were included in this study. Twelve patients underwent successful conservative treatment with nasogastric aspiration. Urgent laparotomy performed in 6 cases and delayed surgical intervention performed in 3 did not show ischemic complication. Surgical management always consisted in lysis of adhesions without intestinal resection.

CONCLUSION

Recently described in the radiological literature, the small bowel feces sign appears to be the first criteria of non-severity in adhesive small bowel obstruction.

Multidetector row CT of the small bowel

Multidetector row CT (MDCT) has become an imaging technique of choice to study routinely the small bowel. Thin collimation and fast scanning allow coverage of the entire abdomen within a single suspended respiration phase allowing the use of multiple enhancement phases after intravenous contrast administration. MDCT of the small bowel can identify and stage most of the common diseases of the small bowel. MDCT is changing the paradigm for diagnosing small bowel disease by becoming the first diagnostic line for almost all small bowel diseases. MDCT has the needed sensitivity and specificity, the availability, and the safety for a front-line diagnostic method.

Identification of adhesions on CT in small-bowel obstruction

Identification of adhesions on computed tomography (CT) in cases of small-bowel obstruction (SBO) is currently a diagnosis of exclusion. The purpose of this study is to examine whether the presence of findings suggestive of an extraluminal band can be used as a CT sign for adhesive SBO. CT scans of 142 patients with surgically proven SBO performed within 72 h of exploratory surgery were reviewed. The studies were evaluated for the cause of SBO and the presence of extraluminal bands. An extraluminal band was considered present if there was a change in the conformation of the transition zone, suggesting extraluminal compression of the bowel by a linear obstructive band. The presence of extraluminal bands in the area of the transition zone had a high positive predictive value for adhesive SBO. Of the 73 cases in which bands were present, SBO was due to adhesions in 52 instances, with a corresponding positive predictive value of 71% (95% confidence interval 0.60-0.80) and a p value of 0.008. The extraluminal band was 61% sensitive and 63% specific for adhesive SBO. The presence of an extraluminal band on CT in the area of the transition zone in cases of SBO correlates well with a diagnosis of SBO secondary to adhesions. In the absence of a source of SBO, the presence of an extraluminal band can serve as a helpful diagnostic adjunct for adhesive SBO.

Advanced abdominal imaging is not required to exclude strangulation if complete small bowel obstructions undergo prompt laparotomy

BACKGROUND

When small bowel obstruction is demonstrated clinically or radiographically to be complete, operation is advocated because of the demonstrated association of strangulation obstruction with complete obstruction and the difficulty of diagnosing strangulation obstruction. Short observation periods, fluoroscopic procedures, and cross-sectional imaging are used in treatment of partial obstruction by those who believe that observation is futile or dangerous. This approach holds that few patients resolve after a day or two of observation; if this premise were true, protracted observation should see few patients resolve and some require resection for necrotic bowel after failed observation. Observer bias and the spectrum of nonnecrotic ischemia makes end-point analysis after laparotomy difficult to interpret; few criteria or incentives exist for a surgeon to speculate that a patient brought to surgery might have recovered without it.

STUDY DESIGN

I reviewed the clinical courses of 413 obstructed patients seen over 13 years.

RESULTS

Seventy-two patients underwent immediate treatment for complete obstruction, 294 resolved without operation, and 47 patients required operation after a period of observation ranging from 3 to 15 days. All observed patients were followed using clinical examination, leukocyte count, and plain film radiography only. No bowel resections were required in patients who were observed.

CONCLUSIONS

Research opportunities exist for use of alternatives to plain film imaging in treatment of partial small bowel obstruction, but this series does not support the premise that there is a risk for bowel ischemia or bowel resection by observing patients with partial small bowel obstruction or by following them with plain films alone. Indeed, such a strategy resulted in resolution in 294 of 341 patients so treated, with readmission and reoperation rates comparable with those reported in series in which earlier operation was undertaken.

Intestinal obstruction in patients with previous laparotomy for non-malignancy

BACKGROUND

Intestinal obstruction is one of the most common surgical emergencies. The aim of this study was to identify important management information from the evaluation of patients with intestinal obstruction who had undergone previous laparotomy for non-malignancy.

METHODS

Data from 176 patients with previous laparotomy for non-malignancy, and who were operated on for intestinal obstruction, were collected and analyzed retrospectively.

RESULTS

Gastroduodenal operations, appendectomy, and obstetric/gynecologic procedures were the 3 most common previous abdominal surgeries. More than half of all bowel obstructions developed within 10 years after previous laparotomy, and particularly within the first 5 years. Most obstructions were related to adhesion, although their etiologies were diverse. The rate of bowel strangulation was much higher in patients with internal herniation, volvulus, intussusception, closed loop, and diaphragmatic hernia than in patients with simple adhesion, bezoar, tumor, and inflammation (48.3% vs 12.2%). The surgical mortality rate correlated significantly with bowel strangulation: the overall rate was 6.8%, that in patients with strangulation was 18.8%, and that in patients without strangulation was 4.2%.

CONCLUSION

The etiologies of intestinal obstruction were not only significantly related to bowel strangulation, but were also an important determinant of therapeutic strategy.

Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review

This review was designed to describe the diagnostic performance of computed tomography (CT) in assessing bowel ischemia and complete obstruction in small bowel obstruction (SBO). A MEDLINE search (1966-2004) identified 15 studies dealing with the CT diagnosis of ischemia and complete obstruction in SBO. Ischemia was defined by operative findings, and complete obstruction was defined by enteroclysis or operative findings. Aggregated sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Eleven of 15 studies reported on the CT diagnosis of ischemia in SBO based on 743 patients. The aggregated performance characteristics of CT for ischemia in SBO were sensitivity of 83% (range, 63-100%), specificity of 92% (range, 61-100%), PPV of 79% (range, 69-100%), and NPV of 93% (range, 33.3-100%). Seven of 15 studies evaluated the CT classification of complete obstruction based on 408 patients. The aggregated performance characteristics of CT for complete obstruction were sensitivity of 92% (range, 81-100%), specificity of 93% (range, 68-100%), PPV of 91% (range, 84-100%), and NPV of 93% (range, 76-100%). This review demonstrates the high sensitivity of CT for ischemia in the setting of SBO and suggests that a CT scan finding of partial SBO is likely to reflect a clinical condition that will resolve without surgical intervention.

Helical CT diagnosis of small bowel obstruction in the acute clinical setting

Definite confirmation or exclusion closed loop obstruction (CLO) is one of the most difficult tasks the radiologist has to face in the clinical practice. Aim of this retrospective work was to study the value of spiral computed tomography (CT) in the diagnosis of closed loop obstruction complicated by intestinal ischemia. The state of the art CT signs of closed loop obstruction were taken into consideration. Serrated beaks with poor or no contrast enhancement of the bowel walls, ascites or engorgement of the mesenteric vasculature allowed the CT diagnosis of CLO complicated by ischaemia. U or C-sharped of dilated loops, radial distribution of the mesenteric vessels, beaks and whirls suggested CLO, but did not help differentiate CLO from strangulation. CLO is a dynamic entity which may regress or need laparotomy depending on the time and degree of rotation of the incarcerated loops. CT is a reliable imaging modality able to differentiate CLO from strangulation, which is rarely simple and obvious. Detection of ischemic changes in the bowel walls and/or attached mesentery on CT scans imply strangulation highlighting the need for laparotomy; if only signs of CLO are detected, the existence and/or development of strangulation cannot be predicted.

Valeur du scanner dans l’occlusion mécanique de l’intestin grêle

Small bowel obstruction is a leading cause of admission in surgical and emergency units. During the last two decades, the classical philosophy of "never let the sun set or rise on small-bowel obstruction" has been succeeded by a new management based especially on the cause and the severity of the obstruction. It most often allows a correct choice between medical therapy and surgery using laparotomy or laparoscopy. This changing attitude is still in progress and is mainly related to the high accuracy of computed tomography. This review will discuss the semiology and value of computed tomography compared with clinical examination and other imaging modalities.

The multifaceted role of radiology in small bowel obstruction

Small bowel obstruction is a common clinical condition, often presenting with signs and symptoms similar to those seen in other acute abdominal disorders. The diagnosis and treatment of this dynamic process continues to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the changes related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.

Clinical Studies of Strangulating Small Bowel Obstruction

Reliable preoperative diagnosis of intestinal necrosis in strangulating small bowel obstruction (SSBO) is difficult, and, as yet, no reliable marker has been described. We, therefore, retrospectively examined clinical symptoms and hematobiochemical data of patients with SSBO in our surgical wards. Thirty-seven patients with SSBO were analyzed in this study. They were divided into two groups: group A (13 patients), the presence of gangrenous intestine; and group B (24 patients), the absence of it. By means of χ2 test, Student t test, or Welch t test, peritoneal signs, white blood cell count (leukocytosis or leukopenia), systemic inflammatory response syndrome (SIRS), shock, and base deficit were significantly associated with whether gangrenous intestine existed or not. Next, in simple regression analysis, base deficit was significantly correlated with the length of gangrenous intestine. In stepwise logistic regression analysis, SIRS was independently correlated with the presence of gangrenous intestine. If SIRS or metabolic acidosis is seen in patients with SSBO, the intestine is certainly gangrenous

The efficacy of helical CT in the diagnosis of small bowel obstruction

OBJECTIVE

To evaluate the usefulness and reliability of helical computed tomography (CT) for patients with small bowel obstruction.

METHODS AND MATERIAL

Helical CT findings of 41 patients were evaluated prospectively on the basis of the presence and the cause of obstruction, and the presence of strangulation.

RESULTS

In the determination of the cause of the obstruction sensitivity and specificity of CT were 84 and 90%, respectively. Of the 19 patients undergoing surgery, 6 had strangulation and were correctly identified by CT.

CONCLUSION

Helical CT is an accurate method in the detection of small bowel obstruction, especially for evaluating the cause and vascular complications of obstruction.

Delay in operative treatment among patients with small bowel obstruction

BACKGROUND AND AIMS

Delay in operative treatment for small bowel obstruction (SBO) has been shown to affect outcome adversely. The objective of this study was to detect time trends in treatment delay for patients with SBO during the study period 1961 to 1995 and to investigate factors influencing and factors affected by delay.

MATERIALS AND METHODS

The records of 815 patients with 921 operations for SBO from 1961-1995 were studied. Patients with large bowel obstruction, paralytic ileus and SBO caused by abdominal cancer or intussusception were excluded. Data were analysed with descriptive statistics and multiple linear regression analyses.

RESULTS

Old age and female sex were associated with increased treatment delay. Delay in hospital increased from 5 hours (median) in the 1960'ies to 16 hours (median) in the 1990'ies. Treatment delay correlated significantly with postoperative morbidity and hospital stay. Mortality increased after prolonged treatment delay in SBO caused by hernias whereas no significant increase in mortality was observed among adhesive obstructions.

CONCLUSIONS

Hospital delay increased throughout the study period. Old patients and women had a longer median treatment delay than did young ones and men. Treatment delay led to an increase in postoperative morbidity and hospital stay after surgery for SBO.

[Small bowel obstruction by a congenital band in 16 adults]

During embryogenesis, abnormal adhesion of the peritoneal folds induces a congenital band which can cause small bowel obstruction.

PATIENTS AND METHODS

From 1987 to 2001, 16 adult patients underwent surgery for small bowel obstruction due to a congenital band. There were 8 men and 8 women with a mean age of 59 years (range 23-90). None presented previous abdominal surgery.

RESULTS

Six patients presented acute abdominal pain the month before hospitalization. Among the 16 patients, 9 were operated at admission, and 7 after initial surveillance. Suspected diagnosis before operation was small bowel obstruction in 8 cases (with a diagnosis of congenital band in 3); perforated duodenal ulcer (n = 2); appendicitis (n = 2); mesenteric infarction (n = 1); diverticultis (n = 1); cholecystitis (n = 1); and strangulated hernia (n = 1). During operation performed through laparotomy or laparoscopy, a congenital band was noted in 100% of the cases, associated with intestinal necrosis in 5. One patient died postoperatively.

CONCLUSION

Because small bowel obstruction by congenital band is a rare condition, it represents a frequent problem of diagnosis. In this situation, the possibility of intestinal necrosis expose the patient to a possible fatal outcome.

[Post-operative small bowel obstruction: spiral computed tomography]

INTRODUCTION

The aim of this study was to evaluate prospectively the impact of the routine use of abdominal spiral computed tomography (SCT) in patients with postoperative small bowel obstruction (SBO) for whom initial conservative treatment was proposed.

PATIENTS AND METHODS

We have compared the management of SBO in patients with clinical stable condition in two successive periods : from 1989 to 1998, 127 patients (preSCT group) for whom management was based on standard clinical-biological-radiological assessment (CBRA) et from 1999 to 2000, 30 patients (SCT group) for whom management included SCT. The decision of surgical team was correlated with the type of small bowel obstruction at laparotomy : closed-loop obstruction without intestinal necrosis (true-positive), intestinal necrosis as a consequence of delayed diagnosis defined as false-negative, diffuse adhesion defined as false-positive et patient non operated defined as true-negative.

RESULTS

Among the 127 patients from the preSCT group, 87 were treated conservatively and 40 were operated : SBO with closed-loop obstruction without intestinal necrosis (n = 29,72%), SBO with diffuse adhesion (n = 4, 10%) and SBO with intestinal necrosis (n = 7, 17%). Among the 30 patients from the SCT group, 16 were treated conservatively and 14 were operated: SBO with closed-loop obstruction without intestinal necrosis (n = 8, 57%), SBO with diffuse adhesion (n = 6,43%) and SBO with intestinal necrosis (n = 0,0%; NS). Both groups were similar for rates of patients with SBO with or without necrosis and rate of patients treated conservatively (NS). In SCT group, there was significantly more patients operated for diffuse adhesions (p < 0,01). Negative predictive value of CBRA + TDM was significantly higher than those of CBRA alone (p = 0,041).

CONCLUSION

Due to a very high sensibility, TDM increase probably the rate of early laparotomies, maybe unnecessary, in patients without any sign of SBO due to closed-loop obstruction. Thus, systematic use of TDM in patients with clinical suspicion of SBO remains to be evaluated.

Acute intestinal obstruction: diagnosis and management

In acute intestinal obstruction, the clinician must distinguish between acute small bowel obstruction (ASBO) and acute colonic obstruction (ACO). In cases of ASBO, management depends on whether the patient has had previous abdominal surgery. Most cases of ACO require surgery, although mechanical causes must be distinguished from pseudo-obstruction for different management techniques.