Suspected Small Bowel Obstruction Research Articles

The utility of a CT grading scale in deciding on surgical intervention for patients with suspected small bowel obstruction

BackgroundA grading system was developed for computerized tomography (CT) scans evaluating patients with suspected small bowel obstruction (SBO). We hypothesized that patients with a higher grade of suspected SBO on CT scan would be more likely to require surgical intervention. MethodsRetrospective chart review of patients who presented to the Emergency Room (ER) who had a CT of the abdomen and pelvis for suspected SBO. Patients were divided into 5 groups: Grade 1 (SBO unlikely), Grade 2 (probable partial or early SBO), Grade 3 (probable high grade SBO), Grade 4 (SBO with changes concerning for ischemia) and Not Graded. ResultsThe CT scans of 655 patients were graded. Of the 22 patients with a grade 1 SBO, only 1 went for surgery (4.5 %). For grade 2 patients, 23 out of 299 had an operation (7.7 %), for grade 3 it was 84 out of 299 (28.1 %) and for grade 4 SBO, 25 out of 35 patients (71.4 %) had surgery. The p value is <0.00001. The three most common intraoperative findings were SBO obstruction from adhesions alone (48 % of cases), followed by incarcerated hernias (12 %) and ischemic bowel (9 %). Only 8 cases out of 133 operations (6 % of total) had no findings at time of surgery other than dilated bowel. ConclusionsThe CT grading scale for SBO developed at our institution shows excellent correlation between grade and going for surgery, with few negative results, and can be a useful tool among other factors for general surgeons when deciding whether or not to operate on a patient with suspected SBO.

Point-of-care ultrasound-first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure.

Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point-of-care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS-first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS). We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS-first approach for SBO. The model assumes that all patients who require surgery or have non-diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved. A POCUS-first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths. If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.

Water-Soluble Contrast Challenge for Suspected Small-Bowel Obstruction: Technical Success Rate, Accuracy, and Clinical Outcomes

Among 109 iohexol-based water-soluble contrast (WSC) challenges performed for suspected small-bowel obstruction, 105 were technically adequate. Among technically adequate studies, colonic contrast (i.e., successful challenge) was seen on 66 abdominal radiographs obtained 8 hours after WSC challenge and 86 abdominal radiographs obtained 24 hours after WSC challenge. Fourteen patients underwent operative management, and 91 underwent nonoperative management (NOM). Successful challenge had a sensitivity of 91.2%, specificity of 78.5%, PPV of 96.5%, NPV of 57.8%, and odds ratio of 38.0 (95% CI, 8.7-165.2) for NOM. Three of 86 patients with successful challenge underwent operative management.

SONO case series: 59-year-old woman with abdominal pain and bloating

A 59-year-old woman presents to the emergency department with 3 days of diffuse abdominal pain with profuse nausea and vomiting. The pain came on gradually and worsens after eating. The...

The Accuracy of Point-of-Care Ultrasound in Detecting Small Bowel Obstruction in Emergency Department.

Radiological imaging plays an essential role in the evaluation of a patient with suspected small bowel obstruction (SBO). In a few studies, point-of-care ultrasound (POCUS) has been utilized as a primary imaging modality in patients with suspected SBO. POCUS has been shown to be an accurate tool in the diagnosis of SBO with multiple research studies noting a consistent high sensitivity with a range of 94–100% and specificity of 81–100%. Specific sonographic findings that increase the likelihood of SBO include dilatation of small bowel loops > 25 mm, altered intestinal peristalsis, increased thickness of the bowel wall, and intraperitoneal fluid accumulation. Studies also reported that emergency physicians could apply this technique with limited and short-term ultrasound training. In this article, we aim to review the sensitivity and specificity of ultrasound examinations performed by emergency physicians in patients with suspected SBO.

Value of MDCT and Clinical and Laboratory Data for Predicting the Need for Surgical Intervention in Suspected Small-Bowel Obstruction: Scrima A, Lubner MG, King S, et al. AJR 2017;208:785-793

Small bowel obstruction (SBO) is a common concern in patients who present to the emergency department (ED) with acute abdominal pain. It is important to determine which patients with suspected SBO's will do well with conservative management versus those who will require urgent surgery, as prior data suggests that those who fail conservative management and ultimately require surgery have increased resultant morbidity and mortality.

Abdominal Multidetector Computed Tomography for Suspected Small-Bowel Obstruction: Multireader Study Comparing Radiologist Performance for Predicting Surgical Outcomes

To compare performance of junior (JR)/senior (SR) abdominal radiologists using multidetector computed tomography (MDCT) to predict surgical intervention, bowel resection, and presence of bowel ischemia in patients with suspected small-bowel obstruction (SBO). Retrospective, institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, blinded, independent review of MDCT studies for suspected SBO in 179 adults (mean age, 55.8 years; 86 men/93 women) was performed by 12 board-certified radiologists (6 JR, 6 SR). Readers rated likelihood of need for surgery, bowel ischemia, and resection. Correlation with clinical outcomes/pathology was performed. Pooled receiver operating characteristic area under the curve for surgery, ischemia, and resection were 0.802, 0.736, and 0.824 and 0.773, 0.851, and 0.751 JR/SR, respectively. Sensitivity/specificity for predicting surgery was 86.7%/65.4% and 79.6%/64.4%. No differences existed between JR/SR performance overall (P = 0.451); highest/lowest performing readers between groups (P < 0.001) and within groups (P = 0.008) varied. Junior radiologists performed as well as SR in predicting surgical outcomes on MDCT in patients with suspected SBO.

Value of MDCT and Clinical and Laboratory Data for Predicting the Need for Surgical Intervention in Suspected Small-Bowel Obstruction.

The purpose of this article is to assess the value of a large panel of clinical and MDCT variables in patients with suspected small-bowel obstruction (SBO) for predicting urgent surgical intervention (< 72 hours), bowel ischemia, and bowel resection. MDCT studies performed at admission for 179 nonconsecutive adults (mean age, 55.8 years; 86 men and 93 women) with suspected SBO were retrospectively reviewed by three board-certified radiologists. In addition to assessing individual CT features, each radiologist scored the overall likelihood of each main outcome measure using a 5-point scale. All relevant clinical and laboratory data were abstracted from electronic medical record review. Univariate and multivariate analyses were performed. Among all 179 patients with suspected SBO, 56 (31.3%) underwent surgical intervention within 72 hours, 10 (5.6%) had ischemia at surgery, and nine (5.0%) required small-bowel resection. On univariate analysis, multiple CT findings were highly significant (p < 0.01) for predicting the main surgical outcomes, including degree of obstruction, 5-point radiology likelihood scores, and the presence of a transition point, closed loop, and mesenteric congestion. None of the objective clinical or laboratory variables (including serum lactate level) reached this level of significance. At multivariate analysis, forward stepwise logistic regression with 0.05 significance level cutoff included both degree of obstruction (p < 0.001) and closed loop (p < 0.01), with the presence of a transition point showing a trend toward significance (p = 0.081). A number of findings at abdominal MDCT are associated with the need for surgery and other important surgical outcomes in patients with suspected SBO. Overall radiologist impression of need for surgical intervention was a better predictor than any clinical or laboratory parameter.

361 Suspected Small Bowel Obstruction in the Emergency Department: Accuracy of Point-of-Care Ultrasound

361 Suspected Small Bowel Obstruction in the Emergency Department: Accuracy of Point-of-Care Ultrasound

MDCT of Small Bowel Obstruction: How Reliable Are Oblique Reformatted Images in Localizing Point of Transition?

The goal of this study is to prospectively assess the additional value of oblique reformatted images for localizing POT, having surgery as a reference standard. Materials and Methods. 102 consecutive patients with suspected small bowel obstruction (SBO) underwent 64-slice multidetector row CT (MDCT) using surgical findings as reference standard. Two independent GI radiologists reviewed the CT scans to localize the exact POT by evaluating axial images (data set A) followed by axial, coronal, and oblique MPR images. CT findings were compared to surgical findings in terms of diagnostic performance. McNemar's test was used to detect any statistical difference in POT evaluation between datasets A and B. Kappa statistics were applied for measuring agreement between two readers. Results. There was a diagnostic improvement of 9.9% in the case of the less experienced radiologist in localizing POT by using oblique reformatted images. The more experienced radiologist showed diagnostic improvement by 12.9%.

The End of X‐rays for Suspected Small Bowel Obstruction? Using Evidence‐based Diagnostics to Inform Best Practices in Emergency Medicine

The End of X‐rays for Suspected Small Bowel Obstruction? Using Evidence‐based Diagnostics to Inform Best Practices in Emergency Medicine

Bedside ultrasonography for the detection of small bowel obstruction in the emergency department

BackgroundPlain film radiography (x-ray) is often the initial study in patients with suspected small bowel obstruction (SBO) to expedite patient care.ObjectiveTo compare bedside ultrasonography (US) and x-ray for the detection...

ACR Appropriateness Criteria® on Small-Bowel Obstruction: A Critique of the Term and Its Terms

The recent article “ACR Appropriateness Criteria® on Suspected Small-Bowel Obstruction” by Drs Ros and Huprich [1] is another example of an attempt by a committee of distinguished radiologists to provide a paradigm for the evaluation of a clinical problem for which a welter of imaging tests are available. The intent of the formulation of the ACR Appropriateness Criteria is admirable, and the deliberations are usually careful and thorough, with considerable reference to the literature for support.

ACR Appropriateness Criteria® on Suspected Small-Bowel Obstruction

With no one generally accepted approach to evaluate patients with suspected small-bowel obstruction (SBO), standard CT has emerged as the preeminent imaging modality and should be considered in the initial evaluation of patients with suspected high-grade SBO. Playing less significant roles in the diagnosis of acute SBO are barium enemas and the small-bowel examination.