Pediatric Small Bowel Obstruction

  • Etiology: AAIIMM – Adhesion, Appendicitis, Inguinal hernia, Intussusception, Malrotation with midgut volvulus, Meckel diverticulum
  • AXR: dilated small bowel loops above the level of the obstruction, normal small bowel loops below the level of the obstruction
  • UGI SBFT: dilated small bowel loops above the level of the obstruction, normal small bowel loops below the level of the obstruction
  • CT: dilated fluid-filled small bowel loops above the level of the obstruction, acute change in bowel caliber, normal or smaller caliber small bowel loops below the level of the obstruction, absence of gastrointestinal contrast in distal bowel, small bowel feces sign, mesenteric swirl / whirlpool sign in cases of obstruction due to small bowel volvulus, wall thickening, pneumatosis intestinalis in cases of bowel ischemia, ascites
  • DDX: AAIIMM – Adhesion, Appendicitis, Inguinal hernia, Intussusception, Malrotation with midgut volvulus, Meckel diverticulum
  • Complications: bowel ischemia
  • Treatment: conservative decompression via nasogastric tube vs. surgery
  • Clinical: most small bowel obstruction is partial as almost always some gas passes through the level of obstruction to the colon

Radiology Cases of Small Bowel Obstruction Due to Adhesion

SBFT of small bowel obstruction due to abdominal adhesions
AXR supine (left) shows several dilated loops of bowel in the left upper quadrant. Upper GI and small bowel follow through delayed image (right) shows contrast filling several dilated loops of jejunum with no contrast passing distally into the colon.

Surgical Cases of Small Bowel Obstruction Due to Adhesion

Surgical image of small bowel obstruction due to abdominal adhesions
Surgical image shows dilated and congested loops of small intestine in the upper right corner and normal sized decompressed loops of small bowel adjacent to them. A volvulus was noted at the level of the terminal ileum, caused by adhesions from the cecum to the small bowel, forming a closed loop obstruction that was causing bowel wall congestion.

Radiology Cases of Small Bowel Obstruction Due to Appendicitis

AXR of small bowel obstruction due to perforated appendicitis
AXR supine (left) shows multiple dilated loops of small bowel that have air fluid levels on the AXR upright (right). There is also a suggestion of a soft tissue mass in the right lower quadrant which is displacing the bowel loops medially.

Radiology Cases of Small Bowel Obstruction Due to Inguinal Hernia

AXR of small bowel obstruction due to inguinal hernia
AXR supine shows massively dilated loops of bowel filling the abdomen with a loop of bowel noted in each of the scrotal sacs.

Radiology Cases of Small Bowel Obstruction Due to Intussusception

AXR of small bowel obstruction due to intussusception
AXR supine (left) shows decompressed loops of bowel (presumed jejunum) in the left upper quadrant and multiple dilated loops of bowel (presumed ileum) in the right lower quadrant. AXR upright (right) shows multiple air-fluid levels.
CT of Meckel's diverticulum causing small bowel obstructin
Axial (above), coronal (lower left) and sagittal (lower right) CT with contrast of the abdomen shows multiple dilated loops of small bowel and a soft tissue mass in the right upper quadrant just beneath the gall bladder that shows the target sign on the sagittal image and the pseudokidney sign on the transverse and coronal images. The soft tissue mass was still present on an US performed 1 hour later.

Radiology Cases of Small Bowel Obstruction Due to Malrotation With Midgut Volvulus

AXR of small bowel obstruction due to malrotation with midgut volvulus
AXR supine shows multiple dilated loops of bowel with thickened walls.

Radiology Cases of Small Bowel Obstruction Due to Meckel Diverticulum

CT of small bowel obstruction due to Meckel's diverticulum
AXR supine (upper left) and coronal CT with contrast of the abdomen (lower left) show multiple dilated loops of small bowel with thin walls throughout the abdomen. The lower axial CT (upper right) shows a small cystic structure in the midline with a thicker wall than the surrounding dilated bowel which is also seen on the midline sagittal CT (lower right) just beneath the umbilicus.

Surgical Cases of Small Bowel Obstruction Due to Meckel Diverticulum

Surgical image of Meckel's diverticulum
Surgical image shows shows multiple dilated loops of small bowel in the background with a sharp transition point seen in the center of the image in the terminal ileum where on its anti-mesenteric border a diverticulum is seen with an omphalomesenteric duct remnant coming off it. This remnant had been attached to the under surface of the umbilicus, serving as a fulcrum for a small bowel volvulus, resulting in a small bowel obstruction.

Radiology Cases of Small Bowel Obstruction Due to Cecal Volvulus

Enema of cecal volvulus
AXR AP taken immediately after an enema shows multiple dilated loops of air-filled small bowel with no reflux of contrast into the terminal ileum. The ascending colon ends in a beak which points to a dilated air-filled cecum in the right lower quadrant.

Surgical Cases of Small Bowel Obstruction Due to Cecal Volvulus

Surgical image of cecal volvulus
Surgical image shows an extremely distended cecum twisted around the pateint’s appendicovesicostomy tract. The distal ileum was also extremely dilated.