CT diagnosis of closed loop bowel obstruction mechanism is not sufficient to indicate emergent surgery

To identify computed tomography (CT) findings associated with successful conservative treatment of closed loop small bowel obstruction (CL-SBO) due to adhesions or internal herniation.

The local institutional review board approved this study while waiving informed consent. Clinical and CT data were collected retrospectively for 96 consecutive patients with a CT diagnosis of CL-SBO due to adhesions or internal herniation established by experienced radiologists who had no role in patient management. Mechanical obstruction with at least two transition zones on the bowel at a single site defined CL-SBO. Two radiologists blinded to patient data independently performed a retrospective review of the CT scans. The patient groups with successful versus failed initial conservative therapy were compared. Univariate and multivariate analyses were performed to look for CT findings associated with successful conservative therapy. Interobserver agreement was assessed for each CT finding.

Of the 96 patients, 34 (35%) underwent immediate surgery and 62 (65%) received first-line conservative treatment, which succeeded in 19 (31%) and failed in 43 (69%). The distance between the transition zones was the only independent predictor of successful conservative therapy (odds ratio, 4.6 when ≥ 8 mm; 95% confidence interval [95% CI], 1.2-18.3). A distance ≥ 8 mm had 84% (95% CI, 60-97) sensitivity and 46% (95% CI, 31-62) specificity for successful conservative treatment. The correlation coefficient for the distance between transition zones between readers 1 and 2 was fair (r = 0.46).

CL-SBO can be resolved without surgery. When there is no CT sign of ischemia, the distance between the transition zones should be assessed.

• Twenty percent (19/96) of all cases of closed loop small bowel obstruction (CL-SBO) representing 31% of the patients given first-line conservative therapy, were resolved without surgery. • The distance between the transition zones may help to choose between conservative and surgical management in patients with a CL-SBO but no CT evidence of ischemia. • A distance < 8 mm between the transition zones suggests a need for emergent surgery.