KEPANITERAAN KLINIK ILMU RADIOLOGI

RSUD K.R.M.T WONGSONEGORO KOTA SEMARANG

FAKULTAS KEDOKTERAN UNIVERSITAS TARUMANGARA
PERIODE 20 MEI – 30 JUNI 2019

Ayu Saraswati
406181075
Pembimbing : dr. Lia Sasdesi Mangiri , Sp.Rad
 Small Bowel Obstruction

Charles P. Mullan, Bettina Siewert, Ronald L.

Eisenberg

Publikasi: 05 April 2017

 Pendahuluan
• Obstruksi usus halus (SBO) masih menjadi penyebab tersering terjadinya morbiditas
dan mortalitas yang signifikan, terutama keadaan akut
• Pencitraan  penting untuk mengidentifikasi SBO serta untuk mengetahui letak
dan penyebab dari obstruksi mekanik  mencegah komplikasi
• Pencitraan  MDCT
• SBO diperkirakan hampir 15% dari semua kasus bedah pada acute non traumatic
abdominal pain
 Pencitraan : radiografi abdomen
• Radiografi abdomen  pencitraan pertama pada kasus yang
dicurigai obstruksi usus,  mendiagnosis SBO dengan sensitivitas
64-82% dan spesifisitas 79-83

• Gambaran radiologi SBO 

– dilatasi of the usus halus proksimal (diameter > 3) dengan nondilatasi
distal bowel loops
– tidak terdapat dilatasi kolon
– multiple air-fluid levels (>2,5 cm) pada upright atau decubitus abdominal
radiographs (Fig.1).
 C

A B

Fig. 1—Small bowel obstruction.

A. Supine abdominal radiograph menunjuka dilatasi loops of small bowel.
B. Erect abdominal radiograph menunjukan dilatasi usus halus dengan multiple
air-fluid levels. (D>2.5 cm)
C. Axial CT image shows transition point in mid ileum (arrows), confirming
mechanical obstruction due to ileal stricture.
A B C

Fig. 2—Small bowel obstruction.

A and B, Supine (A) and erect (B) abdominal Radiographs show loop of dilated small bowel in left lower
quadrant, with paucity of bowel gas elsewhere in abdomen
C, Coronal CT image shows multiple loops of dilated small bowel filled with intraluminal fluid, which are
not visible on radiographs. This 35-year-old patient had small bowel obstruction due to adhesions from
prior laparotomy.
• The string of pearls sign may be seen in predominantly fluid-
filled loops of small bowel on erect or decubitus radiographs as
small amounts of intraluminal gas collecting along the superior
wall separated by the valvulae conniventes (Fig. 3).

Fig. 3—Upright abdominal radiograph shows stringof-

beads sign.
 Fluoroscopy and Follow-Through Examination
• Fluoroscopy and follow-through examination dengan kontras oral agents
jarang digunakan untuk mendiagnosis SBO, tapi pemeriksaan ini bisa
digunakan untuk mengetahui keparahan obstruksi.
• kontras oral agents -> mual dan muntah (Barium dan ater-soluble contrast
agents)
• The prolonged transit of contrast material through obstructed bowel
means that followthrough radiographs may have to be obtained for several
hours, delaying diagnosis
• If high-grade obstruction is present, minimal or no contrast material will
opacify small bowel loops distal to the transition zone on delayed
radiographs
Fig. 4—Small bowel obstruction.
A, Supine abdominal radiograph shows dilated small bowel loops
throughout abdomen.
B, Follow-through radiograph obtained after oral administration of
barium shows dilated jejunum on left flank. Tapering of lumen in
proximal ileum (arrow) without distal passage of contrast material
indicates site of obstruction, which was due to adhesion.
 MDCT
• Piliham pertama dalam mendiagnosis SBO
• Diagnosis SBO requires the dilatasi usus halus (transverse
diameter > 2.5 cm) and the presence of a discrete transition
zone between dilated proximal and nondilated distal bowel
– The transition zone may be a sharply defined point as with band
adhesions (Fig. 5) or a longer segment as with matted adhesions or
radiation enteritis (Fig. 6).
Fig. 6—Radiation enteritis in 53-year-old man who
underwent radiation therapy for colorectal neoplasm.
A and B, Axial (A) and sagittal (B) CT images show
segment of small bowel with mural thickening
(arrows) containing intraluminal contrast material.
This finding corresponds to radiation enteritis,
producing zone of transition in small bowel rather
than discrete transition point.
 Fig. 7—Ischemic small bowel in 74-year-old woman
presenting with acute abdominal pain.
A, Supine abdominal radiograph obtained at admission shows no small bowel
dilatation, with fecal material visible in large bowel.
B, Axial IV contrast-enhanced CT image shows small bowel with generalized mural
thickening (white arrows) and hypoenhancement relative to normal small intestine
(black arrows).
C, Axial CT image shows whirled appearance in left hemipelvis, with twisting of
mesentery (white arrows) and collapsed segment of small bowel (black arrowheads)
at site of volvulus. Edematous bowel is noted (black arrows) There is edema in
adjacent mesenteric fat. At surgery, internal hernia caused by prior gynecologic
surgery was indentified, and necrotic small bowel required extensive resection
B and end-to-end anastomosis.
 USG
• Ultrasound has a limited role in the assessment of small bowel
obstruction because of poor visualization of gas-filled
structures. It is usually restricted to assessment of abdominal
wall hernias that may be the site of incarcerated small bowel.
 Enteroclysis
In the setting of chronic or intermittent small bowel obstruction, enteroclysis
enables the small bowel to be distended adequately to highlight areas of
luminal stenosis. This technique requires the placement of a nasojejunal tube
for Instillation of a large amount of oral contrast material. Traditionally,
enteroclysis has been performed with barium and methylcellulose using
fluoroscopy. The volume challenge caused by methylcellulose administration
accentuates the effect of low-grade obstruction. The transition zone at the
site of obstruction can be missed using enterography or CT without volume
challenge but is readily identified after enteroclysis. CT and MRI are
increasingly used in conjunction with enteroclysis. Cross-sectional imaging
provides additional data that can identify extraintestinal manifestations of
Crohn disease.
 MR Enterography

• MR enterography is an increasingly attractive option for the

assessment of small bowel obstruction. However, the increased
time of image acquisition and the need for repeated breath-holds
to obtain high-quality images limits the application of MRI in
patients with acute small bowel obstruction. Therefore, it is most
useful in the setting of chronic small bowel abnormality and
lowgrade obstruction. This is particularly true in Crohn disease,
where reducing the accumulated dose of ionizing radiation in
young patients is desired. Multiplanar MRI can be used in the same
way as MDCT to look for evidence of a transition point and features
indicative of complications.
 Adhesions
• 80% pasien dengan SBO akibat adhesions memiliki riwayat operasi
intraabdominal -> Appendectomy and gynecologic surgery
• Band adhesions > matted adhesions menyebabkan complete SBO

Fig. 5—Adhesion causing small-bowel obstruction with prior surgery for

Crohn disease. Axial CT image shows sharp transition point (arrows) at site
of band adhesion, which required surgical repair. “Small bowel feces” sign,
presence of particulate material visible in proximal dilated segment of
intestine, is useful in identifying site of obstruction because particulate
matter tends to be most prominent just proximal to transition zone.
 Crohn Disease
• Small bowel obstruction may occur in Crohn disease by the
direct effect of strictured and inflamed segments of bowel or
by adhesions caused by prior surgical procedures.
• MR enterography may therefore be suitable for selected
patients with Crohn disease who have acute small bowel
obstruction, provided they can tolerate the longer imaging
time and need for breath-holding
Fig. 8—Crohn disease in 22-year-old man.
A, Coronal CT image shows grossly dilated segment
of small bowel in lower left flank.
B, Axial CT image shows long segment of ileum with
circumferential wall thickening from wall edema,
and discrete transition point is seen between this
segment and dilated proximal bowel (arrow).
C, Axial image shows stranding in mesenteric fat
immediately superior to thickened segment of small
bowel (arrows), consistent with active inflammatory
disease.
Fig. 9—MR enterography in Crohn disease in 31-yearold
woman.
A, Coronal T2-weighted image shows fluid with high
signal intensity in dilated loops of jejunum in left flank.
B and C, Axial T2-weighted (B) and axial contrastenhanced
T1-weighted fat-suppressed (C) images
show discrete mid ileal segment with circumferential
mural thickening and enhancement (arrows),
consistent with active Crohn disease. There is
transition point between inflamed segment of ileum
and dilated proximal bowel.
 Hernia Abdomen
• Hernias sering terjadi pada kelemahan otot dan ligamen di dinding
abdomenl.
• Although in some cases only fat may protrude into the hernia sac,
at times small or large bowel may become incarcerated within the
hernia, leading to obstruction (Fig. 10) and possible strangulation.
Elective repair is therefore commonly performed for these defects.
• A Richter hernia occurs when only the antimesenteric portion of a
segment of small bowel protrudes through a narrow defect in the
abdominal wall (Fig. 11) -> jarang menyebabkan obstruksi tapi bisa
menyebabkan iskemik
Fig. 10—Femoral hernia in elderly woman with acute
abdominal pain.
A and B, Axial (A) and coronal (B) abdominal CT images
show loop of small bowel (white arrow) protruding into
right groin. There is dilatation of proximal small bowel.
Orifice of hernia arises inferior in relation to inguinal
ligament and lateral to pubic tubercle (black arrow, A),
consistent with femoral hernia.
Fig. 11—Richter’s hernia with strangulated small bowel in 54-
year-old patient with no prior surgical history.
A and B, Sagittal (A) and axial (B) CT images show small defect
in musculature of right anterior abdominal
wall that developed spontaneously. Antimesenteric wall of
segment of small bowel protrudes into hernial sac
(arrows, B). Proximal small bowel is only mildly dilated because
luminal obstruction is not complete; herniated
portion of small bowel, however, was strangulated and
required surgical resection.
 Neoplastic Disease
• Metastatic disease is the most frequent neoplastic cause of small
bowel obstruction.
• Obstruction occurs by extrinsic compression of the small bowel
lumen (Fig. 12) or tethering of bowel loops by the serosal deposits.
• Metastasis tumor ke dinding usus halus, ex: melanoma ->
endoluminal obstruction
• Primary neoplasms pada usus halus jarang menyebabkan obstruksi
mekanik ex: adenocarcinoma, lymphoma, and gastrointestinal
stromal tumors -> luminal narrowing or intussusception.
Fig. 11—Richter’s hernia with strangulated small bowel in 54-
year-old patient with no prior surgical history.
A and B, Sagittal (A) and axial (B) CT images show small defect
in musculature of right anterior abdominal
wall that developed spontaneously. Antimesenteric wall of
segment of small bowel protrudes into hernial sac
(arrows, B). Proximal small bowel is only mildly dilated because
luminal obstruction is not complete; herniated
portion of small bowel, however, was strangulated and
required surgical resection.
Fig. 12—58-year-old woman with ovarian carcinoma.
A, Sagittal IV contrast-enhanced CT image shows
transition point (arrows) between markedly dilated
small bowel and distal bowel, without luminal
dilatation. Widespread peritoneal metastases are
present in abdomen and pelvis.
B, Axial IV contrast-enhanced CT image shows
segment of ileum with relative luminal narrowing
(arrows) in left hemipelvis surrounded by enhancing
soft tissue (arrowheads), consistent with confluent
serosal metastatic implants.
 Intussusception
• Intussusception refers to telescoping of a segment of bowel within another portion of
bowel. This results in a target-like appearance on CT or ultrasound because of multiple
layers of bowel wall adjacent to one another and the interposition of mesenteric fat
between the telescoped layers of bowel (Fig. 13). Ileocolic intussusception is a common
cause of acute abdomen during infancy. Because most childhood cases are idiopathic, air
enema may be sufficient for reduction. In adults, intussusception is most frequently a
transient finding identified on CT, without significant clinical features. Intussusception length
of 3.5 cm or less predicts a self-limiting lesion that will resolve spontaneously, and follow-up
imaging is not required For intussusception greater than 3.5 cm in length, further CT after
30 minutes may be considered to confirm resolution. Small bowel obstruction because of
intussusception is rare in adults and is usually due to an underlying bowel lesion acting as a
lead point. Causes include benign and malignant neoplasms, Meckel diverticulum, and
inflammatory lesions.
Fig. 13—Intussusception in 35-year-old man with melanoma.
A, Axial CT image shows mass in right lower quadrant of
abdomen with target-like appearance due to
multiple adjacent bowel wall layers (arrows). Findings were due
to ileocolic intussusception, with small bowel
metastasis acting as lead point.
B, Coronal image shows intussusception in longitudinal axis.
There is clear transition point between
intussusception and proximal dilated small bowel (arrows).
 Intraluminal Obstruction
• Jarang
• The site of obstruction is usually at the ileocecal valve, where the lumen of
the bowel is smallest.
• Gallstone ileus occurs when a large gallbladder calculus passes into the
small bowel via a biliary-enteric fistula (Fig. 14). Other imaging findings of
gallstone ileus are the usually large gallstone and biliary air.
• A bezoar is composed of ingested material that is not digested within the
gastrointestinal tract and causes an obstructing intraluminal mass. A
phytobezoar is formed by undigested plant or vegetable matter (Fig. 15); a
trichobezoar is caused by ingestion of hair.
Fig. 14—Gallstone ileus in elderly woman with small bowel
obstruction due to gallstone ileus.
A, Axial CT image of pelvis shows large laminated calculus
within dilated loop of distal ileum in midline (arrow).
B, Axial CT image through liver shows pneumobilia (arrows),
consistent with biliary-enteric fistula.
Fig. 15—Phytobezoar in 65-year-old diabetic patient who
consumed vegetarian diet composed predominantly
of chickpeas.
A, Axial CT image shows intraluminal particulate material
within dilated segment of bowel in right lower
quadrant (arrow). Other proximal loops of distended small
bowel contain gas-fluid levels.
B, Sagittal CT image shows transition point in mid ileum with
collapsed small bowel distally (arrows). Operative
findings confirmed presence of phytobezoar.
 Tatalaksana
• The ultimate role of radiologic imaging in small bowel obstruction is to
determine whether the patient can be managed with conservative measures or
surgery is required.
• Indications for emergency surgery include evidence of complete obstruction with
absence of gas or fluid in the distal gastrointestinal tract and signs of
strangulation or bowel perforation.
• A closed-loop obstruction occurs when a segment of small bowel becomes
obstructed at
• two adjacent points. Strangulation is defined as bowel ischemia occurring due to
torsion of
• the mesentery providing vascular supply to the closed loop. Early identification
and surgical reduction of a closed-loop obstruction will restore vascular supply to
the ischemic segment of small bowel (Fig. 16).
Fig. 16—Closed-loop obstruction due to internal hernia in
contiguous axial images in 75-year-old woman with
no significant medical history who presented with acute
abdominal pain.
A and B, There is whorled appearance of mesentery containing
blood vessels (arrows, A), situated just above
U-shaped loop of dilated small bowel (line, B). Although
vascular supply was compromised at laparotomy,
segment of small bowel reperfused normally when hernia was
reduced, and small bowel resection was not
required.
Fig. 17—Closed-loop obstruction with bowel infarction in 49-
year-old man.
A, Axial contrast-enhanced image shows jejunoileal
intussusception, with interposition of mesenteric fat
between telescoped portions of bowel.
B, Coronal CT image shows dilated C-shaped portion of bowel
(line) centered on area of mesentery containing
blood vessels (white arrow). At time of surgery, lead point of
intussusception was found to be submucosal
jejunal neoplasm, later confirmed as gastrointestinal stromal
tumor. Torsion of mesentery at site of
intussusception led to closed-loop obstruction, resulting in
infarction of segment of small bowel. Black arrows
show focal areas of hypoenhancement in liver due to hepatic
metastases from small bowel tumor.
Fig. 18—77-year-old woman with 2-day history of left
flank pain and no previous abdominal surgery.
A, Axial CT image shows vascular engorgement
(white arrows) and edema in mesentery of left flank
(black arrow), with ascites identified in right flank.
B, Coronal CT image shows luminal narrowing at
site of internal hernia in anterior aspect of left lower
abdomen (arrow) and presence of ascites.
C, Sagittal CT image through left side of abdomen
shows hypoenhancement and mural thickening of
loop of small bowel (black arrows) consistent with
ischemia. There is edema of adjacent mesenteric
fat and engorgement of mesenteric veins (white
arrows). At surgery, transomental internal hernia was
reduced, and resection of long segment of infracted
small bowel was performed.
 Kesimpulan
• Small bowel obstruction remains an important cause of acute
abdominal pain in patients presenting to the emergency
department. MDCT is the modality of choice for identifying the
cause of small bowel obstruction and determining whether
emergent surgery is required. Adhesions are by far the most
common cause of small bowel obstruction. Other less frequent
causes include Crohn disease, neoplasms, and abdominal hernias.
Identifying the transition point between dilated and nondilated
small bowel, although not required to make the diagnosis of
obstruction, is the key to establishing the site and cause of small
bowel obstruction.
 Air Fluid Levels sering terlihat pada colon
yang dilatasi pada posisi Upright atau lateral
decubitus

Air fluid level yang muncul menandakan

obstruksi masih akut karena air fluid level
masih belum diserap sepenuhnya.
 Pendekatan Pencitraan : MDCT
Multidetector computed tomography (MDCT)  pencitraan definitif untuk LBO dengan
sensitivitas dan spesifisitas 96% dan 93%

Dapat menentukan penyebab obstruksi dengan menunjukkan patologi luminer, mural,

serta ekstramural

MDCT dapat mendeteksi dini komplikasi seperti iskemia, infark, dan perforasi usus.

Gambaran LBO: Adanya titik transisi dengan dilatasi usus proksimal dan kolon distal yang
kolaps.

MDCT membantu dalam membedakan LBO dan pseudo-obstruksi, volvulus kolon dan
untuk memperjelas kasus LBO yang samar.
 Tabel 1: Penyebab obstruksi usus besar
Kategori Penyebab
Neoplastik Karsinoma kolon
Tumor ekstrakolonik (karsinomatosis peritoneal, invasi lokal,
dan limfadenopati)
Non neoplastik Divertikulitis
Volvulus
Penyakit inflamasi usus
Intususepsi
Enterolith
Impaksi fekal
Endometriosis
Penyakit yang meniru Pseudo-obstruksi kolon (Sindrom Ogilvie)
LBO Megakolon toksik
Ileus adinamik
 Intususepsi
• Intususepsi dewasa relatif jarang  5% dari semua intususepsi dan 1% dari semua LBO.
• Dibandingkan dengan intususepsi pediatrik (etiologi tidak jelas), hampir 90% intususepsi dewasa
memiliki penyebab organik  60% disebabkan neoplasma.
• Berbeda dengan intususepsi ileo-ileal, intususepsi kolikolik dewasa kebanyakan akibat karsinoma
primer.
• Reseksi merupakan penatalaksanaan yang terbaik.
• Temuan klasisk MDCT :
– Tanda target (massa jaringan lunak intraluminal dan densitas lemak eksentrik)
– Pola reniform (densitas berlobus dua dengan atenuasi tinggi di perifer dan atenuasi rendah yang
terpusat)
– Pola seperti sosis (pergantian area dari atenuasi tinggi dan rendah terkait dengan dinding usus,
lemak dan cairan mesenterika, cairan intraluminal, kontras, atau udara).
• MDCT membantu mengkarakterisasi massa utama dengan densitasnya  lipoma yang mengandung
lemak, massa kistik dari sebuah mukokel, atau tumor padat
Adult Intussusception

CT scout image menunjukkan

kolon melebar berisi udara tiba-
tiba berhenti di kuadran kiri atas
(panah)
Adult Intussusception

Gambaran CT potongan koronal

pada abdomen dan pelvis
menunjukkan intusepsi kolon
transversus ( panah)
BARIUM ENEMA

Diagnosis :
• Cupping sign
• Letak invaginasi
• Coiled spring
appearance.
USG
Gambar :
1) Target Sign
2) Pseudokidney Sign

Gambaran :
• Target Sign/doughnut
sign
• Pseudokidney Sign
• Crescent dalam
doughnut sign
Intususepsi

• Gambar 7: Lipoma kolonik yang

dikomplikasi oleh intususepsi. Lipoma
kolonik dikomplikasi oleh intususepsi.
Gambar computed tomography aksial (a)
dengan kontras yang ditingkatkan
menunjukkan lipoma kolonik kecil
(panah). Computed tomography lebih
lanjut 5 tahun kemudian ketika pasien
menunjukkan secara klinis gejala sakit
abdomen dan obstruksi usus subakut.
Gambar computed tomography aksial (b-
d) dengan kontras yang ditingkatkan
menunjukkan interval pertumbuhan yang
signifikan dari lipoma (panah pendek)
dengan intususepsi kolon terkait (panah
panjang).