Closed-Loop Obstruction Secondary to Adhesions

Submitted by John W. Fan, MD, and Bernard Chow, MD

Note: click on image above to enlarge.

The most popular Case in Point (CIP) submission of January 2013, as chosen by CIP users, was “Closed-Loop Obstruction Secondary to Adhesions.” January’s reader favorite explores the case of a 72-year-old man who presented to the emergency department with diffuse abdominal pain and vomiting.

The case was deemed a “very good example” of closed-loop obstruction with “excellent images.” The ACR Bulletin spoke with John W. Fan, MD, former resident at Santa Barbara Cottage Hospital in California, about bowel obstruction and CIP submission.

Q: Why did you select “Closed-Loop Obstruction Secondary to Adhesions” for submission to CIP?

A: This case is an excellent example of an uncommon type of small-bowel obstruction and demonstrates many of the imaging features of a closed-loop obstruction on CT. It is important to recognize this particular subtype of obstruction because it leads to higher mortality and a greater likelihood of bowel ischemia or necrosis.

Q: There seems to be a growing interest in evaluating the small intestine with MRI. Would MRI be of value in determining an etiology for small-bowel obstructions?

A: Given that most patients present acutely with abdominal pain and vomiting due to the obstruction, I believe CT is still the best modality for evaluating small-bowel obstructions. It is more widely available, is cost-effective, and has much faster acquisition times. Sensitivity is excellent, ranging from 94–100 percent.

Q: Apart from post-operative adhesions, what has been the most common cause of closed-loop obstructions in your institution? 

A: We have also seen cases of external hernias causing closed-loop obstructions, such as femoral or inguinal hernias. Internal hernias can also potentially cause closed-loop obstructions, but this is much less common.

Q: If you could leave readers with a single essential learning point from this case, what would it be?

A: The key educational point of this case is the importance of determining whether the bowel obstruction is simple or complicated based on imaging features, since this can change the clinical management of the patient. Complicated small-bowel obstructions are more likely to require surgical treatment because of the higher mortality rate and their association with vascular compromise. Recognizing this diagnosis may potentially prevent unnecessary morbidity and mortality.

“Closed-Loop Obstruction Secondary to Adhesions” was published on January 10, 2013. To view the full case, visit

While CIP serves as a venue for publication of rare and unusual cases, we are also seeking clear discussions and outstanding imaging for the disorders encountered on a more frequent basis. For more information, visit


A Note from the Case Lead Author

“As program director, I encourage all of my residents to submit cases for consideration to ACR CIP. It is an extremely valuable way to promote continual self-learning and to challenge ourselves daily, no matter if the participant is a medical student, resident, fellow, or practicing radiologist. Our program has been quite successful in contributing to the case files of the ACR CIP over the years.”

-Bernard Chow, MD, program director of radiology residency at Santa Barbara Cottage Hospital and clinical professor of radiology at Keck-USC School of Medicine

Anastasia Simkanin works in product development for the ACR IT Department. Michael Opatowsky, MD, is an associate editor for Case in Point. For questions about Case in Point, contact Toni Vega Aiken, Case in Point manager, at This email address is being protected from spambots. You need JavaScript enabled to view it..

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