The Value Of CT In The Diagnosis And Management Of Patients With Acute Small-Bowel Obstruction

BackgroundThe patient with acute abdominal pain represent one of the most common,most important ,and most difficult practical problems that the general surgeon has to face. Intestinal obstruction is responsible for approximately 20% of surgical admissions for acute abdominal conditions. The small bowel is involved in60-80% of cases of intestinal obstruction. In spite of advances in imaging and a better understanding of the pathophysiology of the small bowel ,its obstruction is still frequently misdiagnosed. With the advent of new imaging techniques, disease of intestine has played a more and more important role in abdomen imaging research.The value of diagnostic imaging in such assessments lies in its ability to answer questions relevant to the clinical management of patients. According to Herlinger and Maglinte, the issues of concern to the surgical management of small-bowel obstruction that diagnostic procedures must address are the confirmation of the site, severity, and cause of the obstruction; and the possible presence of strangulation. Underlying these questions is the pivotal issue of whether early laparotomy is indicated or whether a trial of nonoperative management should be instituted. Radiology, assumes considerable importance in this decision. An erroneous choice of diagnostic procedures adds to the costs of workup and delay diagnosis. Some of the most frequently used descriptive terms by surgeons are simple obstruction , closed-loop obstruction, strangulation obstruction ,paralytic ileus, complete obstruction ,partial obstruction, low small-bowel obstruction, high- small-bowel obstruction, functional obstruction, pseudoobstruction, and so on.The causes of small-bowel obstruction, includes inflammatory processes, intussusception, volvulus, congenital lesions, primary or secondary neoplasm, external hernia, small-bowel obstruction after trauma , and the occasional iatrogenic obturation obstruction by a distended balloon of a feeding or decompression tube.According toEllis, the pattern of major causes of small-bowel obstruction has changed during the last five decades. Adhesions and hernias are the two major causes, closely followed by malignancies-most of them metastases. For all practical purposes , these three entities account for approximately 80% of all case, with adhesions accounting for as high as 79% in some reports.The management of patients with adhesive small-bowel obstruction remains a controversial subject. If the obstruction is partial ,an initial trial of intestinal decompression is frequently recommended by surgeons in the belief that this approach is safe and that the need for surgery can be avoided. Other surgeons believe that early surgical intervention is necessary , especially with complete obstruction both because of the difficulty in distinguishing simple from strangulation obstruction and because of the high complication rate associated with delayed operative intervention. The mortality rate of strangulation complicating small-bowel obstruction is approximately 25%. The timing of such surgery is probably most controversial in patients with adhesive obstruction by the use of gastrointestinal tube decompression in these patients is high.Despite plain film radiography remains a mainstay in the evaluation of suspected small-bowel obstruction, it dose not confirm the clinical findings to allow a confident diagnosis of mechanical small-bowel obstruction and, in addition, often fails to answer questions about management and causes. According to Maglinte, CT is able to correctly reveal the cause of obstruction in 73-95 % cases. CT findings in 55 cases with acute small-bowel obstruction, in whom clinical and plain radiographic were inconclusive, were analyzed. The changes in therapy according to CT information were recorded. The objective of this study was to evaluate the role of CT in the diagnosis and management of patients with acute small-bowel obstruction. Materials and Methods1. Patients: From November 2002 to October 2004 , 97 patients (62 men and 35 women,2-84 years old, mean age, 57 y...