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Accuracy of Abdominal Radiography in Acute Small-Bowel Obstruction: Does Reviewer Experience Matter?

¹ All authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —38-year-old woman with closed-loop small-bowel obstruction found at surgery. Highly predictive air-fluid levels are visible. Upright anteroposterior abdominal radiograph shows all three highly predictive types of air-fluid levels: two or more levels (thick arrows), levels with a width of 2.5 cm or more (long line), and levels differing 5 mm or more from one another in same loop (thin arrow, short lines).

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —42-year-old woman with abdominal pain. True-negative findings were reported. Supine (A) and upright (B) abdominal radiographs show multiple nondilated air-containing loops (arrows) of small bowel in left side of abdomen. B shows no significant air-fluid levels. CT on same day as radiography (not shown) did not reveal small-bowel obstruction, and symptoms resolved.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —42-year-old woman with abdominal pain. True-negative findings were reported. Supine (A) and upright (B) abdominal radiographs show multiple nondilated air-containing loops (arrows) of small bowel in left side of abdomen. B shows no significant air-fluid levels. CT on same day as radiography (not shown) did not reveal small-bowel obstruction, and symptoms resolved.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —78-year-old woman with abdominal pain, nausea, and vomiting. True-positive findings were reported. Supine abdominal radiograph shows multiple dilated loops (arrows) of small bowel in right lower quadrant.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —78-year-old woman with abdominal pain, nausea, and vomiting. True-positive findings were reported. Upright radiograph shows multiple air-fluid levels in right lower quadrant, some of which are wider than 2.5 cm, and air-fluid levels (arrows) of unequal height. Patient was treated conservatively, and obstruction resolved.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —83-year-old man with abdominal pain. True-positive findings were reported. Upright radiograph shows dilated small bowel (arrows) in left lower quadrant.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —83-year-old man with abdominal pain. True-positive findings were reported. Left lateral decubitus radiograph shows multiple air-fluid levels (arrows), some of which are wider than 2.5 cm and of unequal heights. Patient was treated conservatively, and obstruction resolved.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —74-year-old man with abdominal distention. False-positive findings were reported. Supine (A) and upright (B) abdominal radiographs show dilated small bowel out of proportion to colon; condition causes air-fluid levels (arrows, B). CT (not shown) performed later same day revealed only ascites and no evidence of small-bowel obstruction.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —74-year-old man with abdominal distention. False-positive findings were reported. Supine (A) and upright (B) abdominal radiographs show dilated small bowel out of proportion to colon; condition causes air-fluid levels (arrows, B). CT (not shown) performed later same day revealed only ascites and no evidence of small-bowel obstruction.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —91-year-old woman with abdominal pain. False-negative findings were reported. Supine radiograph shows little small-bowel gas. Five of six reviewers rated study inadequate owing to motion. All reviewers interpreted findings as no obstruction. CT (not shown) and surgery on same day revealed incarcerated right femoral hernia, which produced marked small-bowel obstruction with fluid-filled loops of dilated small bowel.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —48-year-old woman with nausea and vomiting. True-positive findings were reported. Gasless abdomen and string-of-pearls sign were seen. Supine abdominal radiograph shows paucity of small-bowel gas and suggestion of stretch sign valvulae conniventes in dilated small-bowel loop outlined by air (arrow). Stretch sign is defined as abnormal distention of predominantly fluid-filled small-bowel loops in which luminal gas has striped appearance running perpendicular to long axis of bowel [26].

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —48-year-old woman with nausea and vomiting. True-positive findings were reported. Gasless abdomen and string-of-pearls sign were seen. Upright radiograph shows multiple tiny air-fluid levels (arrows) in small bowel (string-of-pearls sign). Small-bowel obstruction due to adhesions was found at surgery.

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