array:23 [ "pii" => "S2173510723000174" "issn" => "21735107" "doi" => "10.1016/j.rxeng.2022.09.007" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1415" "copyright" => "SERAM" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2023;65 Supl 1:S92-S98" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S2173510723000332" "issn" => "21735107" "doi" => "10.1016/j.rxeng.2022.09.012" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1420" "copyright" => "SERAM" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2023;65 Supl 1:S99-S108" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Complications after abdominal surgery" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S99" "paginaFinal" => "S108" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Complicaciones abdominales posquirúrgicas" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2555 "Ancho" => 1306 "Tamanyo" => 300267 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bowel obstruction after cholecystectomy. CT of abdomen with IV contrast. (A) Axial plane. (B) Coronal reconstruction. Fluid accumulation in the cholecystectomy surgical bed, the lesser sac and the right subphrenic region (blue asterisk); bowel obstruction: dilated small bowel loops (yellow arrow) with a change in lumen at the level of the distal ileum in the right iliac fossa (red arrow). Significant gastric distension with contents (orange cross).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. de Araújo Martins-Romeo, A. Rivera Domínguez" "autores" => array:2 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "de Araújo Martins-Romeo" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Rivera Domínguez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833822002053" "doi" => "10.1016/j.rx.2022.09.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833822002053?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510723000332?idApp=UINPBA00004N" "url" => "/21735107/00000065000000S1/v2_202304071829/S2173510723000332/v2_202304071829/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S217351072300023X" "issn" => "21735107" "doi" => "10.1016/j.rxeng.2022.09.010" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "14180" "copyright" => "SERAM" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2023;65 Supl 1:S81-S91" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Update on acute appendicitis: Typical and untypical findings" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S81" "paginaFinal" => "S91" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización de la apendicitis aguda: hallazgos típicos y atípicos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1912 "Ancho" => 2674 "Tamanyo" => 483923 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Outline of the layers of the appendix on an ultrasound scan. Diagram of the layers of the appendix on an ultrasound scan. A) Diagram of a normal appendix. The muscle fibre layers (muscularis mucosa and muscularis propria) are hypoechoic, and the mucosa, submucosa and serosa are hyperechoic. The normal appendix is usually oval-shaped in axial slices. A1–A2) Ultrasound images in axial and longitudinal slices of the normal appendix. The mucosa shows gas suggestive of patency (arrow). The submucosal layer is thin (asterisk). B–B1) Diagram and axial image of acute appendicitis. Thickening of the submucosal layer (asterisk), loss of the mucosal layer and collapse of the appendix lumen (arrow), and hyperechogenicity of mesoappendix fat (star). C-C1) Diagram and sagittal image of acute appendicitis with discontinuity of the submucosal layer (arrowheads), indicating probable gangrenous appendicitis. D) Diagram of acute appendicitis where the endoluminal content predominates. D1-D2) Axial and sagittal images with colour Doppler mode. Appendix in which the endoluminal content predominates. Hyperaemic submucosa (asterisk) pushed out towards the periphery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Borruel Nacenta, L. Ibáñez Sanz, R. Sanz Lucas, M.A. Depetris, E. Martínez Chamorro" "autores" => array:5 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Borruel Nacenta" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Ibáñez Sanz" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Sanz Lucas" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Depetris" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Martínez Chamorro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003383382200203X" "doi" => "10.1016/j.rx.2022.09.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003383382200203X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217351072300023X?idApp=UINPBA00004N" "url" => "/21735107/00000065000000S1/v2_202304071829/S217351072300023X/v2_202304071829/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "titulo" => "Bowel obstruction: signs indicating the need for urgent surgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S92" "paginaFinal" => "S98" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Gómez Corral, C. Niño Rojo, R. de la Fuente Olmos" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Gómez Corral" "email" => array:1 [ 0 => "jesusgcorral@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Niño Rojo" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "de la Fuente Olmos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Obstrucción intestinal: signos de indicación quirúrgica urgente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1821 "Ancho" => 1675 "Tamanyo" => 215572 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bowel obstruction caused by an adhesive band. MDCT image with intravenous contrast in the sagittal plane. The “beak sign” can be seen in two adjacent loops (yellow stars) and the “fat notch sign” (red arrows) on both sides, which should suggest that the cause is an adhesive band (confirmed at surgery).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0065" class="elsevierStylePara elsevierViewall">Obstruction of the small intestine or colon continues to account for a large number of surgical emergencies treated in Spanish hospitals (20% of acute abdominal symptoms) and is still associated with significant morbidity and mortality. Of these cases, 70% involve obstruction of the small bowel, with post-surgical adhesions being the primary cause<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The other 30% of cases involve obstruction of the colon, with a different aetiology, very often cancerous, and almost always requiring surgical treatment, whether urgent or deferred.</p><p id="par0075" class="elsevierStylePara elsevierViewall">These days, the treatment of small bowel obstruction is mostly conservative, with aspiration through a nasogastric tube and fluid and electrolyte replacement being successful in 70–90% of patients. Treatment with water-soluble oral contrast is sometimes used in patients with persistence of symptoms at 48 h. In general, if the contrast gets through the obstructed area, there is less likelihood of the need for surgery or intestinal resection and of developing complications<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the 10% of cases which do not respond to this treatment, the risk of complications (ischaemia and necrosis) increases the mortality rate by 20–40%<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. In this context, the role of the radiologist is not simply limited to the diagnosis of obstruction, as they also make an essential contribution to the management of the patient, with early identification of those who will not benefit from conservative treatment, in whom urgent surgery will minimise complications and the risk of a fatal outcome<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Conservative treatment is considered to have failed when the obstruction persists after 72 h, the output from the nasogastric tube exceeds 500 ml on the third day, or when the patient develops signs of peritonitis or ischaemia<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The symptoms of obstruction are very nonspecific, with abdominal pain, vomiting, constipation and abdominal distension. Laboratory findings and clinical signs suggestive of strangulation include leucocytosis, elevated <span class="elsevierStyleSmallCaps">C</span>-reactive protein and lactate, and signs of peritoneal irritation.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although used initially, the low sensitivity of plain X-ray, particularly in the diagnosis of ischaemic complications, and the high percentage of false negatives and false positives, have relegated its role, and multidetector computed tomography (MDCT) with its very high sensitivity and specificity rates is now the preferred test<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Analysis of small bowel obstruction</span><p id="par0100" class="elsevierStylePara elsevierViewall">The radiological report needs to establish the diagnosis of bowel obstruction and specify its cause. It should also state whether there are signs pointing to how the patient's condition might progress, informing the surgeon about the likelihood of conservative treatment not being effective, and it should assess the need for early surgical management to avoid morbidity and mortality associated with bowel obstruction-related ischaemia.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We therefore need to answer these four questions<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a>:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">1</span><p id="par0110" class="elsevierStylePara elsevierViewall">Is there a small bowel obstruction?</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">2</span><p id="par0115" class="elsevierStylePara elsevierViewall">Is there a single transition point or is the obstruction in a closed-loop?</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">3</span><p id="par0120" class="elsevierStylePara elsevierViewall">What is the cause of the obstruction?</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">4</span><p id="par0125" class="elsevierStylePara elsevierViewall">Are there signs of complication?</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Is there a small bowel obstruction?</span><p id="par0130" class="elsevierStylePara elsevierViewall">In the diagnosis, we can differentiate between major criteria (necessary for making the diagnosis) and other minor criteria (not necessary, but useful)<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,9–11</span></a>.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Major criteria</span><p id="par0135" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Identification of small bowel loops dilated</span> more than 2.5−3 cm in diameter, with distal loops of normal lumen.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Point of transition</span> between dilated and non-dilated bowel (excludes paralytic ileus). If there is a gradual narrowing of the lumen, it is called the “beak sign”. Identification of the beak sign is important, not only for diagnosis, but also to determine the aetiology, with coronal and sagittal multiplanar reconstructions being helpful.</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">When there are not many dilated loops, they can be assessed directly by looking for the site of obstruction, while when there are a large number, retrograde assessment of non-dilated loops is preferable.</p><p id="par0155" class="elsevierStylePara elsevierViewall">We can determine that the cause is an adhesive band by analysing the transition point in different planes. If other causes of obstruction are excluded, there are radiological features that help us detect adhesive bands or “fibro-fatty bands” on MDCT, consisting of identifying the transition point with an associated central area of fat density ("fat notch" sign)<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>, with which we are able to make the diagnosis of obstruction caused by adhesive bands (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Minor criteria</span><p id="par0160" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Air-fluid levels.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Collapsed colon.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Faeces sign</span><a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a> or faecal-like material in the small bowel. Helping us to locate the transition zone, it consists of intestinal material mixed with air in the small bowel and located in the vicinity of the transition zone. It is produced by stasis of the intestinal contents, increased fluid absorption and bacterial overgrowth (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall">It can sometimes also be seen in patients without intestinal obstruction, but combined with dilated proximal loops and collapsed distal loops, it is highly specific for obstruction. The small bowel faecal sign tells us that the function of the wall is maintained and suggests a greater likelihood of it being resolved with conservative treatment<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Is there a single transition point or is the obstruction in a closed-loop?</span><p id="par0185" class="elsevierStylePara elsevierViewall">Closed-loop obstruction occurs when a bowel segment is obstructed at two or more points adjacent to each other, and is isolated from the rest of the intestine. As the contents cannot advance, the secretions increase and the loop dilates and compromises the proximal mesentery, its vessels and the wall, leading to a high risk of ischaemia and making the situation a surgical emergency.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The dilation of the loop and the existence of two nearby stenosis zones make rotation and volvulus of the loop more likely, increasing the risk of ischaemia.</p><p id="par0195" class="elsevierStylePara elsevierViewall">This type of obstruction is mainly caused by adhesions or adhesive bands, or by external and internal hernias and volvulus, with specific signs on MDCT<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5,10</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Beak sign at the two transition points,</span> which will also be close to each other when there is a single adhesive band or a single hernia orifice.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">“C” or “U” configuration</span> of the closed loop, which, depending on its orientation, is seen in one of the three planes (axial, coronal, sagittal).</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Wheel sign.</span> This occurs in the case of volvulus, due to torsion of the mesentery, where the dilated loops have a radial arrangement in the plane orthogonal to the axis of rotation, with the vessels converging at the central point, acquiring a characteristic “whirlpool” morphology (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">What is the cause of the obstruction?</span><p id="par0215" class="elsevierStylePara elsevierViewall">We have to search for the causes of the obstruction in the transition zone. They can be divided into three large groups<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a>, which are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>:</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">Extrinsic causes<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Adhesions/adhesive bands.</span> These are most common cause, the majority due to previous surgery (being less likely after laparoscopic surgery). The rest, occurring in the 10–15% of patients without previous surgery, are usually due to previous peritoneal inflammatory conditions (such as adnexitis), with congenital bands being more rare<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,11</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">External and internal hernias.</span> External hernias are the second leading cause of obstruction, the most common locations being the inguinal canal and the anterior abdominal wall.</p></li></ul></p><p id="par0235" class="elsevierStylePara elsevierViewall">Internal hernias are difficult to diagnose, with 50% being paraduodenal, and it is important to look for suspicious signs such as “clustered loops”, the “whirlpool sign” of the mesenteric vessels, the “mushroom sign” and “abnormally located loops”.</p><p id="par0240" class="elsevierStylePara elsevierViewall">It is very important to consider a history of Roux-en-Y gastric bypass surgery as a cause of internal hernia (hernias occurring through defects in the mesentery).</p><p id="par0245" class="elsevierStylePara elsevierViewall">The presence of the “whirlpool sign” or tapering of the superior mesenteric vein in patients with a history of Roux-en-Y gastric bypass surgery indicates an internal hernia (even in the absence of dilated loops)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. <ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cancers</span> (extraintestinal).</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Endometriosis</span>.</p></li></ul></p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Intrinsic causes</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Inflammation</span>. In Crohn's disease we can find stenosis both in the inflammatory-active phase and in the fibrostenotic phase.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cancers</span>. Primary cancers in the small intestine are rare (the most common are adenocarcinoma, carcinoid tumour and gastrointestinal stromal tumour [GIST]).</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mesenteric ischaemia</span>.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intramural haematoma.</span> A rare cause, this occurs in patients on anticoagulant therapy.</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Radiation enteritis.</span> This can develop from two months (acute, due to inflammation) to 30 years (chronic, due to fibrosis) after treatment.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intussusception.</span> This is a common cause of obstruction in children. In adults, 80–90% have an organic cause (for example, polyps, adenocarcinoma, lymphoma or metastasis).</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Intraluminal causes</span><p id="par0295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gallstone ileus</span>, due to the passage of gallstones into the intestine, with Rigler's triad being typical (obstruction, lithiasis at the transition point and pneumobilia).</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Foreign bodies and bezoars</span>. Not common.</p></li></ul></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Are there signs of complication?</span><p id="par0310" class="elsevierStylePara elsevierViewall">Identification of signs of ischaemia<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,7,10</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> is vitally important as it means a very serious clinical situation with increased mortality risk (from 8% to 40%)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and indicates the need for urgent surgical treatment.<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Low uptake or lack of enhancement of the bowel wall</span>. This is the most specific sign with a specificity of almost 95%<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, and identification requires comparing it with the enhancement of the adjacent normal loops. The use of dual-energy computed tomography is especially useful in this sign, as it highlights the contrast uptake of the healthy wall and its absence in the ischaemic segment, both when assessing the iodine map and in the low-energy virtual monoenergetic image (KeV), which makes it possible to enhance the difference in density between ischaemic and normal loops<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,16,17</span></a> (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Increase in density of the wall of the ischaemic loop on CT performed without intravenous (</span>IV<span class="elsevierStyleItalic">) contrast.</span> This is a useful sign when IV contrast cannot be administered to perform MDCT due to contraindication. It is produced by intramural haemorrhage as a consequence of venous congestion in the wall of the ischaemic loop and has high specificity for the diagnosis of ischaemia, although low sensitivity<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>.</p></li></ul></p><p id="par0325" class="elsevierStylePara elsevierViewall">It can also be assessed in studies performed with dual-energy MDCT and IV contrast when generating post-processing images without virtual contrast, as it can demonstrate both the hyperdensity of the wall without contrast and the lack of contrast uptake of the loop<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a>. <ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oedema or mesenteric fluid</span> in the area close to the obstruction. This is the result of oedema of the mesenteric fat due to ischaemia and may be increased by the associated venous congestion. It has been found to practically always be present in ischaemia and its absence tells us the likelihood of ischaemia is very low.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Target sign.</span> Wall thickening greater than 3 mm occurs, due to oedema, haemorrhage or both. It is a non-specific sign as it can have many other causes.</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">-</span><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Whirlpool sign.</span> Torsion and congestion of the mesenteric vessels, previously described as an expression of internal hernias and volvulus, and especially in Roux-en-Y gastric bypass. It is not very specific because it can be seen in cases of internal hernia without ischaemia and even in other clinical scenarios as an incidental finding.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">-</span><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Free intraperitoneal fluid</span>. This is a very non-specific sign.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">-</span><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pneumatosis intestinalis.</span> This is the presence of gas in the bowel wall. When found in isolation, it does not always indicate necrosis of the loop wall. It is important to differentiate it from pneumatosis cystoides intestinalis (benign process associated with numerous causes in a patient with no clinical signs or laboratory data of severe illness) and pseudopneumatosis (air trapped with faeces and fluid along the bowel wall).</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gas in portal or mesenteric vessels.</span> In the liver it is located peripherally, unlike the central location of pneumobilia.</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">-</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pneumoperitoneum</span>, as a sign of mural necrosis and perforation of the wall.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">-</span><p id="par0365" class="elsevierStylePara elsevierViewall">Signs associated with closed-loop obstruction.</p></li></ul></p><p id="par0370" class="elsevierStylePara elsevierViewall">Although these signs should make us suspect obstruction complicated by ischaemia, they are often non-specific if considered separately. For that reason, various authors have studied the diagnostic performance of a combination of several of the signs, finding that the association of decreased enhancement of the wall, mesenteric oedema and the presence of various transition zones predict the existence of strangulation and loop ischaemia with a high degree of certainty<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,21</span></a>.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Large bowel obstruction</span><p id="par0375" class="elsevierStylePara elsevierViewall">Large bowel obstruction is less common than small bowel obstruction and differs significantly in terms of aetiology, treatment and prognosis. The most common cause is cancer.</p><p id="par0380" class="elsevierStylePara elsevierViewall">Patients are generally older than in small bowel obstruction. Signs and symptoms are insidious in contrast to the sudden onset of symptoms in small bowel obstruction, with acute colonic obstruction being an abdominal emergency<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a>.</p><p id="par0385" class="elsevierStylePara elsevierViewall">The competence of the ileocaecal valve affects the response of the colon. If it is competent, it presents as a “closed-loop” obstruction and, as the caecum is the segment with the largest diameter in the colon, its walls experience higher pressure than the rest (according to the Law of Laplace), which can lead to a diastatic perforation of the caecum. If the valve is incompetent, the colon decompresses in the small intestine and can simulate small bowel obstruction<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0390" class="elsevierStylePara elsevierViewall">The differential diagnosis is considered with adynamic ileus, Ogilvie's syndrome and toxic megacolon.</p><p id="par0395" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows a summary of the most common causes<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>:<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">-</span><p id="par0400" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cancer.</span> Colon cancer accounts for 60% of cases, most commonly located in the sigmoid colon and the splenic angle of the colon, and the most common site of perforation, the caecum.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">-</span><p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Volvulus</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>. This causes 10–15% of large bowel obstructions. Vascular compromise leads to ischaemia, necrosis and perforation.</p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0410" class="elsevierStylePara elsevierViewall">Sigmoid volvulus is three to four times more common than caecum volvulus.</p><p id="par0415" class="elsevierStylePara elsevierViewall">The classic signs are the “coffee bean sign”, “beak sign”, inverted-U sign, “northern exposure sign”, specific sign of sigmoid volvulus (location of the sigmoid colon above the transverse colon), and the “whirlpool sign”. Ischaemia findings are similar to those described for small bowel loops.<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">-</span><p id="par0420" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Acute diverticulitis.</span> The obstruction is caused by oedema of the wall and pericolic inflammation, common in the sigmoid colon.</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">-</span><p id="par0425" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intussusception.</span> The most common cause in adults is carcinoma, which acts as the intussusception head.</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">-</span><p id="par0430" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hernias.</span> These are less common than in the small bowel and nearly always external.</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">-</span><p id="par0435" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Inflammatory bowel disease</span>.</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">-</span><p id="par0440" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intraluminal obstruction.</span> This is more common in the rectum and sigmoid colon, the most common cause being faecal impaction.</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">-</span><p id="par0445" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Adhesions,</span> rare in the colon.</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">-</span><p id="par0450" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extrinsic compression</span> (endometriosis, lymphadenopathy, peritoneal carcinomatosis).</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0455" class="elsevierStylePara elsevierViewall">Bowel obstruction is a relatively common disease in Spanish hospitals, with initial management conservative. Radiologists not only need to diagnose the process and determine its cause, but also inform the surgeon about any signs of complication (closed loop or intestinal ischaemia) which, in conjunction with the clinical and laboratory data (very often non-specific), should point to early surgical treatment and help avoid the higher morbidity and mortality rates associated with these complications.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Authorship</span><p id="par0460" class="elsevierStylePara elsevierViewall">Jesús Gómez Corral, as main author, having collaborated in the preparation and writing of the paper.</p><p id="par0465" class="elsevierStylePara elsevierViewall">Carmen Niño Rojo and Rebeca de la Fuente Olmos in the different sections of the paper.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0470" class="elsevierStylePara elsevierViewall">We have received no funding from any source.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0475" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:3 [ "identificador" => "xres1877419" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1628511" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1877418" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1628510" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Analysis of small bowel obstruction" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Is there a small bowel obstruction?" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Major criteria" ] ] ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Minor criteria" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Is there a single transition point or is the obstruction in a closed-loop?" ] 9 => array:3 [ "identificador" => "sec0035" "titulo" => "What is the cause of the obstruction?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Intrinsic causes" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Intraluminal causes" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Are there signs of complication?" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Large bowel obstruction" ] 12 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 13 => array:2 [ "identificador" => "sec0065" "titulo" => "Authorship" ] 14 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 15 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-06-21" "fechaAceptado" => "2022-09-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1628511" "palabras" => array:6 [ 0 => "Intestinal obstruction" 1 => "Complications" 2 => "Computed tomography" 3 => "Multidetector" 4 => "Intestinal ischemia" 5 => "Diagnostic imaging" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1628510" "palabras" => array:4 [ 0 => "Obstrucción intestinal" 1 => "Complicaciones tomografía computarizada multidetector" 2 => "Isquemia intestinal" 3 => "Diagnóstico por imagen" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Bowel obstruction is common in emergency departments. Obstruction is more common in the small bowel than in the large bowel. The most common cause is postsurgical adhesions.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nowadays, bowel obstruction is diagnosed with multidetector computed tomography (MDCT). MDCT studies for suspected bowel obstruction should focus on four points that need to be mentioned in the report: confirming the obstruction, determining whether there is a single transition point or whether the obstruction is found in a closed loop, establishing the cause of the obstruction, and seeking signs of complications.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Identifying signs of ischemia is important in the management of the patient because it enables patients at higher risk of poor outcomes after conservation treatment who could benefit from early surgical intervention to avoid greater morbidity and mortality associated with strangulation and ischemia of the obstructed bowel loop.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La obstrucción intestinal es un proceso frecuente en los servicios de Urgencias de nuestros hospitales, siendo la de intestino delgado más frecuente que la de colon y las bridas posquirúrgicas su causa más habitual.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Actualmente el diagnóstico se realiza mediante tomografía computarizada multidetector, debiendo valorar 4 cuestiones en nuestro informe: confirmar la obstrucción intestinal, determinar si hay un único punto de transición o es una obstrucción en asa cerrada, establecer la causa de la obstrucción y buscar signos de complicación.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La identificación de signos de isquemia es importante en el manejo del paciente ya que permite identificar precozmente aquellos pacientes que no van a evolucionar de forma favorable con el tratamiento conservador y son susceptibles de realizar un tratamiento quirúrgico precoz para evitar la mayor morbimortalidad asociada a la estrangulación y la isquemia del asa obstruida.</p></span>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1821 "Ancho" => 1675 "Tamanyo" => 215572 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bowel obstruction caused by an adhesive band. MDCT image with intravenous contrast in the sagittal plane. The “beak sign” can be seen in two adjacent loops (yellow stars) and the “fat notch sign” (red arrows) on both sides, which should suggest that the cause is an adhesive band (confirmed at surgery).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2369 "Ancho" => 1684 "Tamanyo" => 313895 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Small bowel obstruction. MDCT images with intravenous contrast with axial and coronal reconstruction, corresponding to the same patient. Signs of small bowel obstruction, with distension and thickening of the wall of the loops and in some of them the “target sign” (yellow stars) and the “faeces sign” (red arrows). Small amount of free fluid between the loops (green arrow). This patient was treated conservatively and the condition resolved.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1754 "Ancho" => 1684 "Tamanyo" => 352250 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bowel obstruction with signs of closed loop and ischaemia. Intravenous contrast-enhanced MDCT images with coronal (A and B), axial (C) and sagittal (D) reconstructions. Distended loops can be seen, some with thin walls and slight minor enhancement of the wall (yellow stars in A and B), mesenteric fluid (green stars in A, B and C) and with the “wheel sign” (images A and B). Loop with thickened wall and free fluid (red arrow) (C). The “beak sign” (white star) and the “fat notch sign” (blue arrow) can be seen (D). This patient with bowel obstruction and signs of closed loop underwent surgery, confirming adhesive band obstruction and necrosis of a long segment of small bowel.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 3079 "Ancho" => 1684 "Tamanyo" => 392930 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Signs of ischaemia. A) MDCT image with intravenous contrast and coronal reconstruction. B) MDCT with dual-energy (iodine map) and coronal reconstruction. Patient with already established ischaemia of the loops, with pneumatosis of the wall (red arrow in A), gas in mesenteric vessels and intrahepatic portal veins (yellow star and arrows in A). Less uptake of the wall in the affected loops can be seen (blue star in A and B).</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Extrinsic \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intrinsic \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraluminal \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0005" class="elsevierStylePara elsevierViewall">Adhesions</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0010" class="elsevierStylePara elsevierViewall">Inflammatory (Crohn's disease, tuberculosis, diverticulitis, appendicitis)</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Gallstone ileus</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">Hernias</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Cancers</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Bezoar</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>External \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Vascular (ischaemia, intramural haematoma)</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Foreign bodies</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Internal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Radiation enteritis</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cancers</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Intussusception</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Endometriosis</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Causes of small bowel obstruction.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cancers</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Volvulus</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sigmoid colon \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caecum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transverse colon \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Diverticulitis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Intussusception</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Inflammatory bowel disease</span><span class="elsevierStyleItalic">Hernia</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Extrinsic compression from abscesses or other causes</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Faecal impaction</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Intraluminal foreign body</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Causes of large bowel obstruction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bowel Obstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.M. Gore" 1 => "R.I. Silvers" 2 => "K.H. Thakrar" 3 => "D.R. Wenzke" 4 => "U.K. Mehta" 5 => "G.M. Newmark" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rcl.2015.06.008" "Revista" => array:6 [ "tituloSerie" => "Radiol Clin North Am" "fecha" => "2015" "volumen" => "53" "paginaInicial" => "1225" "paginaFinal" => "1240" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26526435" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adhesive small bowel obstruction: Predictive radiology to improve patient management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Zins" 1 => "I. Millet" 2 => "P. Taourel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2020192234" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2020" "volumen" => "296" "paginaInicial" => "480" "paginaFinal" => "492" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32692296" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vascular assessment in small bowel obstruction: Can CT predict requirement for surgical intervention?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Ferris" 1 => "M. Bastian-Jordan" 2 => "J. Fenwick" 3 => "J. Hislop-Jambrich" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00261-020-02698-x" "Revista" => array:6 [ "tituloSerie" => "Abdom Radiol (NY)" "fecha" => "2021" "volumen" => "46" "paginaInicial" => "517" "paginaFinal" => "525" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32770400" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Operative versus non-operative management of adhesive small bowel obstruction: A systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Hajibandeh" 1 => "S. Hajibandeh" 2 => "N. Panda" 3 => "R.M.A. Khan" 4 => "S.K. Bandyopadhyay" 5 => "S. Dalmia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijsu.2017.07.073" "Revista" => array:6 [ "tituloSerie" => "Int J Surg" "fecha" => "2017" "volumen" => "45" "paginaInicial" => "58" "paginaFinal" => "66" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28728984" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Small bowel obstruction and ischemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Diamond" 1 => "J. Lee" 2 => "C.A. 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Pickhardt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2214/AJR.16.16946" "Revista" => array:6 [ "tituloSerie" => "AJR Am J Roentgenol" "fecha" => "2017" "volumen" => "208" "paginaInicial" => "785" "paginaFinal" => "793" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28328258" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: A systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.D. Mallo" 1 => "L. Salem" 2 => "T. Lalani" 3 => "D.R. Flum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gassur.2004.10.006" "Revista" => array:6 [ "tituloSerie" => "J Gastrointest Surg" "fecha" => "2005" "volumen" => "9" "paginaInicial" => "690" "paginaFinal" => "694" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15862265" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Review of small-bowel obstruction: The diagnosis and when to worry" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.K. Paulson" 1 => "W.M. 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Journal Information
Bowel obstruction: signs indicating the need for urgent surgery
Obstrucción intestinal: signos de indicación quirúrgica urgente
J. Gómez Corral
, C. Niño Rojo, R. de la Fuente Olmos
Corresponding author
Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain