Small Bowel Obstruction In Adults Research Articles

REVIEW OF MANAGEMENT OF SMALL BOWEL OBSTRUCTION

A major surgical emergency that is frequently found in the emergency unit is small bowel obstruction (SBO). The management of small bowel obstruction in adults was examined using systematic keyword searches in the Pubmed, Cochrane, and Google Scholar databases. The timely use of CT scans can have an impact on clinical outcomes in the management of SBO. Treatment for small bowel obstruction includes both surgical and non-surgical methods. SBO management is evolving along with the development of evidence-based guidelines and SBO management continues to change. Review will help Surgeons in treating SBO patients.

Recurrence of Small Bowel Obstruction in Adults After Operative Management of Adhesive Small Bowel Obstruction: A Systematic Review.

The objective of this article is to review the existing literature on postoperative recurrence of adhesive small bowel obstruction (ASBO). We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Cochrane Library, and Google Scholar, to identify randomized controlled trials (RCTs) and observational studies investigating recurrence after operative management of ASBO. Our search yielded one RCT, one prospective study, and eight retrospective studies, totaling 36,178 patients. We used Cochrane risk-of-bias tool and the Newcastle-Ottawa scale to assess the risk of bias in the reviewed studies (RCTs and observational studies, respectively). Operative management was associated with a lower risk of recurrence than conservative management, while the difference in recurrence between laparoscopic and open surgery was inconclusive. Diffuse adhesions were associated with a greater risk of recurrence than single band adhesions. We conclude that the “common knowledge” that surgery increases the risk for recurrence of ASBO is outdated and should no longer be applied when determining treatment modalities for ASBO. While conservative treatment still has its place, we need not fear the possibility of shifting patients to operative management earlier.

A Danish study on emergency or urgent surgery for small bowel obstruction in adults: Incidence, causes, administration of antibiotics, and infectious complications

BackgroundSmall bowel obstruction is potentially life-threatening; however, the incidence of surgery for small bowel obstruction is unknown, the patient characteristics are poorly described, and the triggers for giving antibiotics with possible influence on complications are unclear. The aims of this study were to fill these gaps to describe the incidence and the characteristics of patients undergoing surgery for small bowel obstruction and to identify triggers for giving antibiotics and the association with postoperative infections. MethodsFrom July 1, 2014, to July 31, 2015, we included adult patients undergoing surgery for small bowel obstruction at 3 hospitals representing one Danish region. We collected information on patient characteristics, diagnosis, antibiotics, and infectious complications until postoperative day 90 and survival until 1 year. ResultsThe 3 hospitals serve a population of 656,353 adults, and treatment is free of charge. A total of 192 patients underwent emergency surgery for small bowel obstruction in the period (incidence: 27/100,000 citizens or 1,200 operations in Denmark annually). The patients with small bowel obstruction had adhesive obstruction (62%), neoplasms (11%), or hernias (7%). A total of 83% received antibiotic prophylaxis, and triggers were preoperative elevated C-reactive protein [odds ratio (95% confidence intervals): 2.49 (1.04–5.98), P = .041] or resection of the bowel [3.10 (1.22–7.89), P = .017]. The incidence of postoperative infections was not reduced among patients receiving antibiotics. ConclusionWe found that 27/100,000 patients undergo surgery for small bowel obstruction in Denmark each year. Adhesive obstruction was the primary reason (62%). A total of 83% received prophylactic antibiotics triggered by elevated C-reactive protein or bowel resection. We found no association between antibiotic use and infectious complications.

Facing the unexpected: unusual causes of mechanical small bowel obstruction in adults.

Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usuallyacute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through asystematic review and critical analysis of the available evidence, and summarises the essential intra-operativesteps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.

Anomalous Vascular Peritoneal Band Causing Small Bowel Obstruction in an Adult

Peritoneal bands resulting in small bowel obstruction in adults are rare. We present a case study of a 39-year-old male who presented with a 10-day history of signs and symptoms of intestinal obstruction. The patient had no history of abdominal trauma or surgery. Intraoperatively, the small bowel obstruction was caused by a vascularized peritoneal band that had a membrane. The band formed a closed loop and caused the small bowel to herniate and lead to mechanical obstruction. In the band was an anomalous artery that connected the ileocolic artery to the descending branch of the left colic artery. The mainstay for diagnosis is an exploratory laparoscopy or laparotomy. The definitive treatment is transection of the band. This is the first reported case in Sub-Saharan Africa.
 Keywords: Small bowel obstruction, Congenital bands, Peritoneal bands, Vascular bands, Inferior mesenteric artery, Superior mesenteric artery

2539 Case of a Young Man With Small Bowel Obstruction After Trauma

INTRODUCTION: In few reports, trauma has been associated with small bowel obstruction. These cases typically happen in children; however, in adults this is a rare phenomenon. We present a case in a young male with a history of MVA 5 years prior, who presented for small bowel obstruction related to his prior trauma. CASE DESCRIPTION/METHODS: A 27 yo male presented with recurrent abdominal pain for six months. He had intermittent diarrhea, abdominal bloating, and a 15 lb weight loss over that time. Physical examination was normal. Basic laboratory studies were significant for T bili of 1.4 mg/dl (normal 0.1 - 1.0). Diagnostic EGD, colonoscopy, and CT scan of the abdomen/pelvis were normal. Due to concern for a potential diagnosis of small bowel Crohn's disease, a video capsule study was performed, which showed a hold-up in the mid small bowel for over 2 hours, without any other abnormalities. Due to this, an upper double balloon enteroscopy was performed, which was revealing for a stenosis in the distal jejunum. The stenosis was marked with submucosal india ink injection. Biopsies of the stenosis were unrevealing. Previous medical history was negative with the exception of a motor vehicle accident complicated by intra-peritoneal bleeding five years ago, which was managed conservatively without surgery. Review of this patient's medications was negative for any NSAID use. He had no history of radiation exposure or abdominal surgery. He had never experienced any symptoms of abdominal pain or bloating prior to the onset of symptoms 6 months ago. Family history is negative for celiac disease or inflammatory bowel disease. Surgical resection of the stenotic segment was performed. The patient recovered from surgery without complication. Histopathology from the resected segment was consistent with benign small bowel without inflammation or other pathologic features. The conclusion of the medical providers was that this patient developed a symptomatic stricture as the result of previous MVA with hematoma. DISCUSSION: Small bowel obstruction from trauma has been highlighted in few cases in children; however, trauma-causing small bowel obstruction (SBO) in adults is more rare. Throughout the cases we reviewed, the timeline of this trauma causing SBO ranged from thirteen weeks to eight years after the initial event.2,3,4 In this case, the man presented five years after his MVA with symptoms of bowel obstruction, with a prior hematoma being the cause of this obstruction. This case highlights MVA as a cause of SBO in adults.

Jejunostomy tube-induced intussusception

Intussusception involves the telescoping of a segment of bowel into an adjacent segment. It is the leading cause of intestinal obstruction in the pediatric age group; however, it is relatively rare and accounts for just about 1% of the cases of small bowel obstruction in adults. Jejunostomy tube-induced intussusception is an extraordinarily rare complication of feeding jejunostomy tube placement, the exact mechanism of which is not definitively known. The diagnosis of jejunostomy tube-induced intussusception is not easy as it generally does not interfere with the enteral feeding. Computed tomography (CT) scan is widely considered to be the imaging modality of choice in the diagnostic evaluation of adult intussusception. The finding of a heterogeneous sausage-shaped soft-tissue mass consisting of an outer intussuscipiens and central intussusceptum is virtually pathognomonic of intussusception. Surgery is the mainstay of management in an adult with intussusception. Nonoperative treatment strategies including radiologic reductions aided by hydrostatic/contrast/air enemas, which have mainly been attempted in the pediatric age group, have shown unpredictable results and are not recommended in adults. We present an unusual cause of jejunostomy tube-induced intussusception following a salvage laryngopharyngoesophagectomy and gastric pull-up in a patient with a postchemoradiation residue of a locally advanced carcinoma of the postcricoid region. A high degree of suspicion among clinicians and timely imaging with a CT scan are prerequisites for diagnosing intussusception in patients who complain of persistent gastrointestinal symptoms, especially with a jejunostomy tube in situ.

Perspectives on Mechanical Small Bowel Obstruction in Adults

Perspectives on Mechanical Small Bowel Obstruction in Adults

Axial Torsion of Meckel's Diverticulum Causing Small Bowel Obstruction in Adult: A Case Report

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract that occurs in 2–3% of the population (1). The MD results from incomplete obliteration of the proximal most portion of the omphalomesenteric duct within 5 to 7 weeks of fetal development (2). Gastrointestinal bleeding due to ectopic gastric mucosa of MD causing ileal peptic ulceration is the most common complication in childhood. In adults, the more common complication is bowel obstruction caused by either intussusception or small bowel volvulus around a fibrotic band or patent omphalomesenteric duct anchored to the anterior abdominal wall. Other common complications include acute inflammation leading to perforation and hemorrhage. More rare complications include perforation of MD with foreign bodies, vesicodiverticular fistulae, strangulation in Littre’s hernia, or primary neoplasms. Torsion of MD, one of the rarest complications, is the result of axial twisting around its base (3). Pre-operative diagnosis of MD as a cause of small bowel obstruction is difficult, because the diagnosis can be made only if the diverticulum is delineated at the site of obstruction. In many cases, computed tomography (CT) features are similar to those of small bowel obstruction secondary to postoperative adhesions. Imaging features and risk factors of small bowel obstruction secondary to MD suggest the diagnosis. Herein, we reported a rare case of MD with axial torsion; furthermore, we briefly reviewed the relevant literature. Axial Torsion of Meckel’s Diverticulum Causing Small Bowel Obstruction in Adult: A Case Report 성인에서 발생한 멕켈 게실의 급성 염전에 의한 소장 폐색: 증례 보고

English

BACKGROUND: The diagnosis and management of patients with mechanical small bowel obstruction in adults is one of the more challenging emergency that a general surgeon can come across. Although the mortality due to acute mechanical small bowel obstruction is decreasing with better understanding of pathophysiology, early diagnosis due to improvement in diagnostic techniques and skillful operative management carries grateful results. Hence, the present study was conducted at KIMS Hospital & Research centre, Bangalore, Karnataka. AIMS & OBJECTIVES: To study the incidence, etiology, presentation, investigation modalities, surgical procedure done and outcome following surgery with complications. MATERIAL & METHODS: The study period was two years including follow-up, comprising of 50 cases in a prospective manner. OBSERVATION& RESULTS: The study revealed that, incidence was more in male sex, most common etiology being adhesions in 30 to 50 years of age, followed by hernias in 4th decade, manifesting in the form of pain abdomen, vomiting, abdominal distension and constipation. All cases were treated surgically depending upon the cause after evaluation. The patients were followed up regularly during which hardly few complications like wound infections and post operative adhesions was found and treated laparoscopically. CONCLUSION: It can be concluded that early operations for dynamic small bowel obstruction is mandatory to avoid the development of peritonitis and systemic sepsis associated with multiorgan failure. INTRODUCTION: Acute Intestinal Obstruction is one of the common surgical emergencies encountered in KIMS Hospital and Research Centre, Bangalore, Karnataka. Intestinal obstruction is reported in ancient literature and is defined as, “Interference in the passage of food, liquids and contents of the intestine either due to mechanical or neurological cause”. It is predisposed by various underlying conditions which are difficult to define preoperatively. There are various etiologies for acute intestinal obstruction from more common causes like adhesions, hernia, malignancy to uncommon conditions like intussusception. Though the classical presentation is pain abdomen, vomiting, constipation and distension of abdomen, it needs a complete understanding of surgical anatomy, pathophysiology, symptoms and signs of obstruction and necessary investigations for diagnosis. In this study analysis of various causes, anatomical and pathological nature, mode of presentation, age factors, investigation modalities, and surgical management, various complications, mortality and outcomes have been discussed. MATERIALS AND METHODS: 50 patients were included in this study done at KIMS Hospital and Research Centre, Bangalore who presented to the OPD and Emergency Department from June 2010 to July 2012. Cases were thoroughly assessed through detailed history to identify risk factors,

Laparoscopic treatment for adhesive small bowel obstruction: is it the gold standard in children too?

Small bowel obstruction (SBO) due to adhesions is an important cause of surgical admission and postoperative morbidity in the pediatric population [1, 2]. Advanced laparoscopic surgery is now commonly available in the majority of tertiary pediatric centers for the treatment of both urgent and elective cases. In the January edition of Surgical Endoscopy, O’Connor and Winter [3] reviewed the success rate of laparoscopy in the treatment of adult acute SBO. Their review of over 2,000 patients demonstrated clear advantages of laparoscopy (mortality rate 1.5 %, enterotomy rate 6.6 %, and conversion rate 29 %) and concluded that laparoscopic treatment should become the primary surgical technique in the treatment of adult SBO [3]. However, in the pediatric field, data on the laparoscopic treatment of SBO due to adhesions are scarce. We performed a detailed review of the pediatric literature published between 1990 and 2012, and we were able to identify only three retrospective case series on this topic (Table 1). Inclusion criteria for the search were Englishlanguage articles on pediatric SBO and laparoscopy, case series with more than 10 patients, and patients age younger than 18. A meta-analysis of the 150 cases identified showed a mortality rate of 0.7 %, an enterotomy rate of 4.0 %, and a conversion rate of 27.3 % (Table 2). Table 3 lists laparoscopic failure. These results surpass those shown by O’Connor and Winter, suggesting that laparoscopic treatment should also become the gold standard for the treatment of SBO in children. Despite this, a recent report of 20,679 cases of pediatric adhesive bowel obstruction undertaken in the United States from 1997 to 2009 showed that only 17 % were treated with laparoscopy, with laparotomy and open adhesiolysis remaining by far the most common surgical technique used [4]. This study also confirmed the well-known benefits of laparoscopy, such as shorter lengths of stay (6 vs. 8 days), reduced hospital costs ($38,241 vs. $48,552), and reduced complication rates (5.6 vs. 10.4 %) compared to open surgery. Historically, pediatric surgery has shown a delay in embracing minimally invasive surgical techniques. Some could argue that the delay was due to the lack of pediatric instruments at that time, or perhaps due to longer learning curves due to the reduced frequency of some operations (e.g., cholecystectomy), but we also know that the time taken for pediatric surgeons to mentally switch to convert their practice to minimally invasive surgery played a role. On the subject of SBO, a problem common to patients of all ages, pediatric surgeons should be receptive and open to follow adult results, with an aim to better surgical practice and outcomes for children and their families. In conclusion, even if the amount of data is not yet consistent and comparable to that of the adult field, we are confident in supporting the fact that pediatric surgeons with advanced laparoscopic skills are safe and highly efficacious in treating pediatric SBO with minimally invasive techniques and that laparoscopy should become the gold standard for the treatment of this condition in children. Nadja Apelt and Neil Featherstone contributed equally to this work, and both should be considered first author.

Adult Small Bowel Obstruction

Small bowel obstruction (SBO) is a clinical condition that is often initially diagnosed and managed in the emergency department (ED). The high rates of potential complications that are associated with an SBO make it essential for the emergency physician (EP) to make a timely and accurate diagnosis. The primary objective was to perform a systematic review and meta-analysis of the history, physical examination, and imaging modalities associated with the diagnosis of SBO. The secondary objectives were to identify the prevalence of SBO in prospective ED-based studies of adult abdominal pain and to apply Pauker and Kassirer's threshold approach to clinical decision-making to the diagnosis and management of SBO. MEDLINE, EMBASE, major emergency medicine (EM) textbooks, and the bibliographies of selected articles were scanned for studies that assessed one or more components of the history, physical examination, or diagnostic imaging modalities used for the diagnosis of SBO. The selected articles underwent a quality assessment by two of the authors using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data used to compile sensitivities and specificities were obtained from these studies and a meta-analysis was performed on those that examined the same historical component, physical examination technique, or diagnostic test. Separate information on the prevalence and management of SBO was used in conjunction with the meta-analysis findings of computed tomography (CT) to determine the test and treatment threshold. The prevalence of SBO in the ED was determined to be approximately 2% of all patients who present with abdominal pain. Having a previous history of abdominal surgery, constipation, abnormal bowel sounds, and/or abdominal distention on examination were the best history and physical examination predictors of SBO. X-ray was determined to be the least useful imaging modality for the diagnosis of SBO, with a pooled positive likelihood ratio (+LR) of 1.64 (95% confidence interval [CI] = 1.07 to 2.52). On the other hand, CT and magnetic resonance imaging (MRI) were both quite accurate in diagnosing SBO with +LRs of 3.6 (5- to 10-mm slices, 95% CI = 2.3 to 5.4) and 6.77 (95% CI = 2.13 to 21.55), respectively. Although limited to only a select number of studies, the use of ultrasound (US) was determined to be superior to all other imaging modalities, with a +LR of 14.1 (95% CI = 3.57 to 55.66) and a negative likelihood ratio (-LR) of 0.13 (95% CI = 0.08 to 0.20) for formal scans and a +LR of 9.55 (95% CI = 2.16 to 42.21) and a -LR of 0.04 (95% CI = 0.01 to 0.13) for beside scans. Using the CT results of the meta-analysis for the 5- to 10-mm slice subgroup as well as information on intravenous (IV) contrast reactions and nasogastric (NG) intubation management, the pretest probability threshold for further testing was determined to be 1.5%, and the pretest probability threshold for beginning treatment was determined to be 20.7%. The potentially useful aspects of the history and physical examination were limited to a history of abdominal surgery, constipation, and the clinical examination findings of abnormal bowel sounds and abdominal distention. CT, MRI, and US are all adequate imaging modalities to make the diagnosis of SBO. Bedside US, which can be performed by EPs, had very good diagnostic accuracy and has the potential to play a larger role in the ED diagnosis of SBO. More ED-focused research into this area will be necessary to bring about this change.

A rare cause of small bowel obstruction in adults: persistent omphalomesenteric duct

Previous abdominal surgery is the most common cause of mechanical small bowel obstruction. However, in patients with no abdominal surgery history, it is difficult to diagnose and treat. Omphalomesenteric duct is a primitive embryonic structure of fetal development between the midgut and yolk sac. In some cases, it may persist and result in several complications, particularly in childhood. In adults, intestinal obstruction due to persistent omphalomesenteric duct is an extremely rare circumstance. We report a 42-year-old male patient presenting with omphalomesenteric duct remnant causing small bowel obstruction.

Intussusception caused by an inverted Meckel diverticulum: a rare cause of small bowel obstruction in adults

Intussusception caused by an inverted Meckel diverticulum: a rare cause of small bowel obstruction in adults

Loop formation of Meckel's diverticulum causing small bowel obstruction in adults: report of two cases

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, and in the majority of cases it remains asymptomatic. The total lifetime rate of complications is 4%. It is an uncommon cause of intestinal obstruction in adults. Loop formation of Meckel's diverticulum leading to small bowel obstruction is an extremely rare event. We report two such cases in which the bowel became obstructed and strangulated in a loop formed by adhesion of the distal end of the Meckel's diverticulum to the proximal ileum and mesentery.

Non-Hodgkin’s lymphoma revealed by an ilio-colic intussusception in a Moroccan patient: a case report

Intussusceptions are rare but well-known causes of the small bowel obstruction in adults and an underlying cause is present in the majority of cases. Lymphoma's involvement of the ileum is one of the rare causes of intussusception. CT is a sensitive examination that diagnoses intussusceptions and provides an excellent pre-operative evaluation including possible extension and dissemination especially in intestinal lymphomas. The treatment is almost always surgical and the pathological study is needed for diagnostic confirmation. Authors present an unusual case of intestinal intussusception due to lymphoma of the terminal part of the ileum in a 49-year-old man. Computed tomography confirmed the diagnosis of intussusception and non-Hodgkin's lymphoma of B-cell was diagnosed by histological examination after surgical treatment. Primary intestinal lymphomas differ from gastric lymphomas in clinical features, treatment, and prognosis. They are not well characterized and the standardized concepts for their clinical diagnosis and management are absent. The aim of this rare observation is to shed light on NHL of the small bowel, its clinical and radiological diagnosis and its treatment especially in forms revealed by intussusceptions in adults.

Volvulus: Small Bowel and Colon

Volvulus of the intestine is a surgical emergency. Volvulus of the small bowel is more common in children and is most often secondary to malrotation. Small bowel volvulus is an uncommon cause for small bowel obstruction in adults, and is more likely to be secondary to postoperative adhesive bands. Colonic volvulus is a rare cause of large bowel obstruction, but more common than small bowel volvulus. The sigmoid is most frequently involved, with redundant colon as the primary cause. Cecal volvulus most commonly is due to lack of fixation. Colonic volvulus has a specific radiographic appearance; however, small bowel volvulus is difficult to distinguish from other causes of small bowel obstruction by radiographic means. New surgical techniques with minimally invasive surgery are increasingly being applied to this old problem with good results in selected cases.

An Unusual Cause Of Small Bowel Obstruction By Dead Mesenteric Calcified Hydatid Cyst

The most common cause of small bowel obstruction in adults is adhesions due to the previous abdominal surgery. Intestinal obstruction may arise from enterolith formation, intussusception or volvulus [1,2,3]. In the latter situation the diverticulum acts as a pivot, especially where previous diverticulitis results in adhesive band formation. Such adhesions may also cause obstruction by direct kinking of the bowel or by trapping another loop of bowel underneath. The case is discussed of a 55-year-old male with small bowel obstruction caused by dead mesenteric echinococcal cyst. The small bowel was strangulated by the calcified entity. Although it is an uncommon condition, it is the dread of every surgeon in endemic regions. The diagnosis was highly suggestive by plain abdominal radiography and confirmed on Abdominal computed tomography, where a radio-opaque structure with hyperdense border is noted. The case was treated surgically and the patient passed uneventful post operative recovery.

Do All Adult Patients with Small Bowel Intussusception Need Surgery?

Introduction: Intussusception of the small bowel accounts for less than 1% of cases of small bowel obstruction in adults. It has traditionally been regarded as a condition requiring surgery, because up to 90% of cases are said to be associated with a lead point disease. We present a case of small bowel intussusception in an adult, which was transient and managed conservatively without surgical intervention. Case: A 23-year-old man presented to the Emergency Department with a three-day history of right-sided abdominal pain, nausea and bilious vomiting. On arrival, his temperature was 97.7° F and his pulse rate was 79 beats per minute. Examination revealed a non-distended abdomen with right lower quadrant tenderness without guarding or rebound tenderness. His white cell count was 13,000 per cmm and hematocrit was 50 percent. Plain-film radiograph of the abdomen revealed a non-obstructive bowel gas pattern. Computed tomographic scanning of the abdomen showed a “target lesion”, suggestive of small bowel intussusception (Figure 1). However, no abnormality was demonstrated on barium small bowel follow-through performed the next day. The patient's general condition improved with bowel rest. Discussion: The reported frequency of lead point disease with adult small bowel intussusception is based on surgical series in which patients had obstructive symptoms and the diagnosis was made intraoperatively. However recent series using CT or MRI diagnosis of intussusception found increased rate of idiopathic transient intussusception approaching 50%, especially in small bowel. Features suggestive of transient intussusception are incidental presentation, proximal small bowel location, absence of peristaltic obstruction, absence of any apparent cause, target like lesion on CT scan and intussusception length less than 3.5 centimeter. Many cases of adult small bowel intussusception that are detected with computerized tomography are self-limiting. This highlights the need for considering conservative approach in management of small bowel intussusception in adults.[figure 1]Figure

The relevance of free fluid between intestinal loops detected by sonography in the clinical assessment of small bowel obstruction in adults

Introduction: The main role of the radiologist in the management of patients with suspicion of small bowel obstruction is to help triage patients into those that need immediate surgical intervention from those that require medical therapy or delayed surgery. Ultrasound examination is usually considered not helpful in bowel obstruction because of air in the intestinal lumen that interferes the evaluation of the intestinal loops, however recently some Authors attested the increasing important role of sonography in the acute abdominal disease. Aim of our report is to demonstrate the value of free fluid detected by US in differentiating between low and high-grade small bowel obstruction. Materials and methods: The study is based on 742 consecutive patients who presented symptoms of the acute abdomen; all patients had undergone initial serial abdominal plain film and US examinations prior to any medical intervention. We reviewed the imaging findings of 150 cases in whom small bowel obstruction was clinically suspected and confirmed at surgery. We consider the following radiographic and US findings: dilatation of small bowel loops; bowel wall thickness; presence of air–fluid levels; thickness of valvulae conniventes; evidence of peristalsis; presence and echogenicity of extraluminal fluid. We looked at the value of extraluminal peritoneal fluid at US examination in differentiating low and high-grade small bowel obstruction based on the surgical outcome. Results: In 46 patients altered peristaltic activity, thin bowel walls, fluid filled loops with hyperechoic spots in the bowel segment proximal to obstruction were noted at US, whereas radiographic features were: moderate dilatation of small bowel loops, with thin bowel wall and evidence of numerous and subtle valvulae conniventes; presence of air–fluid levels was also noted. In 70 other patients, US examination revealed all the findings described in the precedent cases and also the presence of free extraluminal fluid; abdominal plain film showed an increased dilatation of small bowel loops with moderate thickened wall and air–fluid levels. In 34 other patients US examination revealed the presence of thick-walled loops, hypoperistalsis and a larger amount of free extraluminal fluid. Radiographic findings in these patients were: horizontal featured and markedly dilated small bowel loops presenting parietal thickness, presence of intraluminal fluid stasis and evidence of thickened, sparse and incomplete valvulae conniventes. At surgery etiology of small bowel obstructions was various, but most of cases related to adhesions (70 cases). The presence of extraluminal fluid were confirmed at surgery in 104 patients. Conclusions: Our experience using sonography in suspicion of SBO (small bowel obstruction) suggests the usefulness of this imaging modality to differentiate a functional or obstructive ileus, demonstrating the evidence of intestinal peristalsis. Furthermore, the presence of a large amount of fluid between dilated small bowel loops suggests worsening mechanical small bowel obstruction, that requires not a medical therapy but immediate surgery.