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PERBEDAAN ILEUS OBSTRUKSI DAN ILEUS PARALITIK Gas Distribution Obstruction : Too much air in the small bowel (and not much gas in the large bowel) or too much air in the large bowel (and not much gas in the small bowel). Poor gas distribution or gasless. Ileus : Good gas distribution over most of the abdomen. Too much air in both large and small bowel. Bowel Dilatation. Obstruction : Smooth bowel walls (resembles sausages or a hose). Preferential dilatation of the bowel proximal to the obstruction. Ileus : Dilatation of the bowel in proportion to each other, so that the colon remains larger than the small intestine. Look for sentinel loops. Air-fluid Levels. Obstruction : Many dilated air-fluid levels in both limbs of a given loop, at different heights (candy canes). Ileus : Fewer and/or smaller (less dilated) air-fluid levels scattered throughout the abdomen. Arrangement of loops (supine view only) Obstruction : Dilated loops arranged in "stepladder" fashion. Orderly. A bag of sausages. Ileus : Disorderly loops scattered throughout the abdomen. A bag of popcorn.

Radiologi Ileus Obstruksi Dan Ileus Paralitik

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PERBEDAAN ILEUS OBSTRUKSI DAN ILEUS PARALITIK

Gas Distribution Obstruction: Too much air in the small bowel (and not much gas in the large bowel) or too much air in the large bowel (and not much gas in the small bowel). Poor gas distribution or gasless.

Ileus: Good gas distribution over most of the abdomen. Too much air in both large and small bowel. Bowel Dilatation.

Obstruction: Smooth bowel walls (resembles sausages or a hose). Preferential dilatation of the bowel proximal to the obstruction.

Ileus

: Dilatation of the bowel in proportion to each other, so that the colon remains larger than the small intestine. Look for sentinel loops.

Air-fluid Levels.

Obstruction: Many dilated air-fluid levels in both limbs of a given loop, at different heights (candy canes).

Ileus: Fewer and/or smaller (less dilated) air-fluid levels scattered throughout the abdomen.

Arrangement of loops (supine view only) Obstruction: Dilated loops arranged in "stepladder" fashion. Orderly. A bag of sausages.

Ileus

: Disorderly loops scattered throughout the abdomen. A bag of popcorn.

KASUS

1. 18-month old male.

Interpretasi

Gas Distribution: There are pockets of gas scattered in several areas of the abdomen. There is gas in the small bowel, colon, and rectum.

Bowel Dilatation: No excessively dilated bowel. The bowel walls are not smooth. Haustra and plicae are preserved.

Air-Fluid Levels: None.

Arrangement of Loops: Large loops are not present.

Impression

: Within normal limits.

2. 7-day old female

Interpretasi

Gas Distribution: There are pockets of gas scattered in several areas of the abdomen. There is gas in the small bowel, colon, and rectum.

Bowel Dilatation: There is mild dilation of the bowel, mostly in the colon. The dilated segment of bowel in the left upper quadrant shows relatively smooth bowel walls. However, most of the bowel does not show this. In other words, the haustra and plicae of most of the bowel are well preserved.

Air-Fluid Levels: None.

Arrangement of Loops: The loops are not arranged in an orderly pattern.

Impression

: Ileus.

3. 17-day old male

Interpretasi

Gas Distribution: There is gas over most of the abdomen. There are loops of bowel mostly in the central abdomen. The dilated loops are mostly small bowel.

Bowel Dilatation: The bowel walls are smooth indicating that the bowel is dilated.

Air-Fluid Levels: There are multiple short air fluid levels on the upright film (hair pin loops).

Arrangement of Loops: Orderly, although not truly in a stepladder fashion. The arrangement here resembles a bag of sausages more so that a bag of popcorn.

Impression

: Small bowel obstruction. In this age, the mostly likely cause is an incarcerated inguinal hernia. This is confirmed clinically.

4. 1-month old female

Interpretasi

Gas Distribution

: There is a lot of gas in the small and large bowel distributed hroughout the abdomen.

Bowel Dilatation

: The degree of bowel dilation here is proportional throughout. In other words, the large bowel is slightly dilated, as is the small bowel. Air-Fluid Levels: None.

Arrangement of Loops

: Disorderly arrangement of dilated bowel. This resembles a bag of popcorn rather than a bag of sausages.

Impression

: Ileus. The differential is extensive, including gastroenteritis, urinary tract infection, etc. However, an ileus is still compatible with several surgical conditions such as appendicitis.

5. 3-1/2 year old male

Interpretasi

Gas Distribution: Increased gaseous distribution in both small and large bowel, with more colonic involvement. Gas is also present in the rectum.

Bowel Dilatation: Note the smooth bowel walls resulting in the "sausage-like" appearance of some of the loops. There are several areas of extreme dilation. The stomach is also very dilated.

Air-Fluid Levels: Multiple loops of bowel with air fluid levels. The typical "candy cane" appearance is not very dramatic.

Arrangement of Loops: The loops are stacked in a somewhat orderly fashion. However, this is not definite. The "arrangement" should be best determined on the supine flat view and not the upright view. Although this arrangement resembles a bag of sausages more so than a bag of popcorn, this is not as clear-cut as in other cases.

Impression

: The gas distribution throughout the bowel suggests that this is not an obstruction. However, the reason for the extreme bowel dilatation is uncertain. This is still suspicious for an obstruction. Note the frothy density over the left flank area (supine view). This probably represents fecal matter. Though a fecal obstruction is possible, a BE or an UGI series would be helpful to evaluate other causes of obstruction such as malrotation or Hirshsprung's disease. A contrast enema and an UGI series were performed on this patient. Both were normal. His symptoms and bowel dilation gradually resolved after several enemas and bowel movements.

6. 7-month old male

Interpretasi

Gas Distribution: Relatively gasless in both large and small bowel. This is a poor gas distribution.

Bowel Dilatation: In some of the few bowel loops that are seen, the bowel walls appear smooth.

Air-Fluid Levels: There are no obvious air-fluid levels. However, in the upright view, the central abdomen shows the presence of two bowel loops resembling arches that are air-fluid levels which do not have the typical candy cane appearance. The candy cane appearance of air-fluid levels is usually not seen in infants.

Arrangement of Loops: It is difficult to comment on the arrangement given the minimal gas pattern.

Impression

: Probable obstruction based mainly on the paucity of gas and its distribution. Since these radiographs are highly suspicious, the next recommended exam should be an ultrasound and/or a BE to evaluate the possibility of intussusception or appendicitis. An intussusception is often the cause of a bowel obstruction associated with a paucity of gas on plain radiographs A BE performed in this patient demonstrated an intussusception.

7. Newborn male.

Interpretasi

In this case, only a supine view is shown on the left. The image on the right is a contrast enema study.

Gas Distribution: There is poor gas distribution with only 3 dilated loops of bowel, triple bubbles, probably representing high (i.e., proximal) small bowel loops. There is some gas in the left lower quadrant. This cannot be the colon since there is no gas in any other intervening bowel segments evident.

Bowel Dilatation: As noted above, dilation is present in the loops seen. There is no colon gas evident.

Air-Fluid Levels: An upright or lateral decubitus view is not shown here.

Arrangement of Loops: Too few to comment.

Impression

: This is a proximal small bowel obstruction. The contrast enema on the right shows a microcolon indicating the absence of bowel contents passing to the colon during gestation. In a proximal small bowel obstruction, a microcolon is usually not present. The presence of a microcolon suggests that the distal small bowel is also atretic. This patient was ultimately diagnosed with a long segment small bowel atresia. Note that the contrast enema study also shows the cecum in the wrong position. It should be in the right lower quadrant, but it appears to be more medial than its expected positions. Malpositioning of the cecum is highly indicative of a malrotation.

8. 3-day old female

Interpretasi

Gas Distribution: Generalized presence of gas throughout all quadrants.

Bowel Dilatation: The degree of bowel dilatation is proportional. The right lower quadrant may demonstrate some smooth bowel walls, but this is probably just the descending colon. Some of the haustra in these segments are still preserved. For the remainder of the bowel, the haustra and plicae are well preserved.

Air-Fluid Levels: None.

Arrangement of Loops: Disorderly arrangement resembling a bag of popcorn.

Impression

: Ileus.

9. 2-1/2 year old female

Interpretasi

Gas Distribution: Well distributed throughout all quadrants.

Bowel Dilatation: There are two dilated regions seen on the supine view in both lower quadrants. However, the bowel walls do not appear smooth. The typical sausage or hose appearance of dilated small bowel is not present. The haustra and plicae are still fairly well preserved.

Air-Fluid Levels: The upright view shows many small air fluid levels. The typical hairpin or candy cane appearance is not present indicating that these air fluid levels are small and not present in large loops.

Arrangement of Loops: Disorderly loops resembling a bag of popcorn more so than a bag of sausages (supine view).

Impression

: Moderate ileus versus partial obstruction. An ileus is more likely.

10. 3-year old female

Interpretasi

Gas Distribution: There is gas distributed throughout the abdomen. Most of the gas present is in the colon.

Bowel Dilatation: There is moderate dilation of the colonic regions. There is a dilated loop of small bowel on the left (supine view) which overlaps the colon. The haustra and plicae are preserved. No sausages or hoses are seen (i.e., no smooth bowel walls are present).

Air-Fluid Levels: None.

Arrangement of Loops: Disorderly arrangement resembling a bag of popcorn more so than a bag of sausages.

Impression

: Ileus.

11. 9-day old male

Interpretasi

Gas Distribution: Poor distribution. Although gas is present throughout most of the abdomen, its distribution appears to be limited to just a few bowel segments.

Bowel Dilatation: Marked bowel distention though difficult to determine small versus large bowel. The bowel walls are smooth.

Air-Fluid Levels: Multiple air-fluid levels mostly on the left. Hair pins and candy canes are not present.

Arrangement of Loops: Not very helpful in this case. The arrangement is best evaluated on the supine view which is not obviously orderly or disorderly. In other words, it is not easy to say whether this arrangement resembles a bag of sausages or a bag of popcorn.

Impression

: Obstruction based mainly on the gas distribution and the degree of bowel dilatation. This is not a normal abdominal series for a 9-day old. A

contrast enema demonstrated a transition zone consistent with Hirschsprung's disease.

12. 12-month old female

Interpretasi

Gas Distribution: Small areas of gas are present throughout the entire abdomen. Many of the areas are foamy suggesting the presence of excessive amounts of stool.

Bowel Dilatation: Most of the bowel is not dilated. There is a modest paucity of gas. There are two dilated loops in the RLQ on the supine view (RLQ sentinel

loops).

Air-Fluid Levels: None.

Arrangement of Loops: Disorderly. Despite the paucity of gas, the supine view resembles a bag of popcorn more so than a bag of sausages.

Impression

: Ileus. RLQ sentinel loops raise the possibility of appendicitis.

13. 7-month old female

Interpretasi

Gas Distribution: There is a definite paucity of gas which is poorly distributed.

Bowel Dilatation: Nothing obvious.

Air-Fluid Levels: None.

Arrangement of Loops: Not a useful sign here because of the paucity of gas.

Other comments: There is a "target sign" in the right upper quadrant. The target sign is discussed in detail in Case 2 of Volume 1. The target is faintly visible as a doughnut shape (with the doughnut center still present) in the right upper quadrant below the liver (supine view). This is subtle. You may have to turn

down the room lights and adjust the contrast and brightness on your monitor. This sign indicates the presence of an intussusception. This radiograph also demonstrates the "absent liver edge" sign (liver edge not well defined in any view), which is also a sign of intussusception (though less specific than the target sign). If you have difficulty identifying the target and liver edge findings in this radiograph, review Case 2 of Volume 1 for other examples that are easier to identify.

Impression

: Suggestive of an obstruction based mainly on the paucity of gas. The target sign indicates the presence of an intussusception. A barium enema confirmed an intussusception.

14. 22-month old

Interpretasi

Gas Distribution: Good distribution except for one portion in the LUQ. Although the upright view appears to be somewhat gasless with most of the gas seen localized to the upper abdomen only, the supine view shows a better distribution of gas.

Bowel Dilatation: There are no dilated regions. The haustra and plicae are well preserved.

Air-Fluid Levels: None.

Arrangement of Loops: Disorderly.

Other Comments: The supine view demonstrates "thumb printing" suggesting bowel wall edema such as that seen in colitis. This is best seen in the LUQ region (or left middle region) where the colon shows thumb-shaped indentations into its lumen.

Impression: Ileus, colitis.

15. 11-month old male

Interpretasi

Gas Distribution: Poorly distributed. Gas is concentrated in the left upper quadrants in both the supine and upright views.

Bowel Dilatation: There are two dilated bowel segments seen on the supine view. The bowel walls are smooth and resemble sausages.

Air-Fluid Levels None.

Arrangement of Loops: Orderly. Note the two dilated bowel segments on the supine view are stacked on top of each other resembling a step ladder. Also, this view clearly resembles a bag of sausages (only two big ones), rather than a bag of popcorn. Impression

: Obstruction. A barium enema in this case demonstrated intussusception.

16. 6-1/2 year old male

Interpretasi

Gas Distribution: Well distributed except for a paucity of gas in the left lower quadrant.

Bowel Dilatation: The haustra and plicae are well preserved. No smooth bowel walls are visible. The caliber of the bowel is proportional to the normal bowel size.

Air-Fluid Levels: None.

Arrangement of Loops: Disorderly. Does not resemble a bag of sausages. Nor does it truly resemble a bag of popcorn. However, there is no order to the arrangement.

Impression

: Ileus. There is a possible appendicolith in the right lower quadrant (spherical density). This is highly suggestive of acute appendicitis. This again stresses the point, that an ileus is not necessarily benign.

References1. Swischuk LE. The Abdomen. In: Swischuk LE. Emergency Radiology of the Acutely Ill or Injured Child, second edition. Baltimore, Williams & Wilkins, 1986, pp. 153-164.

2. Swischuk LE. The Alimentary Tract. In: Radiology of the Newborn and Young Infant, second edition. Baltimore, Williams & Wilkins, 1980, pp. 487-490.

3. Kirks DR. The Gastrointestinal Tract. In: Practical Pediatric and Diagnostic Radiology of Infants and Children. Boston, Little, Brown and Company, 1984, pp. 551-553.

4. Parker BR. The Abdomen and Gastrointestinal Tract. In: Silverman FN, Kuhn JP. Caffey's Pediatric X-Ray Diagnosis, Ninth edition. St. Louis, Mosby, 1993, pp. 1059-1089.

5. Squire LF, Novelline RA. The Abdominal Plain Film: Distended Stomach, Small Bowel, Colon, Free Fluid and Free Air. In: Fundamentals of Radiology, 4th edition. Cambridge, MA, Harvard University Press, 1988, pp. 194-205.