Bowel Obstruction (Suspected)

Population Covered By The Guidance

This pathway provides guidance for imaging adult patients with suspected bowel obstruction, including the roles of plain abdominal radiography and more advanced imaging.

Lead Researcher: Dr Sian Chin

Experts & Contributors: Dr Ravinder Dhillon, Dr David Leong, Clin Prof Richard Mendelson, Dr Cecilia Wee

Editorial Panel: Core Membership
Link to Editorial Panel

Date reviewed: December 2018

Date Published: March 2019

Image 1a (Plain radiograph, Supine view): Multiple dilated loops of small bowel.

Small Bowel Obstruction

Image 1b (Plain radiograph, Erect view): Multiple dilated loops of small bowel with air-fluid levels and

Small Bowel Obstruction

Image 2a (Plain radiograph): Multiple dilated loops of small bowel in the upper abdomen.

Incarcerated Small Bowel Hernia

Image 2b (Plain radiograph): Lower abdominal film showing increased density in the right obturator foramen.

Incarcerated Small Bowel Hernia

Image 2c (Computed Tomography): Coronal view of the same patient demonstrating an incarcerated small bowel. Dilated proximal loops of small bowel enter a large right inguinal hernia. The distal small bowel loop exiting the hernia is collapsed.

Incarcerated Small Bowel Hernia

Image 2d (Computed Tomography): Axial view showing the dilated small bowel loop in the right inguinal hernia (arrow).

Incarcerated Small Bowel Hernia

Image 3 (Small bowel enteroclysis): Small bowel obstruction due to a serosal metastasis (arrow).

Malignant Small Bowel Obstruction

Image 4 (Plain radiograph): Multiple loops of distended small bowel with air in the biliary tree (arrow).

Gallstone Ileus

Image 5 (Computed Tomography): A large gallstone is impacted in the small bowel causing mechanical obstruction. Note air in the biliary tree.

Gallstone Ileus

Pneumoperitoneum Image 6 (Plain radiograph): Perforated bowel and pneumoperitoneum. The intraabdominal gas outlines the liver edge, gallbladder and falciform ligament.

Pneumoperitoneum

Image 7 (Plain radiograph, Lateral decubitus): Perforated bowel with pneumoperitoneum. The intraabdominal gas outlines the liver edge and chest wall.

Pneumoperitoneum

Image 8a (Plain radiograph): Distension of the caecum, ascending and transverse colon.

Large Bowel Obstruction

Image 8b (Computed Tomography): CT of the same patient showing marked caecal distension secondary to a constricting tumour (arrow).

Large Bowel Obstruction

Image 9a: A right hemicolectomy showing a large, ulcerated and exophytic caecal adenocarcinoma.

Colorectal Carcinoma

Image 9b (H&E, x2.5) Histological sections showing a moderately differentiated colorectal adenocarcinoma composed of malignant glands invading into the bowel wall (blue arrows). The glands are lined by cells showing marked nuclear atypia. Normal colonic mucosa is included for comparison (green arrow).

Colorectal Carcinoma

Image 9c (H&E, x10): Histological sections showing a moderately differentiated colorectal adenocarcinoma composed of malignant glands invading into the bowel wall (blue arrows). The glands are lined by cells showing marked nuclear atypia. Normal colonic mucosa is included for comparison (green arrow).

Colorectal Carcinoma

Image 10 (Plain radiograph): Markedly distended loop of large bowel from a caecal volvulus.

Caecal Volvulus

Image 11 (Plain radiograph): Markedly dilated loop of large bowel. The dense white line between the limbs (arrow) points to the origin of the volvulus.

Sigmoid Volvulus

Image 12 (Computed Tomography): Sigmoid volvulus with the classical

Sigmoid Volvulus

  • CT is generally the investigation of choice to diagnose bowel obstruction, the location, cause and complications
  • Plain radiographs may miss low-grade obstruction and are rarely able to show the cause, however they are a fast, inexpensive and widely available investigation
  • In low-grade small bowel obstruction or during relatively asymptomatic intervals between episodes of recurrent obstruction, the small bowel can be assessed with CT or MR enteroclysis or enterography. The small bowel is dilated with intraluminal contrast; areas of obstruction that may be missed on conventional CT are non-distendable and more easily identified

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

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  30. Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in the diagnosis of intestinal ischemia in small-bowel obstruction. AJR Am J Roentgenol. 2000;175(6):1601-7. (Level II-III evidence). View the reference
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  45. Branco BC, Barmparas G, Schnuriger B, Inaba K, Chan LS, Demetriades D. Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction. Br J Surg. 2010;97(4):470-8. (Level I evidence). View the reference
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  51. Beattie GC, Peters RT, Guy S, Mendelson RM. Computed tomography in the assessment of suspected large bowel obstruction. ANZ J Surg. 2007;77(3):160-5. (Level II evidence). View the reference
  52. Frager D, Rovno HD, Baer JW, Bashist B, Friedman M. Prospective evaluation of colonic obstruction with computed tomography. Abdom Imaging. 1998;23(2):141-6. (Level II evidence). View the reference
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Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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