1
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Eze VN, Parry T, Boone D, Mallett S, Halligan S. Prognostic factors to identify resolution of small bowel obstruction without need for operative management: systematic review. Eur Radiol 2024; 34:3861-3871. [PMID: 37938387 PMCID: PMC11166786 DOI: 10.1007/s00330-023-10421-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/06/2023] [Accepted: 09/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES To identify imaging, clinical, and laboratory variables potentially prognostic for surgical management of small bowel obstruction. METHODS Two researchers systematically reviewed indexed literature 2001-2021 inclusive for imaging, clinical, and laboratory variables potentially predictive of surgical management of small bowl obstruction and/or ischaemia at surgery, where performed. Risk of bias was assessed. Contingency tables for variables reported in at least 5 studies were extracted and meta-analysed to identify strong evidence of association with clinical outcomes, across studies. RESULTS Thirty-one studies were ultimately included, reporting 4638 patients (44 to 313 per study). 11 (35%) studies raised no risk of bias concerns. CT was the modality reported most (29 studies, 94%). Meta-analysis of 21 predictors identified 5 strongly associated with surgical intervention, 3 derived from CT (peritoneal free fluid, odds ratio [OR] 3.24, 95%CI 2.45 to 4.29; high grade obstruction, OR 3.58, 95%CI 2.46 to 5.20; mesenteric inflammation, OR 2.61, 95%CI 1.94 to 3.50; abdominal distension, OR 2.43, 95%CI 1.34 to 4.42; peritonism, OR 3.97, 95%CI 2.67 to 5.90) and one with conservative management (previous abdominopelvic surgery, OR 0.58, 95%CI 0.40 to 0.85). Meta-analysis of 10 predictors identified 3 strongly associated with ischaemia at surgery, 2 derived from CT (peritoneal free fluid, OR 3.49, 95%CI 2.28 to 5.35; bowel thickening, OR 3.26 95%CI 1.91 to 5.55; white cell count, OR 4.76, 95%CI 2.71 to 8.36). CONCLUSIONS Systematic review of patients with small bowel obstruction identified four imaging, three clinical, and one laboratory predictors associated strongly with surgical intervention and/or ischaemia at surgery. CLINICAL RELEVANCE STATEMENT Via systematic review and meta-analysis, we identified imaging, clinical, and laboratory predictors strongly associated with surgical management of small bowel obstruction and/or ischaemia. Multivariable model development to guide management should incorporate these since they display strong evidence of potential utility. KEY POINTS • While multivariable models incorporating clinical, laboratory, and imaging factors could predict surgical management of small bowel obstruction, none are used widely. • Via systematic review and meta-analysis we identified imaging, clinical, and laboratory variables strongly associated with surgical management and/or ischaemia at surgery. • Development of multivariable models to guide management should incorporate these predictors, notably CT scanning, since they display strong evidence of potential utility.
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Affiliation(s)
- Vivienne N Eze
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Tom Parry
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Darren Boone
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.
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2
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Schulwolf S, Brower C, Karam A, Havens J, Shokoohi H, Duggan NM, Goldsmith AJ. Clinical Features vs CT Findings to Estimate Need for Surgery in Small Bowel Obstruction. JAMA Netw Open 2023; 6:e2341376. [PMID: 37917064 PMCID: PMC10623188 DOI: 10.1001/jamanetworkopen.2023.41376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/18/2023] [Indexed: 11/03/2023] Open
Abstract
This comparative effectiveness research compares the ability of clinical features vs clinical features with computed tomography (CT) to estimate the need for small bowel obstruction surgery.
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Affiliation(s)
- Sara Schulwolf
- University of Connecticut School of Medicine, Farmington
| | - Charles Brower
- University of Cincinnati Emergency Medicine Residency, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Joaquim Havens
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Nicole M. Duggan
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J. Goldsmith
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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3
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Murphy PM. Visual Image Annotation for Bowel Obstruction: Repeatability and Agreement with Manual Annotation and Neural Networks. J Digit Imaging 2023; 36:2179-2193. [PMID: 37278918 PMCID: PMC10502000 DOI: 10.1007/s10278-023-00825-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/21/2023] [Accepted: 03/29/2023] [Indexed: 06/07/2023] Open
Abstract
Bowel obstruction is a common cause of acute abdominal pain. The development of algorithms for automated detection and characterization of bowel obstruction on CT has been limited by the effort required for manual annotation. Visual image annotation with an eye tracking device may mitigate that limitation. The purpose of this study is to assess the agreement between visual and manual annotations for bowel segmentation and diameter measurement, and to assess agreement with convolutional neural networks (CNNs) trained using that data. Sixty CT scans of 50 patients with bowel obstruction from March to June 2022 were retrospectively included and partitioned into training and test data sets. An eye tracking device was used to record 3-dimensional coordinates within the scans, while a radiologist cast their gaze at the centerline of the bowel, and adjusted the size of a superimposed ROI to approximate the diameter of the bowel. For each scan, 59.4 ± 15.1 segments, 847.9 ± 228.1 gaze locations, and 5.8 ± 1.2 m of bowel were recorded. 2d and 3d CNNs were trained using this data to predict bowel segmentation and diameter maps from the CT scans. For comparisons between two repetitions of visual annotation, CNN predictions, and manual annotations, Dice scores for bowel segmentation ranged from 0.69 ± 0.17 to 0.81 ± 0.04 and intraclass correlations [95% CI] for diameter measurement ranged from 0.672 [0.490-0.782] to 0.940 [0.933-0.947]. Thus, visual image annotation is a promising technique for training CNNs to perform bowel segmentation and diameter measurement in CT scans of patients with bowel obstruction.
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Affiliation(s)
- Paul M Murphy
- University of California-San Diego, 9500 Gilman Dr, 92093, La Jolla, CA, USA.
- UCSD Radiology, 200 W Arbor Dr, 92103, San Diego, CA, USA.
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4
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Besler E, Teke E, Akkuş D, Demir MH, Aksaray S, Aydın Aksu S, Gürleyik MG. A new risk scoring system for early prediction of surgical need in patients with adhesive small bowel obstruction: a single-center retrospective clinical study. Ann Surg Treat Res 2023; 105:165-171. [PMID: 37693288 PMCID: PMC10485350 DOI: 10.4174/astr.2023.105.3.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/16/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose Cases of adhesive small bowel obstruction are a nuisance to surgeons. There have been years of ongoing discussions, and various guidelines have been published for the management of this disease. Both surgical and conservative approaches can have their own complications. It is often difficult to decide which treatment to apply to which patient. We aimed to create a multiparametric scoring system for the optimal management of adhesive small bowel obstruction patients. Methods The retrospective laboratory, clinical and radiological records of 100 patients who were hospitalized and followed-up/treated for adhesive small bowel obstruction secondary to surgery in the General Surgery Clinic of Haydarpaşa Numune Education and Research Hospital (Istanbul) between 2011 and 2021 were reviewed and statistically analyzed. Results Admittance CRP and the largest diameter of the small intestine in the horizontal section of the admittance CT scans were significantly higher (P = 0.006 and P = 0.007), and the admittance albumin and sodium values were significantly lower (P < 0.001 and P = 0.031) in patients operated on for adhesive small bowel obstruction than in patients not operated on. Free intraperitoneal fluid in CT scans was detected at a higher rate in the operated group. An adhesive small bowel obstruction surgery score above 3.5 points out of 7 was found to be significant (P < 0.001). Conclusion With this easy and applicable scoring system, complications of existing disease may be avoided by considering earlier surgical intervention in patients with a score of 4 and above.
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Affiliation(s)
- Evren Besler
- General Surgery Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
| | - Emre Teke
- General Surgery Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
| | - Doğukan Akkuş
- General Surgery Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
| | - Mahmut Hüdai Demir
- General Surgery Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
| | - Sebahat Aksaray
- Department of Microbiology and Central Laboratory, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
| | - Sibel Aydın Aksu
- Radiology Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
| | - Meryem Günay Gürleyik
- General Surgery Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Türkiye
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5
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Liu X, Zhu M, Wu M, Cheng Z, Wu X, Zhu R. Unenhanced CT-based predictive model to identify small bowel necrosis in patients with mechanical small bowel obstruction. BMC Med Imaging 2023; 23:80. [PMID: 37308879 DOI: 10.1186/s12880-023-01041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVES To investigate the diagnostic value of unenhanced CT in mechanical small bowel obstruction (SBO) with small bowel necrosis, and to establish a predictive model. METHODS From May 2017 to December 2021, the patients with mechanical SBO admitted to our hospital were retrospectively collected. Taking pathology-confirmed small bowel necrosis as the gold standard, the experimental group was composed of patients with small bowel necrosis confirmed by pathology, and the control group was composed of patients with no intestinal necrosis confirmed by surgery or successful conservative treatment with no recurrence of intestinal obstruction during 1-month followed-up. RESULTS A total of 182 patients were enrolled in this study, 157 patients underwent surgery, of which 35 patients were accompanied with small bowel necrosis and 122 patients were not (33 patients with ischemic findings at surgery without necrosis). Finally, there were 35 patients in the experimental group and 147 patients in the control group. Multivariable logistic regression showed that increased attenuation of small bowel wall (P = 0.002), diffuse mesenteric haziness (P = 0.010), difference of CT value between mesenteric vessel and aorta (P = 0.025) and U-/C-shaped small bowel loop (P = 0.010) were independent risk factors for the diagnosis of mechanical SBO with small bowel necrosis. Through internal verification, the area under curve (AUC) of the predictive model reached 0.886 (95%CI: 0.824-0.947), and the calibration result was moderate. CONCLUSION Multiple features (increased attenuation of small bowel wall; difference of CT values between mesenteric vessel and aorta; diffuse mesenteric haziness; and U-/C-shaped small bowel loop) of unenhanced CT have clinical value in the diagnosis of mechanical SBO with small bowel necrosis. The predictive model based on these four features could achieve satisfactory efficiency.
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Affiliation(s)
- Xianwei Liu
- Department of General Surgery, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, Jiujiang, China.
| | - MingJie Zhu
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Sichuan province, Leshan, China
| | - Ming Wu
- Department of Image Center, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, China
| | - Zhangsong Cheng
- Department of Image Center, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, China
| | - Xiaoyu Wu
- Department of General Surgery, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, Jiujiang, China
| | - Renfang Zhu
- Department of General Surgery, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, Jiujiang, China
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Gómez Corral J, Niño Rojo C, de la Fuente Olmos R. Bowel obstruction: signs indicating the need for urgent surgery. RADIOLOGIA 2023; 65 Suppl 1:S92-S98. [PMID: 37024235 DOI: 10.1016/j.rxeng.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/11/2022] [Indexed: 04/08/2023]
Abstract
Bowel obstruction is common in emergency departments. Obstruction is more common in the small bowel than in the large bowel. The most common cause is postsurgical adhesions. Nowadays, bowel obstruction is diagnosed with multidetector computed tomography (MDCT). MDCT studies for suspected bowel obstruction should focus on four points that need to be mentioned in the report: confirming the obstruction, determining whether there is a single transition point or whether the obstruction is found in a closed loop, establishing the cause of the obstruction, and seeking signs of complications. Identifying signs of ischemia is important in the management of the patient because it enables patients at higher risk of poor outcomes after conservation treatment who could benefit from early surgical intervention to avoid greater morbidity and mortality associated with strangulation and ischemia of the obstructed bowel loop.
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Affiliation(s)
- J Gómez Corral
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - C Niño Rojo
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain
| | - R de la Fuente Olmos
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain
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7
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Chen B, Sheng WY, Ma BQ, Mei BS, Xiao T, Zhang JX. Progress in diagnosis and treatment of surgery-related adhesive small intestinal obstruction. Shijie Huaren Xiaohua Zazhi 2022; 30:1016-1023. [DOI: 10.11569/wcjd.v30.i23.1016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022] Open
Abstract
Adhesive small bowel obstruction is a relatively common surgical acute abdomen, which is caused by various factors that result in the contents of the small bowel failing to pass smoothly. The clinical symptoms include abdominal pain, distension, nausea and vomiting, and defecation disorder. The chance of adhesive small bowel obstruction to develop in patients with a history of abdominal surgery is around 2.4%. This paper discusses the most recent developments in the conservative and surgical management of adhesive small bowel obstruction based on clinical manifestation, laboratory analysis, and imaging examination.
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Affiliation(s)
- Biao Chen
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Wei-Yong Sheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Bing-Qing Ma
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Bo-Sheng Mei
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Tian Xiao
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jin-Xiang Zhang
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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8
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Understanding CT imaging findings based on the underlying pathophysiology in patients with small bowel ischemia. Jpn J Radiol 2022; 41:353-366. [PMID: 36472804 PMCID: PMC10066158 DOI: 10.1007/s11604-022-01367-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
AbstractBecause acute small bowel ischemia has a high mortality rate, it requires rapid intervention to avoid unfavorable outcomes. Computed tomography (CT) examination is important for the diagnosis of bowel ischemia. Acute small bowel ischemia can be the result of small bowel obstruction or mesenteric ischemia, including mesenteric arterial occlusion, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. The clinical significance of each CT finding is unique and depends on the underlying pathophysiology. This review describes the definition and mechanism(s) of bowel ischemia, reviews CT findings suggesting bowel ischemia, details factors involved in the development of small bowel ischemia, and presents CT findings with respect to the different factors based on the underlying pathophysiology. Such knowledge is needed for accurate treatment decisions.
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9
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Obstrucción intestinal: signos de indicación quirúrgica urgente. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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10
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Yang SJ, Lim HJ, Park SH, Choi SJ, Shim YS. Interpretation discrepancies of abdominal imaging by on-call radiology residents: Evaluation of risk factors. PLoS One 2022; 17:e0274313. [PMID: 36084145 PMCID: PMC9462765 DOI: 10.1371/journal.pone.0274313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to determine the rate, important findings, and risk factors related to discrepancies between on-call residents’ and attending radiologists’ interpretations of abdominal examinations. We identified 1132 eligible patients with abdominal radiology findings that were preliminary interpreted by on-call residents between February 2016 and September 2019. The preliminary interpretations were compared with the final interpretations by abdominal attending radiologists, including clinical data. The preliminary interpretations were analyzed by three radiologists in consensus, who categorized the reports according to organs, important findings (i.e., active bleeding, bowel obstruction, organ ischemia or infarction, and organ rupture), clinical outcomes, and discrepancies with respect to final interpretations. Multiple logistic regression analysis was used to evaluate the risk factors for important discrepant findings. Of 1132 patients, the bowel (n = 567, 50.1%) was the most common organ interpreted by on-call residents, followed by gallbladder/bile duct/pancreas (n = 139, 12.3%) and liver (n = 116, 10.2%). Of 1132, 359 patients (31.7%) had disease with 379 important findings: active bleeding (n = 222), organ rupture (n = 77), bowel obstruction (n = 52), bowel ischemia (n = 24), and organ infarction (n = 4). Sixty-four patients (5.6%) showed discrepancies, and 30 (2.6%) showed 32 important discrepant findings comprising 14 active bleeding, 10 bowel obstructions, 6 organ ruptures, and 2 cases of bowel ischemia. Of the 64 discrepant patients, 33 underwent delayed surgery (n = 18, 28.1%) or interventional treatment (n = 15, 23.4%). In multivariable analysis, bowel obstruction (adjusted odds ratio, 2.52; p = 0.049) was an independent risk factor for determining discrepancy between preliminary and final interpretations. The rate of overall and important discrepancies between on-call residents’ and final interpretations was low. However, given that the bowel was the most frequently interpreted organ, bowel obstruction was identified as a risk factor for discrepant interpretations. The identified risk factor and findings may be useful for residents to minimize discrepancies.
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Affiliation(s)
- Su Jeong Yang
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - Hee Joong Lim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - So Hyun Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
- * E-mail:
| | - Seung Joon Choi
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - Young Sup Shim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
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Machine Learning Based Prediction Model for Closed-Loop Small Bowel Obstruction Using Computed Tomography and Clinical Findings. J Comput Assist Tomogr 2022; 46:169-174. [PMID: 35297573 DOI: 10.1097/rct.0000000000001269] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of the study was to develop a prediction model for closed-loop small bowel obstruction integrating computed tomography (CT) and clinical findings. METHODS The radiology database and surgical reports from 2 suburban teaching hospitals were retrospectively reviewed for patients undergoing surgery for suspected closed-loop small bowel obstruction (CLSBO). Two observers independently reviewed the CT scans for the presence of imaging features of CLSBO, blinded to the surgically confirmed diagnosis and clinical parameters. Random forest analysis was used to train and validate a prediction model for CLSBO, by combining CT and clinical findings, after randomly splitting the sample into 80% training and 20% test subsets. RESULTS Surgery confirmed CLSBO in 185 of 223 patients with clinically suspected CLSBO. Age greater than 52 years showed 2.82 (95% confidence interval = 1.13-4.77) times higher risk for CLSBO (P = 0.021). Sensitivity/specificity of CT findings included proximal dilatation (97/5%), distal collapse (96/2%), mesenteric edema (94/5%), pneumatosis (1/100%), free air (1/98%), and portal venous gas (0/100%). The random forest model combining imaging/clinical findings yielded an area under receiver operating curve of 0.73 (95% confidence interval = 0.58-0.94), sensitivity of 0.72 (0.55-0.85), specificity of 0.8 (0.28-0.99), and accuracy of 0.73 (0.57-0.85). Prior surgery, age, lactate, whirl sign, U/C-shaped bowel configuration, and fecalization were the most important variables in predicting CLSBO. CONCLUSIONS A random forest model found clinical factors including prior surgery, age, lactate, and imaging factors including whirl sign, fecalization, and U/C-shaped bowel configuration are helpful in improving the prediction of CLSBO. Individual CT findings in CLSBO had either high sensitivity or specificity, suggesting that accurate diagnosis requires systematic assessment of all CT signs.
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12
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Lawrence EM, Pickhardt PJ. Evaluating suspected small bowel obstruction with the water-soluble contrast challenge. Br J Radiol 2022; 95:20210791. [PMID: 34826227 PMCID: PMC8822578 DOI: 10.1259/bjr.20210791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
With optimized technique, the water-soluble contrast challenge is effective at triaging patients for operative vs non-operative management of suspected small bowel obstruction. Standardized study structure and interpretation guidelines aid in clinical efficacy and ease of use. Many tips and tricks exist regarding technique and interpretation, and their understanding may assist the interpreting radiologist. In the future, a CT-based water-soluble contrast challenge, utilizing oral contrast given as part of the initial CT examination, might allow for a more streamlined algorithm and provide more rapid results.
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Affiliation(s)
- Edward M. Lawrence
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Perry J. Pickhardt
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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13
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Chai Y, Xing J, Lv P, Liang P, Xu H, Yue S, Gao J. Evaluation of ischemia and necrosis in adhesive small bowel obstruction based on CT signs: Subjective visual evaluation and objective measurement. Eur J Radiol 2021; 147:110115. [PMID: 34990890 DOI: 10.1016/j.ejrad.2021.110115] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/23/2021] [Accepted: 12/19/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the diagnostic performance of CT signs for detecting bowel ischemia and necrosis in adhesive small bowel obstruction(SBO) with subjective and objective methods. MATERIALS AND METHODS 113 adhesive SBO patients were enrolled and divided into ischemic group (49 cases in necrotic group and 35 cases in reversible ischemic group) and non-ischemic group (29 cases) according to the operation results. Subjective visual assessment of CT signs associated with ischemia and necrosis was performed by two radiologists independently. Elevated unenhanced attenuation and enhancement value of involved bowel wall were objectively measured and compared by single factor analysis of variance. Cut-off value and diagnostic performance were evaluated by receiver operating characteristic curve (ROC). RESULTS Closed-loop mechanism, reduced bowel wall enhancement, and mesenteric edema were associated with bowel ischemia, with sensitivity of 81.0%, 65.5%, 75.0%, and specificity of 86.2%, 96.6%, 89.7%, respectively. Increased unenhanced bowel wall attenuation was a specific sign for necrosis with 100.0% specificity and 51.0% sensitivity. The sensitivity and specificity for ischemia were 86.0% and 91.9% with cut-off enhancement value lower than 33.5 HU. The sensitivity and specificity for necrosis were 58.2% and 100.0% with cut-off elevated unenhanced attenuation higher than 16.5 HU, 86.7% and 83.3% with cut-off enhancement value lower than 21.5 HU. CONCLUSION Reduced bowel wall enhancement and increased unenhanced bowel wall attenuation were good indicators of bowel ischemia and necrosis. The objective measurement of elevated unenhanced attenuation and enhancement value can predict bowel ischemia and necrosis more accurately.
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Affiliation(s)
- Yaru Chai
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Jingjing Xing
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Peijie Lv
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Pan Liang
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Huanan Xu
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Songwei Yue
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Jianbo Gao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China.
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Water-Soluble Contrast Challenge for Suspected Small Bowel Obstruction: Technical Success Rate, Accuracy, and Clinical Outcomes. AJR Am J Roentgenol 2021; 217:1365-1366. [PMID: 34161132 DOI: 10.2214/ajr.21.26132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Among 109 iohexol-based water-soluble contrast challenges performed for suspected small bowel obstruction, 105 were technically adequate. Among technically-adequate studies, colonic contrast (i.e., successful challenge) was seen in 66 on 8-hour, and 86 on 24-hour, radiograph. Fourteen patients underwent operative magnement; 91 underwent non-operative management (NOM). Successful challenge had sensitivity 91.2%, specificity 78.5%, PPV 96.5%, NPV 57.8%, and odds ratio 38.0 (95% CI, 8.7-165.2) for NOM. Three of 86 patients with successful challenge underwent operative management.
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15
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Payza U, Kayali A, Bilgin S, Karakaya Z, Esad Topal F. When is the right time to take an emergency surgery decision in Mechanical Intestinal Obstruction? Asian J Surg 2021; 44:854-859. [PMID: 33712329 DOI: 10.1016/j.asjsur.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/27/2021] [Accepted: 02/21/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND /Objective: Ischemia is a leading cause of morbidity in Mechanical Intestinal Obstruction (MIO) in which the timing of decisions of whether to proceed to surgical or conservative treatment is critical in emergency departments (ED). While advanced technological options are available, patients may be negatively affected by the application of contrast agents or radiation. The use of ultrasound is limited because of the air in the intestines does not allow a good field of vision. While biomarkers can be considered as a good alternative option at this point. In the present study we examine the effect of hemogram and blood gas parameters on early surgical decision-making in MIO patients. METHOD Involved in this observational prospective study were 264 patients diagnosed with MIO who presented to the Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University between February 2018 and February 2019. Contrast-enhanced tomography (CECT) and laboratory results of the patients were recorded. Pathology reports of the patients who underwent surgery were collected. Laboratory data were analyzed by comparing CECT and pathology reports. RESULTS In a ROC analysis of the laboratory values of the patients who were diagnosed with ileus, the sensitivity was calculated as 80% and the specificity was 57.7 in values above WBC>10.75 (109/L), 96.6%, and the specificity was 31.1% in N/L > 2.9. For intestinal ischemia, the cut-off values were WBC> 12.6 and N/L > 3.2, Lactate >2.8 mmol/L and B.E < -3.6 mmol/L. CONCLUSION Diagnoses of ileus are based on the results examinations and imaging methods. More data are needed to support decisions on the timing of surgery in ED. WBC, N/L, Lactate and Base Excess indicate an ischemic segment. When the parameters are evaluated together, they strongly support early surgical decision-making regarding the treatment of intestinal ischemia.
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Affiliation(s)
- Umut Payza
- Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University, İzmir, Turkey.
| | - Ahmet Kayali
- Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University, İzmir, Turkey.
| | - Serkan Bilgin
- Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University, İzmir, Turkey.
| | - Zeynep Karakaya
- Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University, İzmir, Turkey.
| | - Fatih Esad Topal
- Department of Emergency Medicine, Ataturk Research and Training Hospital, Katip Celebi University, İzmir, Turkey.
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Computed Tomography Findings Predicting the Need for Surgery in Cases of Small Bowel Obstruction: Emphasis on Duodenal Distension. J Comput Assist Tomogr 2021; 45:5-11. [PMID: 32558767 DOI: 10.1097/rct.0000000000001045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study is to retrospectively evaluate the utility of computed tomography (CT) findings, especially newly defined duodenal distension, for predicting the need to operate on small bowel obstruction (SBO) cases. METHODS During a 51-month period, 228 patients (100 women and 128 men; mean age, 55 years) were included in this study, among 438 patients who were hospitalized with a prediagnosis of SBO. The final study population was then divided into 2 groups: a surgery group (n = 76) and a conservative group (n = 152). The CT findings of the SBO patients whose treatment decisions and outcomes were unknown were examined by 2 gastrointestinal radiologists with consensus. Statistical analyses were conducted using univariate and binary logistic regression analyses. RESULTS According to the univariate analysis, the degree of obstruction (P = 0.001), small bowel diameter (P = 0.014), and presence of mesenteric fluid (P < 0.001), intraperitoneal free fluid (P = 0.04), intra-abdominal free gas (P < 0.001), and duodenal distension (P < 0.001) showed statistically significant differences between the surgery and conservative groups. However, there were no statistically significant group differences regarding the presence of a transition point, small bowel feces or mesenteric congestion. According to the binary logistic regression analysis, the degree of obstruction (P = 0.012), presence of mesenteric fluid (P = 0.008), intra-abdominal free gas (P = 0.019), and duodenal distension (P < 0.001) were significant predictors of the need for surgery in SBO cases. CONCLUSIONS Duodenal distension as a CT finding predicted the need for surgery in SBO cases.
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Image Annotation by Eye Tracking: Accuracy and Precision of Centerlines of Obstructed Small-Bowel Segments Placed Using Eye Trackers. J Digit Imaging 2020; 32:855-864. [PMID: 31144146 DOI: 10.1007/s10278-018-0169-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Small-bowel obstruction (SBO) is a common and important disease, for which machine learning tools have yet to be developed. Image annotation is a critical first step for development of such tools. This study assesses whether image annotation by eye tracking is sufficiently accurate and precise to serve as a first step in the development of machine learning tools for detection of SBO on CT. Seven subjects diagnosed with SBO by CT were included in the study. For each subject, an obstructed segment of bowel was chosen. Three observers annotated the centerline of the segment by manual fiducial placement and by visual fiducial placement using a Tobii 4c eye tracker. Each annotation was repeated three times. The distance between centerlines was calculated after alignment using dynamic time warping (DTW) and statistically compared to clinical thresholds for diagnosis of SBO. Intra-observer DTW distance between manual and visual centerlines was calculated as a measure of accuracy. These distances were 1.1 ± 0.2, 1.3 ± 0.4, and 1.8 ± 0.2 cm for the three observers and were less than 1.5 cm for two of three observers (P < 0.01). Intra- and inter-observer DTW distances between centerlines placed with each method were calculated as measures of precision. These distances were 0.6 ± 0.1 and 0.8 ± 0.2 cm for manual centerlines, 1.1 ± 0.4 and 1.9 ± 0.6 cm for visual centerlines, and were less than 3.0 cm in all cases (P < 0.01). Results suggest that eye tracking-based annotation is sufficiently accurate and precise for small-bowel centerline annotation for use in machine learning-based applications.
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Kim J, Lee Y, Yoon JH, Lee HJ, Lim YJ, Yi J, Jung WB. Non-strangulated adhesive small bowel obstruction: CT findings predicting outcome of conservative treatment. Eur Radiol 2020; 31:1597-1607. [PMID: 33128599 DOI: 10.1007/s00330-020-07406-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To clarify CT findings that predict outcome of conservative treatment in patients with non-strangulated adhesive small bowel obstruction (SBO). METHODS Unenhanced and contrast-enhanced abdominopelvic CT studies in 189 patients with adhesive SBO who had initial conservative treatment were reviewed. The CT findings included transition zone, beak signs, maximum bowel diameter, bowel diameter ratio, decreased bowel wall enhancement, increased unenhanced bowel wall attenuation, anterior parietal adhesion, bowel wall thickening, closed-loop obstruction, small bowel feces sign, whirl sign, mesenteric haziness, mesenteric, peritoneal fluid, and submucosal edema. These findings were statistically compared according to the success or failure of treatment. RESULTS Conservative treatment succeeded in 144 patients (76.2%) and failed in 45 patients (23.8%). At multivariate analysis, the lack of small bowel feces sign, focal, diffuse mesenteric haziness, and moderate amount of mesenteric fluid were independent findings predicting failure of conservative treatment, with odds ratios of 5.23, 5.5, 13.55, and 4.89, respectively. The presence of all significant findings showed a high specificity of 97.2% with positive likelihood ratio of 8.8. If CT scans showed none of the three significant findings, the negative predictive value was 97.6% and negative likelihood ratio was 0.08. CONCLUSIONS The lack of small bowel feces sign, focal, diffuse mesenteric haziness, and moderate amount of mesenteric fluid are independent CT findings predicting the failure of conservative treatment in patients with non-strangulated adhesive SBO. The combination of all CT findings suggests the need for surgery; absence of two or all CT findings should suggest an attempt for conservative treatment. KEY POINTS • To minimize delayed operation, it is important to identify non-strangulated adhesive small bowel obstruction patients in whom initial conservative treatment is likely to fail. • The lack of small bowel feces sign, the presence of mesenteric haziness, and a moderate amount of mesenteric fluid are independent factors predicting the failure of conservative treatment in patients with non-strangulated adhesive small bowel obstruction. • The combination of all three CT findings suggests the need for surgery; absence of two or all three CT findings should suggest an attempt for conservative treatment.
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Affiliation(s)
- Jieun Kim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea.,Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yedaun Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea.
| | - Jung-Hee Yoon
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Ho-Joon Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Yun-Jung Lim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Jisook Yi
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Won Beom Jung
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
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19
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Zins M, Millet I, Taourel P. Adhesive Small Bowel Obstruction: Predictive Radiology to Improve Patient Management. Radiology 2020; 296:480-492. [PMID: 32692296 DOI: 10.1148/radiol.2020192234] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adhesive small bowel obstruction (SBO) remains one of the leading causes of emergency room visits and is still associated with high morbidity and mortality rates. Because the management of adhesive SBO has shifted from immediate surgery to nonoperative treatment in the absence of ischemia, it is crucial to rapidly detect or predict strangulation, which requires emergent surgery. CT is now established as the best imaging technique for the initial assessment of patients suspected of having adhesive SBO. CT helps confirm the diagnosis of mechanical SBO, locate the site of obstruction, establish the cause, and detect complications. This article is a review of the role of imaging in answering specific questions to help predict the management needs of each individual patient. It includes (a) an update on the best CT signs for predicting ischemia and a need for bowel resection; (b) a discussion of the CT features that help differentiate open-loop from closed-loop obstruction and a single adhesive band from matted adhesions and how these differences can influence the management; and (c) a review of the main CT predictors of the success or failure of nonoperative management in adhesive SBO.
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Affiliation(s)
- Marc Zins
- From the Department of Medical Imaging, Saint Joseph Hospital, 185 rue Raymond Losserand, 75014 Paris, France (M.Z.); Department of Medical Imaging, Lapeyronie Hospital, Montpellier, France (I.M., P.T.); and Department of Medical Imaging, University of Montpellier, Montpellier, France (I.M., P.T.)
| | - Ingrid Millet
- From the Department of Medical Imaging, Saint Joseph Hospital, 185 rue Raymond Losserand, 75014 Paris, France (M.Z.); Department of Medical Imaging, Lapeyronie Hospital, Montpellier, France (I.M., P.T.); and Department of Medical Imaging, University of Montpellier, Montpellier, France (I.M., P.T.)
| | - Patrice Taourel
- From the Department of Medical Imaging, Saint Joseph Hospital, 185 rue Raymond Losserand, 75014 Paris, France (M.Z.); Department of Medical Imaging, Lapeyronie Hospital, Montpellier, France (I.M., P.T.); and Department of Medical Imaging, University of Montpellier, Montpellier, France (I.M., P.T.)
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20
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Chang KJ, Marin D, Kim DH, Fowler KJ, Camacho MA, Cash BD, Garcia EM, Hatten BW, Kambadakone AR, Levy AD, Liu PS, Moreno C, Peterson CM, Pietryga JA, Siegel A, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. J Am Coll Radiol 2020; 17:S305-S314. [PMID: 32370974 DOI: 10.1016/j.jacr.2020.01.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Kevin J Chang
- Boston University Medical Center, Boston, Massachusetts.
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Benjamin W Hatten
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians
| | | | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | | | | | | | | | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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21
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Zhou J, Cong R, Shi J, Chen F, Zhu J, Xiao J, Sheng M, Yang J, He B. Diagnostic significance of multidetector computed tomography (MDCT) in patients with small bowel obstruction: a meta-analysis. Jpn J Radiol 2020; 38:458-462. [PMID: 32189176 DOI: 10.1007/s11604-020-00923-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/21/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To assess the diagnostic value of multidetector computed tomography (MDCT) in small bowel obstruction (SBO) patients. METHODS Relevant literature was searched from the Cochrane Library, Pubmed and Embase. The extracted effective data was calculated using the Meta-Disc 1.4 software; statistical heterogeneity was evaluated using Cochran's Q test and I2. RESULTS A total of five articles were selected for the meta-analysis. In addition, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), as well as the diagnostic odds ratio (DOR) were 0.878 (95% CI 0.822-0.921), 0.807 (95% CI 0.753-0.854), 8.137 (95% CI 2.268-29.192), 0.127 (95% CI 0.040-0.4078) and 72.384 (95% CI 10.841-483.31), respectively. Furthermore, the AUC was 0.9648 with the Q of 0.9116. CONCLUSIONS The data suggest that MDCT is an effective method for diagnosis of SBO.
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Affiliation(s)
- Jie Zhou
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Ruochen Cong
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Jianhua Shi
- Department of Biochemistry, Nantong University Medical School, Nantong, 226019, Jiangsu, China
| | - Feixiang Chen
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Jianfeng Zhu
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Jing Xiao
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, 226019, Jiangsu, China
| | - Meihong Sheng
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China
| | - Jushun Yang
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China.
| | - Bosheng He
- Department of Radiology, Affiliated Hospital 2 of Nantong University, No. 6 Hai Er Xiang North Road, Nantong, 226001, Jiangsu, China.
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Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy. AJR Am J Roentgenol 2020; 215:69-78. [PMID: 31913069 DOI: 10.2214/ajr.19.21989] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific considerations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy. CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
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Li Z, Zhang L, Liu X, Yuan F, Song B. Diagnostic utility of CT for small bowel obstruction: Systematic review and meta-analysis. PLoS One 2019; 14:e0226740. [PMID: 31887146 PMCID: PMC6936825 DOI: 10.1371/journal.pone.0226740] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Zhengyan Li
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ling Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xijiao Liu
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Fang Yuan
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Bin Song
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Kuang LQ, Tang W, Li R, Cheng C, Tang SY, Wang Y. Optimized protocol of multiple post-processing techniques improves diagnostic accuracy of multidetector computed tomography in assessment of small bowel obstruction compared with conventional axial and coronal reformations. World J Gastroenterol 2019; 25:1100-1115. [PMID: 30862998 PMCID: PMC6406184 DOI: 10.3748/wjg.v25.i9.1100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/13/2019] [Accepted: 02/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Axial and coronal reformations have been a widely used image post-processing protocol for the ordinary multidetector computed tomography (MDCT) examination of patients with small bowel obstruction (SBO) or other abdominal diseases. The diagnostic accuracy of MDCT for assessing SBO is expected to be further improved through the use of multiple post-processing techniques.
AIM To systemically evaluate the diagnostic accuracy and efficiency of an optimized protocol using multiple post-processing techniques for MDCT assessment of SBO and secondary bowel ischemia.
METHODS This retrospective cross-sectional study included 106 patients with clinically suspected SBO. Two readers applied three protocols to image post-processing and interpretation of patients’ MDCT volume data. We compared the three protocols based on time spent, number of images, diagnostic self-confidence, agreement, detection rate, and accuracy of detection of SBO and secondary bowel ischemia.
RESULTS Protocol 2 resulted in more time spent and number of images than protocols 1 and 3 (P < 0.01), but the results of the two readers using the same protocol were not different (P > 0.05). Using protocol 3, both readers added multiple post-processing techniques at frequencies of 29.2% and 34.9%, respectively, for obstruction cause, and 32.1% and 30.2%, respectively, for secondary bowel ischemia. Protocols 2 and 3 had higher total detection rates of obstruction cause and secondary bowel ischemia than protocol 1 (P < 0.01), but no difference was detected between protocols 2 and 3 (P > 0.05). The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of protocols 2 and 3 were superior to those of protocol 1 for evaluating obstruction cause and secondary bowel ischemia.
CONCLUSION Our optimized protocol of multiple post-processing techniques can both guarantee efficiency and improve diagnostic accuracy of MDCT for assessing SBO and secondary bowel ischemia.
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Affiliation(s)
- Lian-Qin Kuang
- Department of Radiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
| | - Wei Tang
- Department of Radiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Ran Li
- Department of Radiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
| | - Cheng Cheng
- Department of Radiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
| | - Shuang-Yue Tang
- Department of Radiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
| | - Yi Wang
- Department of Radiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
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25
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Management of adhesive small bowel obstruction: A distinct paradigm shift in the United States. J Trauma Acute Care Surg 2019; 86:383-391. [DOI: 10.1097/ta.0000000000002150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hepatic portal venous gas associated with Klebsiella oxytoca infection in the absence of preceding antibiotic treatment. Clin J Gastroenterol 2019; 12:316-319. [PMID: 30739249 DOI: 10.1007/s12328-019-00947-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
Abstract
Klebsiella oxytoca (K. oxytoca) is a causative organism for hemorrhagic antibiotic-associated colitis. K. oxytoca infection is a typical example of microbial substitution diseases caused by exposure to antibiotics prior to the onset of diarrhea. Here, we repot a case with ileitis associated with K. oxytoca infection in the absence of preceding antibiotic treatment. Interestingly, abdominal computed tomography revealed wall thickening of the ileum and hepatic portal venous gas (HPVG). K. oxytoca was isolated from the stool. This very elderly patient had been treated with azathioprine for long-standing history of ulcerative colitis. Immuno-compromised state of this patient was considered to allow overgrowth of K. oxytoca in the small bowel to cause not only ileitis but also HPVG.
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Abstract
PURPOSE To analyze CT signs of bowel ischemia in patients with surgical bowel obstruction, and thereby improve CT diagnosis in this common clinical scenario. Surgical and histopathological findings were used as the reference standard. METHODS We retrospectively analyzed CT findings in patients brought to surgery for bowel obstruction over 13 years. Etiology of obstruction (adhesion, hernia, etc.) was recorded. Specific CT features of acute mesenteric ischemia (AMI) were analyzed, including bowel wall thickening, mucosal hypoenhancement, and others. RESULTS 173 cases were eligible for analysis. 21% of cases were positive for bowel ischemia. Volvulus, internal hernia, and closed-loop obstructions showed ischemia rates of 60%, 43%, and 43%; ischemia rate in obstruction from simple adhesion was 21%. Patients with bowel obstruction related to malignancy were never ischemic. Sensitivities and specificities for CT features predicting ischemia were calculated, with wall thickening, hypoenhancement, and pneumatosis showing high specificity for ischemia (86%-100%). CONCLUSION Wall thickening, hypoenhancement, and pneumatosis are highly specific CT signs of ischemia in the setting of obstruction. None of the evaluated CT signs were found to be highly sensitive. Overall frequency of ischemia in surgical bowel obstruction is 21%, and 2-3 times that for complex obstructions (volvulus, closed loop, etc.). Obstructions related to malignancy virtually never become ischemic.
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Bower KL, Lollar DI, Williams SL, Adkins FC, Luyimbazi DT, Bower CE. Small Bowel Obstruction. Surg Clin North Am 2018; 98:945-971. [PMID: 30243455 DOI: 10.1016/j.suc.2018.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.
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Affiliation(s)
- Katie Love Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA.
| | - Daniel I Lollar
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Sharon L Williams
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Farrell C Adkins
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - David T Luyimbazi
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Curtis E Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
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29
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Increased unenhanced bowel-wall attenuation: a specific sign of bowel necrosis in closed-loop small-bowel obstruction. Eur Radiol 2018; 28:4225-4233. [DOI: 10.1007/s00330-018-5402-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/20/2018] [Accepted: 02/21/2018] [Indexed: 12/24/2022]
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Clinical Relevance of the Feces Sign in Small-Bowel Obstruction Due to Adhesions Depends on Its Location. AJR Am J Roentgenol 2018; 210:78-84. [DOI: 10.2214/ajr.17.18126] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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31
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Sun Should Not Rise and Set on a Case of Acute Intestinal Obstruction. Dig Dis Sci 2018; 63:27-31. [PMID: 28500588 DOI: 10.1007/s10620-017-4612-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/08/2017] [Indexed: 12/09/2022]
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