Case jj -  Small bowel obstruction

There are dilated loops of small bowel with air fluid levels (1, 2).  Distally, the loops of small bowel are decompressed.  This is a small bowel obstruction.  Your job now is to find the transition point and attempt to identify evidence of ischemia or a closed loop.  The transition point is seen in the left upper abdomen. Scroll through this area to convince yourself. 

There is mild stranding but no ascites or bowel wall thickening to suggest ischemia.   There is no evidence of a closed loop.  There is no obstructing mass.  Given the history of prior surgery, the obstruction is likely caused by an adhesion.  It is very rare to see an actual adhesion on CT.

Notice the appearance of fecalization of the bowel.  This loop of small bowel looks like it contains feces.  This is crud and debris in the bowel just proximal to the site of obstruciton.  Fecalization is a nonspecific sign for bowel pathology.  It is seen in obstruction, ischemia, ileus, inflammation, and infection.

This patient has his terminal ileum and portions of the cecum removed as a child.  There is no ileocecal valve or appendix.  The ileo-colonic anastamosis is seen here.  Scroll through this region to convince yourself.  When you cannot find a terminal ileum or appendix, suspect prior surgery.  In this case, there are no radio-opaque staple lines to assist you.  Notice that the patient still has a retroperitoneal ascending colon.

The patient went to the OR where adhesions were seen causing a small bowel obstruction.