The flower bouquet sign and the fat notch sign in adhesive small bowel obstruction

A 55-year-old woman presented with vomiting and abdominal pain. Physical examination revealed abdominal tenderness, but no rebound tenderness. A computed tomography (CT) scan revealed a distended small intestine called the flower bouquet sign, as well as the fat notch sign. These findings supported the suspicion of adhesive small bowel obstruction (SBO). Emergency surgery confirmed the presence of an adhesive band formed and it was resected. The patient recovered uneventfully. Most cases of SBO are caused by adhesions, followed by internal hernias and volvulus. CT scanning is essential for diagnosing adhesive SBO, which exhibits characteristic signs such as the beak sign, fat notch sign, small bowel feces sign, and flower bouquet sign. The flower bouquet sign refers to the distended small bowel segments arranged radially within a closed loop, resembling flowers and stretched mesenteric vessels that converge toward the transition zone, resembling stems. The fat notch sign indicates extraluminal compression of the bowel by an adhesive band at the transition zone. This case underscores the importance of recognizing adhesive SBO early on through characteristic imaging signs to mitigate the risk of life-threatening complications, such as ischemia or perforation.