Hi, so Dr. Martin and I will be going over the first radiologic case study, which will be a small bowel obstruction. So the first two polling questions, the first question is, what is not a symptom of small bowel obstruction? Very good. So common symptoms are abdominal pain and cramping, nausea and vomiting, cessation of passage of stool or flatus, but not blurred vision. Okay. The next polling question, what are causes of developing a small bowel obstruction? Excellent. Yes, absolutely. All of the above. So what I'd like to do is we're going to be going over the signs and symptoms of small bowel obstruction, define the term transition zone and review the advantages of CT imaging versus plain films and review the causes of small bowel obstruction. So the definitions of small bowel obstruction, one is complete or high grade obstruction, which includes no fluid or gas that passes beyond the site of the obstruction, incomplete or partial obstruction, which indicates some fluid or gas beyond the obstruction, strangulated obstruction indicates that the blood flow is compromised, which may lead to intestinal ischemia and necrosis and perforation and closed loop obstruction, which occurs when a segment of bowel is obstructed at two points along that course, resulting in that progressive accumulation of fluid and gas within that isolated loop, placing it at risk for the volvulus or subsequent ischemia. So these are common patients that I know I see in my practice as general GI practice. And it's always a patient that comes in with abdominal pain on a Friday afternoon. So what do you do? So symptoms that we encounter during our week of patients that come in with abdominal pain are going to be either mild or moderate or severe. So as I go through this case, Dr. Martin and I do, I know we're all going to have a case in our mind that that has come up during our practice. So the symptoms that present are nausea and vomiting, proximal small bowel obstruction, which is going to be the area of the duodenum and the proximal dejunum, can cause the severe nausea and vomiting. And as a result, patients typically will stop eating or taking in food or liquids orally. And usually it seems like it's our elderly patients that will have these symptoms that will continue on for sometimes several days, but they want to wait for your office visit to come in and to see you. Cramping abdominal pain, abdominal pains associated with small bowel obstruction is frequently described as peri-umbilical and cramping with this paroxysmal pain occurring every four to five minutes. And then the progression from cramping to more focal or constant pain that can indicate peritoneal irritation related to complications. So this is your ischemia, your bowel necrosis, and a sudden onset of severe pain that may actually suggest intestinal perforation. Obstipation, so cessation of passions of stool or flatus that indicates a complete obstruction. However, the passage of the gas or stool can continue for 12 to 24 hours, even after the onset of these obstructive symptoms. And I think that's the time that we can get confused in the office is the decision point is, do I order imaging now? And how soon am I going to get that information? Hematochesia can also be a sign of tumor or ischemia or inflammatory mucosal injury or intussusception. So these are some of the causes of a small bowel obstruction, and you can think of it in your mind from an extrinsic lesion, intrinsic, and then intraluminal obstruction of the normal bowel. So as the polling question had mentioned, adhesions is one of the number one causes of small bowel obstruction. The risk factors are prior surgery or acute diverticulitis or Crohn's disease. So when you see a patient in your office who has Crohn's disease, one of your first questions is where is that disease process? Is it in the small bowel? Is it near the jejunum? Is it near the ileum? Have you had any type of surgery? Because that's also going to increase your risk for having a patient's having risk of small bowel obstruction. Also their history. Patients know if they've had small bowel obstructions in the past, and they'll give you a good history of the date and time when they had it, when they went to the emergency room, if it resolved, if they had that surgical consultation come in and the surgeon waited and then it resolved and they were put on fluids and they were discharged from the hospital. Some of these intermittent episodes, patients can tell them they'll give you a good history. Hernias, congenital or acquired abdominal wall hernias can cause this problem, either inguinal or femoral or diaphragmatic hernias, and then a volvulus. So that's when the actual colon will flip on its side, it'll turn or cause a torsion. And this can happen anywhere in the small intestine, even the large intestine too, especially if you have megacolons. But specifically to the small intestine, this can happen in chronic constipation and also patients that have mesenteric attachments from a congenital aspect. Peritoneal carcinomatosis can be a cause. This is due to risk of ovarian cancer or colon cancer or gastric cancer. And then from an intrinsic lesion perspective, you've got the large bowel and the small bowel. And these can be related to your hereditary cancer syndromes like familial adenomatous polyposis or Putes-Jager syndrome. Then from an interluminal obstruction of the normal bowel is the intussusceptions and gallstones. So intussusception can be related to a small bowel tumor or your gallstones can be related to cholecystitis. So how do you evaluate small bowel obstruction? Well, the literature shows that your first line imaging is your acute abdominal series. This is going to show signs of bowel ischemia, pneumatosis, if there is any venous gas or pneumoperitoneum, which you want to have a prompt urgent surgical referral. Also CT imaging is your next line. Now the CT imaging will not only tell you if you have a small bowel obstruction, but it's going to tell you where it is. And one of the precautions is you want to consider contrast-induced nephropathy for your patients with CKD. And radiologic findings, that transition zone is required on your small bowel obstruction imaging, which shows you where that point of time is, is where there's a loop, whether it's completely closed or partially closed, where all of a sudden that you have that discontinuation of the continuity of your bowel. And this is when you, I just want to go back here. This is when you start thinking about your decision-making of how ill or acute your patient is in your office and what type of imaging is going to be appropriate for it. If it's on a Monday and you suspect that the patient may have a small bowel obstruction, but they're not acute, but they're distended, but they're still passing gas, they're not elderly with many comorbid conditions, then you could order a stat CT scan, say get it within the next 24 to 48 hours. But if it's on a Thursday afternoon or Friday morning, you don't want to order an abdominal x-ray series because you don't want to look at that lab over the weekend and not knowing how that patient is going to progress. So your decision-making is really going to determine on how ill or acute the patient is in your office and the availability of the imaging at that time. From a safety perspective and for caring for your patients, then if you really suspect that there's a small bowel obstruction, then you should be sending the patient to the emergency room for urgent evaluation. So one of the imaging studies is the upright abdominal x-ray. This is going to look for the dilated loops of small bowel or air fluid levels. So advantages of that CT scan imaging, it's going to look and be able to pick up if there's poor or absent segmental bowel wall enhancement, and it's going to show specific radiologic characteristics, if it shows if there's a delayed hyper enhancement, bowel wall thickening, if there is any small bowel feces sign, if there's air in the bowel wall, if it's edematous, if there's thick mesentery, all of these are going to be radiologic signs that's going to show more of a degree of your small bowel obstruction and what could be causing it. And of course, also the degree of the severity of it. So we have a case here, 37 year old male that presents in clinic with a right lower quadrant abdominal pain for one week. It's colicky, then the pain worsens over the past two days, developed nausea and vomiting, but no bowel movement for three days. This is an ill appearing 37 year old, abdomen is distended in your office and is tender with rebound. So your first thought is you're thinking of a possible appendicitis, or could it be a small bowel obstruction or a perforation, but someone who's 37 year olds, it's really not something that you're going to consider necessarily, but you refer them to the emergency room. And then what you do is you're looking at the emergency room report the next day. And you find out that it shows that the patient on the CT scan imaging, it shows that there's a dilated cecum and the CT scan is showing that there's this large air pocket trapped in the cecal volvulus, which is causing a cecal volvulus. So sure enough, the surgical evaluation did show that there was a cecal volvulus. And so it proceeded to the emergency room, I mean, to the OR for emergency laparotomy. And when the operative report reviewed that the right iliac fossa was empty and the cecal volvulus had twisted on itself exactly 360 degrees. So it was causing ischemia and lack of blood flow. So fortunately, the patient had a great outcome. He was discharged from the hospital with no sequela. So cecal type volvuluses are classified in three types. You have type 1, type 2, and type 3. And the cecal volvulus forms by a clockwise, axial twisting, or torsion of the cecum along the axis. And that's the location of the cecal volvulus in the right lower quadrant. The cecal type 2, the volvulus develops from a twisting or torsion of a portion of the cecum and then around the area of the terminal ilium. Traditionally, but not all cases, the type 2 cecal volvulus will encounter this counterclockwise twist. And then the type 3, which is known as a cecal volvulus, is an upward type folding of the cecum. And John, I think you're up. Well, sounds great, Jill. You know, I think this is a great case because I think it shows that patients who clinically have a small bowel obstruction could have an obstruction that's literally just next door to the small bowel, right? I mean, the cecum in the human is essentially part of the colon. It's sort of the tip top of the colon, although it's kind of upstream from the ileocecal valve. But that cecum becoming torsed like that is obstructing the small bowel upstream. So de facto, from a clinical standpoint, the patient has a very distal, most small bowel obstruction, right Jill? Right. So it's important to think about these things. These days, we're so lucky that we have great cross-sectional imaging studies that can inform you not only of the underlying condition, but the so-called point of transition that Jill was pointing out earlier, where you can see exactly where the level of obstruction which often informs you about the differential diagnosis of what the potential actual causes of that obstruction can be, because where the obstruction is tells you a lot about what could be causing that underlying obstruction. You're not going to have a cecal torsion causing midjejunal obstruction, for example. That's not going to happen. This case that you're showing here also is interesting because it shows you that a small bowel obstruction can be the result of something from the bile duct. So here you're seeing a gallstone that's eroded from the gallbladder into the small intestine. And there's a couple of choke points where that stone, if it's going to obstruct the small bowel, is going to get stuck. There are existing narrow points in the anatomy. One is the ligament of trites where the duodenum joins the top of the jejunum, and the other is at the ileocecal valve. But importantly, particularly in patients who've been operated on before or might have inflammatory bowel disease, they may have intrinsic strictures of the intestine or adhesions in the intestine or anastomosis of the small intestine that were created at surgical resection that could also be narrow points where such a stone could impact. Anything to add to that, Jill? No. That was great, John. Also, here are some important references. I don't know if you wanted to point any of those out in particular. No, these are going to be great resources. I think part of the challenge of reviewing CT scan imaging is that if you don't review them with assistance, you don't develop the eye for it. But when you start reading the reports and then actually not just focusing on the impression, but reading the actual body of your even abdominal series and your CT imaging, you start to pick up what the radiologic signs are, what they're looking for. And it's a great way to also communicate that to the patient of why you are, if you do get that acute abdominal x-ray and it shows that there's a partial bowel obstruction, but they're having nausea and vomiting, you're describing to the patient, this is why I want you to go to the emergency room now. That is such an important point, Jill, because I think depending on what institution you're at or many of us work at different locations, how much detail you're going to get in your radiology report from any individual radiologist is going to be highly variable. I'm very fortunate because I work with abdominal imaging radiologists who are into abdominal imaging. And they're not only going to call out findings, but they're going to tell you which series and which image of which series to specifically look at to point out the particular findings. And so every report is an education for me when I look at the report and correlate it with looking at the images myself. And I don't frequently have to call the radiologist to go over the images together real time or actually physically visit them, which can be impossible. But you know what, if you don't get detailed radiology reports, remember that you're fighting for your patient. So feel confident and feel powerful to call that radiologist, page them, go to their reading room, whatever you need to do to get the clarification that you deserve for the benefit of your patient. And Jill, I'm sure your message would be exactly the same. Exactly the same. In fact, please do not feel nervous about picking up the phone and asking to speak to a radiologist. There are several things that I've caught throughout my career that they've had to make an addendum to, to their radiologic finding, whether it's an abdominal X-ray or it's a CT exam. So there is auto dictation, just like we have with Dragon, that they have templates and the templates go through and they sign off on it. And I had a patient once tell me, she goes, she goes, why is it telling me I have a gallbladder? I don't have a gallbladder. So you have to follow up with your radiologic colleagues and they appreciate that. So, and even call to ask a question, you know, this is the scenario of my patient. Should I order a CT scan of the abdomen or CT enterography? You know, what do you think would be the best to find this? So yes, that's a common question that we may have with our physician colleagues, our gastroenterologists, but, but learn to utilize the brain power that's in the radiologic department as well. Makes so much sense. So much of it is your interpreting the radiology to remember the radiology folks do not see the patient and the radiology study is only important in the clinical context of your evaluation of the patient and you're the one who's going to manage that patient. So feel confident knowing that you are the advocate for the patient and you are the one knitting the whole case together. Get the information that your patient deserves, whatever you need to do to extract as much information as you can extract from the study. If you're not getting the detail on the reports that you need to take care of your patient the best way you can, then have a discussion with your radiology department. Let them know what you need. They are there to serve you and the patient and their insurance company are paying big bucks for these studies. And so you and they deserve to get what they are paying for. Now, Jill, I think you're controlling the slides, so if you can advance for me, I'm just going to take a minute here to go over an interesting case I saw a couple of days ago, which is a little bit of a curve ball for you just to wake you up in the middle of the afternoon. So you all remember what a Whipple procedure is. Usually for a pancreatic mass, most commonly cancer in the head of the pancreas, the surgery team will not only take out the head of the pancreas, but because the head of the pancreas where the tumor is, is intimately associated with the duodenum, the distal common bile duct, which goes through the head of the pancreas and often the lower part of the stomach. All of that will have to come out, not just the pancreatic tumor itself. And that, in fact, is a Whipple surgery or a Whipple procedure. And that cartoon on the right demonstrates what it looks like conceptually after that has all been taken out and stitched back together. Now, taking all the stuff around the outside away, this is what it looks like simply. So if you go down with a scope and you go through the esophagus and the stomach, you run into an anastomosis and it's going to look like a double barrel lumen, where if you go this way, you're going up the afferent limb, which is connected to the bile duct in the pancreas. But if you go this way, that goes down towards the colon. So the food goes this way in the bile and pancreas secretions come down and meet the food down here. And that is a classic Whipple anatomy. Now here's a patient who had pancreas cancer. They're known to have a have a recurrence of their pancreas cancer after a Whipple. Here is their liver and their bile duct seen on an MRI. And they came in jaundiced, which is the reason for the MRI. And they noticed that this is the afferent limb. That is this limb here. And the radiologist in that MRI is seeing that it's very, very dilated, abnormally so when the patient is jaundiced. Here's another MRI image showing that dilated afferent limb and the patient is jaundiced and the ducts are a little dilated too, bile ducts are. So they had a radiologist introduce a percutaneous needle followed by a catheter into the bile duct. They injected dye into the bile duct to perform a percutaneous cholangiogram. And they noticed that the anastomosis between the bile duct and the afferent limb of small bowel, the dye, they filled it and they noticed that it was obstructed downstream. So they left the drain in so that the patient's biliary obstruction could be dealt with right away. But they sent the patient to us in endoscopy to see if we could do something about this blockage downstream so that they could ultimately remove this catheter and the bile drain back, which they'd placed for the patient, so that he could be more comfortable. And when we went down with the scope, here's what we found. Sure enough, it's obstructed. We couldn't get the scope through into the afferent limb of small bowel because it was blocked from the outside, presumably from metastatic tumor in the same way in which that could happen with tumor mets and the rest of the small bowel downstream. But here, it's not blocking the flow of food. It's blocking the flow of bile here. So here's our scope where the intestine is closed off. We advance a guide wire across that blockage, follow that with a catheter to inject dye. And you can see that narrow segment here. It's about four times the diameter of the scope, so about four centimeters because that's a one-centimeter-in-diameter scope. And you can see, as we inject dye, it's actually open all the way up to the bile duct, just like the radiologist had noted. So the problem is not up in the bile duct. It's in that narrow spot. And here, what we have delivered is a self-expanding metal stent across that narrowing. Here it is on endoscopic view opening up. And now the patient will be able to drain bile right across that afferent limb like they did before the substruction resulted. And the radiologist will be able to remove that drain because all the bile will drain internally like it should. And we've checked to make sure that our open stent isn't blocking the efferent limb where the food needs to go, and it certainly looks like it is not. So that's the end of that case. And that was a nice outcome for us. So that is it. Jill, anything to add to that? Just wanted to throw a curveball and say not all small bowel obstructions result in symptoms that suggest that food isn't passing. Sometimes it's bile and surgical anatomy. No, that was a great case. Thank you.

small bowel obstruction

diagnostic imaging methods

cecal volvulus

radiology reports interpretation

biliary obstruction

endoscopic intervention