Intestinal Obstruction - Xray
6/18/2009 09:35:00 PM | Author: fadzly
Topic today would be identifying Intestinal Obstruction in an abdominal X-ray. It's more or less like a quiz. Let's get started

Case 1
A 36 year old male with vomiting- for 1/7

Ok. How to interpret this?
It looks normal isn't it? Of coz it's normal. We need to know which one is normal. But if this normal, u still need to comment. What to look for in a 'normal' x-ray anyway?

Things to look for are
  • Technical – Is the X-ray adequate?
  • Is the gas in the correct place?
  • Is there abnormal calcification or mass?
  • Is the visualised bone and soft tissue normal?
  • Any foreign bodies?

Case 2
8year old boy with abdominal pain

Hoho.. what do u think? Looks a bit shiny isn't it?
  • It's a metallic foreign body projected over the left iliac fossa
  • No dilated bowel loops
  • Very unlikely to cause intestinal obstruction

Case 3
50 year old male with vomiting and NBO for 5/7

Look a bit bizarre rite? Take a proper look at the right side of the inguinal region. Is that a bowel?
This is actually an inguinal hernia basically a clinical diagnosis. Why do we do an Xray then? To rull out intestinal obstruction.
  • Radiograph shows dilated small bowel in abdomen
  • Bowel in the left inguinal region extending into the scrotum

Case 4
52 year old female with abdominal distension and vomiting for 2 days with a previous history of appendicectomy

Based from the history, adhesion would be more likely to cause intestinal obstruction due to adhesions from the previous appendicectomy.
  • Note the multiple air fluid levels on the erect AXR
  • On the supine radiograph – dilated loops of air filled small bowel

There is one question so common to ask in viva - How do you differentiate dilated small and large bowel?
  • Easy - Look a the bowel fold
  • Small bowel folds extend from one end of the bowel wall to the other
  • Large bowel folds- Haustra extend about one third of the way
  • Small bowel is also more central in position in the abdomen

Case 5
45 year old female with abdominal distension for 5 months

This one abit difficult. Where is the bowel actually? This is a large abdominal mass!
Bowel loops are displaced laterally and superiorly by a large soft tissue mass which appears to arise from the pelvis. Note a dilated small bowel loop in the right lumbar region.

Case 6
48 year old male – post gastrectomy 1 day

This could be paralytic ileus. I forgot to tell u that apart from adhesion, paralytic ileus could also be the cause of Intestinal Obstruction. However, an ileus can be diagnose based on abdominal examination by absence of bowel sound.
Note dilated small and large bowel. Apart from paralytic ileus, sub acute distal large bowel obstruction can give a identical appearance

Case 7
76 year old female with loss of weight for 3 months and now presents with NBO for 3 days.

Note the dilated air filled large bowel, from the caecum to the splenic flexure. This is a large bowel obstruction at the level of the splenic flexure.
This was due to carcinoma of the colon. A colonscopy would confirm this diagnosis
Ba Enema (Limited)- would also confirm the diagnosis. A CT would show the mass and is useful for staging

Case 8
30 year old female with non specific abdominal pain – 1 year

Non specific abdominal pain.. If you see this in Primary Care, sure you handle this as an irritable bowel syndrome.. HAHA.. yup this one is a normal small bowel enema. Note the “small bowel enema tube”. Normal small bowel folds which become less prominent in the ileum

Case 9
33 year old male with loss of weight – 4 months and vomiting for 5/7

There is thickened small bowel folds and strictures

It's a Lymphoma

Case 10
43 year old male with vomiting and lower abdominal pain- 1/7

This is a dilated loop of Large bowel. Inverted ‘U’ shaped loop of large bowel arising from the pelvis. Inverted ‘U’ shaped loop of large bowel arising from the pelvis. Suspect a volvulus (twist) of the sigmoid colon. How to confirm?

By doing a barium enema
Note the site of twist. This has been called the ‘Bird’s Beak’ sign

Case 11
20 year old male with history of chronic constipation since childhood

Diagnosis: Hirschprung Disease
Grossly dilated large bowel
Filled with faeces
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