Closed loop bowel obstruction

CASE
Nam, 52 tuổi, vào viện vì đau bụng quặn cơn, nôn nhiều, diễn biến 1 ngày
Tiền sử: Mổ nang ống mật chủ cách 5 năm. Mổ VRT 25 năm
Khám LS: Dấu hiệu Von Wahl (+): bụng chướng lệch sang mạn sườn trái, quai ruột nổi, căng, không di động, ấn đau.
Nghe: mất nhu động ruột
PUTB (+), CUPM (-)




CT


Phẫu thuật



CASE 2
Nữ, 36 tuổi, vào viện vì đau bụng thượng vị âm ỉ, không nôn, không buồn nôn. Sau vào viện 5h đau quặn cơn hố chậu phải, buồn nôn.
Không sốt.
Tiền sử mổ đẻ cách 5 năm
Khám: PUTB HCP(+), CUPM (+)



CT



Closed loop bowel obstruction

Definication
-

Closed loop obstruction is a specific type of bowel
obstruction in which two points along the course of a
bowel are obstructed, usually but not always with the
transition points adjacent to each other at a single
location.

-

Usually secondary to adhesions (65–75%), volvulus, or
hernia (1%).
In the large bowel: volvulus


Paththology
-

Mechanical obstruction of the blood vessels due to twisting of
the bowel loop
Pressure in bowel wall resulting in arterial and venous
microcirculation blockage
Venous congestion in the distended loop
=> Venous obstruction -> arterial occlusion-> rapid ischemia
of the bowel wall -> edematous and infarcts -> gangrene and
perforation

=> Closed loop obstructions are at higher risk than non-closed loop
obstructions for strangulation (compromised blood supply) or distensionrelated ischemia, resulting in intestinal necrosis and perforation.


Clinical presentation

-

Crampy abdominal pain
Vomiting
Abdominal distension
High pitched or absent bowel sounds.
Shock


X-ray


Ultrasound


CT
The CT-presentation of a closed loop obstruction in the small bowel depends on two things:

1.
2.

Length of the bowel segment that forms the closed loop
Orientation of the loop in relation to the imaging plane

If we have a short closed loop oriented within the plane of imaging, we will see a U- or C-shaped loop of bowel.
If the closed loop is longer and is oriented perpendicular to the plane of section, we will see a radial layout of the loops and mesenteric vessels
converging towards the place of torsion.


U- or C-shaped loop of bowel.


Clump of bowel loops


a radial array of dilated small bowel loops with the mesenteric vessels converging to a central point.



Odd configuration of small bowel loops


Mesenteric edema
Result of venous obstruction due to strangulation.


Two point of obstruction