Small-bowel obstruction due to bezoar: CT diagnosis and characterization Poster No.: C-1450 Congress: ECR 2013 Type: Scientific Exhibit Authors: I. lópez blasco, S. Paz Maya, R. Dosdá Muñoz, D. Soriano Mena, J. M. Sanchis Garcia, R. Sanchez Oro; Valencia/ES Keywords: Abdomen, CT DOI: 10.1594/ecr2013/C-1450 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 9
Purpose To describe the CT characteristics of bezoars associated to small bowel obstruction by a retrospective review of the CT images of 16 patients with surgical confirmation of intestinal obstruction by bezoar. Methods and Materials A retrospective review was made of the CT images of 16 consecutive patients treated surgically at our institution, from 2005 to 2011, for intestinal obstruction due to bezoar, including 12 men and 4 women, with an age range from 57 to 88 years and an mean age of 69.4 years. The radiologic findings evaluated were: Location Existence of a gastric mass similar to intestinal lesion Morphology Length Contours Presence of "wall / capsule" Floating fat-density debris inside the dilated loops, proximal to the obstructive bezoar, corresponding to the sum of the density of soft particles and the attenuation very negative of the air. Results All patients had an intraluminal mottled mass containing air bubbles, located immediately proximal to the transition point of intestinal caliber. However, these findings are similar to "small-bowel feces sign", a frequent finding in patients with high-grade intestinal obstruction, especially when occlusion develops progressively. The most common location was in ileum, in 14 patients (87%), identifying a mass in the stomach with similar CT appearance in 12 patients (75%), corresponding to a gastric bezoar. This lesion was characterized as a gastric intraluminal mass with mottledappearing and containing air bubbles. Page 2 of 9
The morphology of the lesion was well defined and ovoid in 11 patients (69%), with the presence of peripheral capsule or high-attenuation wall in 7 patients (43%), findings not observed or described in small-bowel feces. Bezoar length was less than 10 cm in 14 patients (87%), while small-bowel feces associated to intestinal obstruction tend to be longer. Floating fat-density debris were detected in dilated bowel loops proximal to bezoars in all cases (100%), by measuring the attenuation in regions of interest (ROI), ranging between -50 and -150 HU. This sign corresponds to the sum of the soft particles density and the very negative attenuation of the air-bubbles. Images for this section: Fig. 1: Small-bowel phytobezoar in a 43 year-old-woman. Unenhanced CT shows numerous loops of dilated small bowel suggestive of obstruction and an ovoid intraluminal mass with mottled gas pattern consistent with bezoar, located in the distal ileum. Page 3 of 9
Fig. 2: Gastric bezoar in a 75 year-old man. Enhanced CT with oral contrast material reveals a rounded mass, floating on the water-air surface and surrounded by the oral contrast material. Page 4 of 9
Fig. 3: 63 year-old man with a small-bowel bezoar. Unenhanced CT shows a well defined ovoid mass containing gas at site of obstruction. Page 5 of 9
Fig. 4: 59 year-old woman with a small-bowel obstruction due to a bezoar. EnhancedCT reveals a rounded mass containing gas located at the transition point in the ileum and with an encapsulating wall. Page 6 of 9
Fig. 5: 67 year-old man with a small-bowel bezoar. Enhanced-CT shows a well defined ovoid mass with a mottled gas pattern at site of obstruction. Note the encapsulating wall that shows the mass. Page 7 of 9
Fig. 6: 76 year-old woman with a small-bowel bezoar, showing fat-density debris (-148 HU) floating in bowel lumen proximal to obstructive bezoar. Page 8 of 9
Conclusion Typically, bezoar appears in CT as a mottled intraluminal mass containing air bubbles, proximal to the point of caliber change, with radiologic appearance similar to small-bowel feces. However, other imaging characteristics may allow the diagnosis and differentiation of bezoars, such as the presence of a gastric bezoar, a length shorter than 10 cm, a peripheral wall and the detection of fat-density debris in the bowel loops proximal to obstruction. References 1. 2. 3. 4. 5. Delabrousse E, Lubrano J, Sailley N, Aubry S, Mantion GA, Kastler BA. "Clinical Observations: Small-Bowel Bezoar Versus Small-Bowel Feces: CT Evaluation". AJR. 2008; 191:1465-8 Ko SF, Lee TY, Ng SH. "Smallbowel obstruction due to phytobezoar: CT diagnosis". Abdom Imaging1997;22:471-473 Ripollés T, García-Aguayo J, Martínez MJ, Gil P. "Gastrointestinalbezoars: sonographic and CT characteristics". AJR2001;77:65-69 Quiroga S, Alvarez-Castells A, Sebastià MC, Pallisa E, Barluenga E. "Smallbowel obstruction secondary tobezoar: CT diagnosis". AbdomImaging1997;22:315-317 Zissin R, Osadchy A, Gutman V, Rathaus V, Shapiro-Feinberg M, Gayer G. "CT findings in patients withsmallbowel obstruction due to phytobezoar". Emerg Radiol2004;10:197-200 Personal Information Page 9 of 9