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Thursday, 1 March 2012

Digestive surgery series : Obstructive ileus and Paralytic Ileus, Hallow Viscus Perforation (Typhoid Perforation or Trauma) and Others Disorder in Radiology Appearance

In everyday practice at the surgery, especially when an emergency case, we often find cases of gastrointestinal ileus where sometimes we have to carefully distinguish paralytic ileus with obstructive ileus. Here will be presented on radiologic images to understand the disorder or ileus cases to facilitate and support the diagnosis so that treatment more quickly and accurately, of course, the radiological picture is not the only support for the diagnosis. Clinical appearance is a clue for the basis of diagnosis that we perform an action.

Ileus: the passage of intestinal contents which interruption is a sign of acute intestinal obstruction requiring immediate aid or action. Obstructive ileus: damage or loss of the passage of intestinal contents caused by mechanical obstruction. Obstructive Ileus = Obstruction

                 Paralytic ileus: damage or loss of the passage of intestinal contents caused by other than mechanical blockage. Paralytic ileus Adynamic ileus = non-obstructive = ileus
Location of obstruction:
The location is high: the duodenum to the jejunum
Low lies the: colon - sigmoid - rectum
iliocecal limited by junction

Partial: partial clog the lumen
Simple / Complete: clog the entire lumen
Strangulation: simple with an strangulated vasa

Etiologi :
Small bowel obstruction :                                            Large bowel obstruction :
·       Adhesion                                                                    - tumor
·       hernia *                                                                       - volvulus
·       volvulus                                                                      - hernia
·       intussusception                                                           - diverticulitis
·       invagination                                                                - intucuseption
·       Askariasis
·       More

Pathophysiology :

Local result:
- Dilatation of the proximal
- ↑ pressure Pe intraluminar intestinal distension → urgent vasa (lymph veins → artery) proteolysis → perforation

due to Systemic
- hypokalemia
- Alkalosis, metabolic acidosis
- endotoxemia → ARDS, renal / hepatic

Clinical symptoms of :
·       Colicky abdominal pain, which is
·       Vomiting and obstipasi,
·       intestinal distension
·       The absence of flatus
·       Abdominal pain feels like a stabbing or a severe heartburn, pain usually does not spread. At the time of the attack, usually accompanied by feelings that are wrapped around the abdomen.

Radiological examination
·       Plain photo abdomen
·       barium Enema
·       CT-Scan Abdomen


Normal Gas Overview :
- there is always a

Subtle bowel (Small Bowel)
- A maximum of 2-3 loops on the non-distended bowel
- Normal diameter = 2.5-3 cm

Colon (Large Bowel)
- In the rectum or sigmoid - almost always there

White: psoas line and the air in rectosigmoid
Black: The air in the gastric and a little air in the 2-3 loop of small bowel not dilated
Fluid Levels are Normal
- Always (unless the supine images)

Subtle bowel (Small Bowel)
- A maximum of 2 -3 obtained

- Normally there is no

Colon Vs Fine
- peripherals
- Haustral markings does not extend from wall to wall
- Intestinal bracelet +

Small intestine
- Central
- Valvulae stretches along the lumen
- Diameter <2 "
- Intestinal bracelet + + +

Valvulae Conniventes
The small bowel has a wall pattern that is known as valvulae conniventes (white arrow).
The muscular bands encircling the small bowel are usually seen to traverse the bowel wall at right angles to the long axis of the bowel

Plicae Semilunaris and Haustra
The large bowel wall features pouches or sacculation that protrude into the lumen that are known as haustra(black arrow).
"haustral pattern".
In between the haustra are spaces known as plicae semilunaris- white arrow (semilunaris refers to their semi-lunar shape)

Abdomen 3 Position supine
- picture of gas
- calcification
- Soft tissue mass

Abdomen 3 Position erect
·        Free air
·        Air-fluid levels

Abdomen 3 Position - Left Lateral Decubitus

Abdomen 3 Position – Erect Chest
- free water
- Pulmonary and cardiovascular disorders

Picture Of Abnormal Gas
Functional Ileus                                                              Mechanichal Obstruction             
·        Localized (Sentinel Loops)                            - SBO
·        Generalized adynamic ileus                          - LBO
  • Adynamic Ileus = paralytic ileus = non-obstructive ileus = non-functioning bowel for reasons other than obstruction à ileus à ileus paralitik
  • Obstructive Ileus = stasis of bowel contents for reasons related to obstruction à obstruction à ileus obstruktif
·       Proximal loop of the obstruction will dilate
·       Distal loop of the obstruction will terdekompresi or airless
·       The most dilated loops are:
- The most distended
- Located on the proximal intestine of obstruction

Ileus Lokal (Localized Ileus) – Description
-        2-3 persistently dilated loop of the colon or small
-        Gas in the rectum or sigmoid

        Ileus Local
        Sentinel Sign

Generalized Ileus
Ileus Umum (Generalized Ileus) Description
-        Gas in the small intestine and colon to the rectum is dilated
-        Long air-fluid levels
-        Usually the post-op patient

Dilatation of the colon, small intestine and rectum

Subtle Mechanical Intestinal Obstruction Mechanical SBO
-Mechanical small bowel obstruction = Mechanical SBO

-Small bowel dilatation

-A little gas in the colon, especially rectum

-Disproportionate dilatation of the small intestine


-hernia *



* The cause can be seen on plain
                                                          SBO due to left inguinal hernia
                                                     SBO Multiple dilated bowel loops
A little air in the colon
Partial SBO, the air in the colon, dilatation of the disproportion between the small intestine and colon

Mechanical Bowel Obstruction Mechanical LBO
Mechanical small bowel obstruction = Mechanical LBO

Dilatation of the colon to the point of obstruction

Little or no air in the rectum / sigmoid

Little or no gas in the small intestine, if Ileocecal valve remains competent






Signs of obstruction
-Small bowel dilatation> 30mm
-Herring bone appearance
-Multiple Air fluid level
-Extensive water fluid level> 2.5 cm
-Circle 1 = 2 Air intestine of different fluid levels> 5 mm
-The string-of-pearls sign / string of beads sign
-The stretch / slit sign
-Coiled spring sign
Normal Gasless Small Bowel 

Normal Air-filled Small Bowel

Minimally Dilated Small Bowel 

Severely Dilated Air-filled Small Bowel (Coiled Spring Sign)

String-of-Pearls Sign 

The string-of-pearls sign

Slit/Stretch Sign 

Multiple Air-fluid Levels / step ladder sign

The Large Bowel String of Pearls Sign

Herring bone appearance

Multiple Air fluid level, fluid level water area> 2.5 cm, a Circle of the small intestine = 2 different Air fluid level> 5 mm

-Anterior Subhepatic Air Space
-Doges Cap Sign (free water in Morrison's Pouch)
-Air Anterior to Ventral Surface of Liver
-Rigler's sign on supine AXR (also known as double-wall or bas-relief sign)
-Sign Falciform ligaments
-The 'football' sign
-The cupola. Accumulation of water Beneath the central tendon of the diaphragm
-Continuous diaphragm sign
-The triangle-air trapped Between three loops of bowel
-Air under diaphragm on erect CXR
-Water outlined against liver / flank on decub AXR
-Other-diaphragmatic muscle slips, ligamentum teres water, Double Gastric Fundus sign, The Inverted V-sign, scrotal water
-Gas abscess

Anterior Subhepatic Space Free Air

Doges Cap Sign (free air in Morrison's pouch)


Massive pneumoperitoneum and
could reasonably be said to display football sign.
There is also falciform ligament sign, Rigler’s sign and air in the scrotum.

Continuous Diaphragm Sign

Double Bubble Sign
Diaphragm (black arrow) is a thinner walled structure than the stomach wall (white arrow)

Crescent sign

The Cupola Sign
Air accumulation beneath the central tendon of the diaphragm (white arrows)

Lesser Sac Gas
cupola sign (white arrows)
a lesser sac gas sign (black arrows)
The lesser sac is positioned posterior to the stomach and is usually a potential space. There is free connection between the lesser sac and the greater sac through the foramen of Winslow.

Rigler’s Sign
Air on both sides of bowel wall – Rigler’s Sign / double-wall / bas-relief sign

Differential Diagnosis

-Normal abdominal diagnosis, Adynamic / Paralitic ileus (local and general) and obstruction (SBO / LBO) (complete / partial) can be seen from the water and air fuid level in the small intestine, sigmoid colon and rectum abdomen 3 position on photos.

The main sign of obstruction:
-Multiple Air fluid level
-Extensive water fluid level> 2.5 cm
-Circle 1 = 2 Air intestine of different fluid levels> 5 mm

The main sign of perforation (complication):
-free air

1 comment:

  1. terimakasih dok, sangat membantu saya dalam memahami ileus..mungkin bisa ditambahkan apa saja referensinya agar saya bisa membaca lebih lanjut...