Diagnostic utility of CT for small bowel obstruction: Systematic review and meta-analysis

Autoři: Zhengyan Li aff001;  Ling Zhang aff002;  Xijiao Liu aff001;  Fang Yuan aff001;  Bin Song aff001
Působiště autorů: Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China aff001;  Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China aff002
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0226740



To perform a systematic review and meta-analysis evaluating the diagnostic performance of computed tomography (CT) for small bowel obstruction (SBO), including diagnostic accuracy, ischemia, predicting surgical intervention, etiology and transition point.


PubMed/MEDLINE and related databases were searched for research articles published from their inception through August 2018. Findings were pooled using bivariate random-effects and summary receiver operating characteristic curve models. Meta-regression and subgroup analyses were performed to evaluate whether publication year, patient age, enhanced CT, slice thickness and pathogenesis affected classification accuracy.


In total, 45 studies with a total of 4004 patients were included in the analysis. The pooled sensitivity and specificity of CT for SBO were 91% (95% confidence interval [CI]: 84%, 95%) and 89% (95% CI: 81%, 94%), respectively, and there were no differences in the subgroup analyses of age, publication year, enhanced CT and slice thickness. For ischemia, the pooled sensitivity and specificity was 82% (95% CI: 67%, 91%) and 92% (95% CI: 86%, 95%), respectively. No difference was found between enhanced and unenhanced CT based on subgroup analysis; however, high sensitivity was found in adhesive SBO compared with routine causes (96% vs. 78%, P = 0.03). The pooled sensitivity and specificity for predicting surgical intervention were 87% and 73%, respectively. The accuracy for etiology of adhesions, hernia and tumor was 95%, 70% and 82%, respectively. In addition, the pooled sensitivity and specificity for transition point was 92% and 77%, respectively.


CT has considerable accuracy in diagnosis of SBO, ischemia, predicting surgical intervention, etiology and transition point.

Klíčová slova:

Computed axial tomography – Diagnostic medicine – Etiology – Ischemia – Pediatric surgery – Pediatrics – Surgical and invasive medical procedures


1. Nicolaou S, Kai B, Ho S, Su J, Ahamed K. Imaging of acute small-bowel obstruction. AJR Am J Roentgenol. 2005;185(4):1036–1044. doi: 10.2214/AJR.04.0815 16177429

2. Hastings RS, Powers RD. Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med. 2011;29(7):711–6. doi: 10.1016/j.ajem.2010.01.045 20825873

3. Paulson EK, Thompson WM. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology. 2015;275(2):332–42. doi: 10.1148/radiol.15131519 25906301

4. Taylor MR, Lalani N. Adult small bowel obstruction. Acad Emerg Med. 2013;20(6):528–44. doi: 10.1111/acem.12150 23758299

5. Ros PR, Huprich JE. ACR Appropriateness Criteria on suspected small-bowel obstruction. J Am Coll Radiol. 2006;3(11):838–41. doi: 10.1016/j.jacr.2006.09.018 17412182

6. Atri M, McGregor C, McInnes M, Power N, Rahnavardi K, Law C, et al. Multidetector helical CT in the evaluation of acute small bowel obstruction: comparison of non-enhanced (no oral, rectal or IV contrast) and IV enhanced CT. Eur J Radiol. 2009;71(1):135–40. doi: 10.1016/j.ejrad.2008.04.011 18534800

7. Balthazar E, Birnbaum B, Megibow A, Gordon R, Whelan C, Hulnick D. Closed-loop and strangulating intestinal obstruction: CT signs. Radiology. 1992;185(3):769–75. doi: 10.1148/radiology.185.3.1438761 1438761

8. Balthazar EJ, Liebeskind ME, Macari M. Intestinal ischemia in patients in whom small bowel obstruction is suspected: evaluation of accuracy, limitations, and clinical implications of CT in diagnosis. Radiology. 1997;205(2):519–22. doi: 10.1148/radiology.205.2.9356638 9356638

9. Chang WC, Ko KH, Lin CS, Hsu HH, Tsai SH, Fan HL, et al. Features on MDCT that predict surgery in patients with adhesive-related small bowel obstruction. PloS One. 2014;9(2):e89804. doi: 10.1371/journal.pone.0089804 24587047

10. Daneshmand S, Hedley CG, Stain SC. The utility and reliability of computed tomography scan in the diagnosis of small bowel obstruction. Am Surg. 1999;65(10):922–6. 10515535

11. Deshmukh SD, Shin DS, Willmann JK, Rosenberg J, Shin L, Jeffrey RB. Non-emergency small bowel obstruction: assessment of CT findings that predict need for surgery. Eur Radiol. 2011;21(5):982–6. doi: 10.1007/s00330-010-1983-4 20963444

12. Donckier V, Closset J, Van Gansbeke D, Zalcman M, Sy M, Houben JJ, et al. Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction. Br J Surg. 1998;85(8):1071–4. doi: 10.1046/j.1365-2168.1998.00813.x 9717999

13. Duda JB, Bhatt S, Dogra VS. Utility of CT whirl sign in guiding management of small-bowel obstruction. AJR Am J Roentgenol. 2008;191(3):743–7. doi: 10.2214/AJR.07.3386 18716103

14. Filippone A, Cianci R, Grassedonio E, Di Fabio F, Storto ML. Four-section multidetector computed tomographic imaging of bowel obstruction: usefulness of axial and coronal plane combined reading. J Comput Assist Tomogr. 2007;31(4):499–507. doi: 10.1097/01.rct.0000238013.87802.3c 17882022

15. Frager D, Baer JW, Medwid SW, Rothpearl A, Bossart P. Detection of intestinal ischemia in patients with acute small-bowel obstruction due to adhesions or hernia: efficacy of CT. AJR Am J Roentgenol. 1996;166(1):67–71. doi: 10.2214/ajr.166.1.8571907 8571907

16. Frager D, Medwid SW, Baer JW, Mollinelli B, Friedman M. CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. AJR Am J Roentgenol. 1994;162(1):37–41. doi: 10.2214/ajr.162.1.8273686 8273686

17. Fukuya T, Hawes DR, Lu CC, Chang PJ, Barloon TJ. CT diagnosis of small-bowel obstruction: efficacy in 60 patients. AJR Am J Roentgenol. 1992;158(4):765–9; discussion 71–2. doi: 10.2214/ajr.158.4.1546591 1546591

18. Geffroy Y, Boulay-Coletta I, Julles MC, Nakache S, Taourel P, Zins M. Increased unenhanced bowel-wall attenuation at multidetector CT is highly specific of ischemia complicating small-bowel obstruction. Radiology. 2014;270(1):159–67. doi: 10.1148/radiol.13122654 24029649

19. Peck JJ, Milleson T, Phelan J. The role of computed tomography with contrast and small bowel follow-through in management of small bowel obstruction. Am J Surg. 1999;177(5):375–8. doi: 10.1016/s0002-9610(99)00066-5 10365873

20. Walsh DW, Bender GN, Timmons H. Comparison of computed tomography-enteroclysis and traditional computed tomography in the setting of suspected partial small bowel obstruction. Emerg Radiol. 1998;5(1):29–37.

21. Wang Q, Chavhan GB, Babyn PS, Tomlinson G, Langer JC. Utility of CT in the diagnosis and management of small-bowel obstruction in children. Pediatr Radiol. 2012;42(12):1441–8. doi: 10.1007/s00247-012-2497-9 23052726

22. Yaghmai V, Nikolaidis P, Hammond NA, Petrovic B, Gore RM, Miller FH. Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images? Emerg Radiol. 2006;13(2):69–72. doi: 10.1007/s10140-006-0513-9 16941110

23. Chang YJ, Yan DC, Lai JY, Chao HC, Chen CL, Chen SY, et al. Strangulated small bowel obstruction in children. J Pediatr Surg. 2017;52(8):1313–7. doi: 10.1016/j.jpedsurg.2017.03.002 28318600

24. Chuong AM, Corno L, Beaussier H, Boulay-Coletta I, Millet I, Hodel J, et al. Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT. Radiology. 2016;280(1):98–107. doi: 10.1148/radiol.2016151029 26866378

25. Kim JH, Ha HK, Kim JK, Eun HW, Park KB, Kim BS, et al. Usefulness of known computed tomography and clinical criteria for diagnosing strangulation in small-bowel obstruction: analysis of true and false interpretation groups in computed tomography. World J Surg. 2004;28(1):63–8. doi: 10.1007/s00268-003-6899-6 14648046

26. Sheedy SP, Earnest Ft, Fletcher JG, Fidler JL, Hoskin TL. CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation. Radiology. 2006;241(3):729–36. doi: 10.1148/radiol.2413050965 17114622

27. Hwang JY, Lee JK, Lee JE, Baek SY. Value of multidetector CT in decision making regarding surgery in patients with small-bowel obstruction due to adhesion. Eur Radiol. 2009;19(10):2425–31. doi: 10.1007/s00330-009-1424-4 19415288

28. Pricolo VE, Curley F. CT scan findings do not predict outcome of nonoperative management in small bowel obstruction: Retrospective analysis of 108 consecutive patients. Int J Surg. 2016;27:88–91. doi: 10.1016/j.ijsu.2016.01.033 26808325

29. Li Zhengyan, Song Bin. Diagnostic utility of CT for small bowel obstruction: systematic review and meta-analysis. PROSPERO. 2015; CRD42015024658 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015024658.

30. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. doi: 10.1136/bmj.b2535 19622551

31. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–36. doi: 10.7326/0003-4819-155-8-201110180-00009 22007046

32. Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005;58(10):982–90. doi: 10.1016/j.jclinepi.2005.02.022 16168343

33. Jones CM, Athanasiou T. Summary receiver operating characteristic curve analysis techniques in the evaluation of diagnostic tests. Ann Thorac Surg. 2005;79(1):16–20. doi: 10.1016/j.athoracsur.2004.09.040 15620907

34. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58. doi: 10.1002/sim.1186 12111919

35. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. doi: 10.1136/bmj.327.7414.557 12958120

36. Deeks JJ, Macaskill P, Irwig L. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol. 2005;58(9):882–93. doi: 10.1016/j.jclinepi.2005.01.016 16085191

37. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emergency medicine journal: EMJ. 2011;28(8):676–8. doi: 10.1136/emj.2010.095729 20732861

38. Maglinte DD, Reyes BL, Harmon BH, Kelvin FM, Turner WW Jr, Hage JE, et al. Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol. 1996;167(6):1451–5. doi: 10.2214/ajr.167.6.8956576 8956576

39. Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. Am J Emerg Med. 2018;36(2):234–42. doi: 10.1016/j.ajem.2017.07.085 28797559

40. Wale A, Pilcher J. Current Role of Ultrasound in Small Bowel Imaging. Semin Ultrasound CT MR. 2016;37(4):301–12. doi: 10.1053/j.sult.2016.03.001 27342894

41. Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in the diagnosis of intestinal ischemia in small-bowel obstruction. AJR Am J Roentgenol. 2000;175(6):1601–7. doi: 10.2214/ajr.175.6.1751601 11090385

42. Millet I, Taourel P, Ruyer A, Molinari N. Value of CT findings to predict surgical ischemia in small bowel obstruction: A systematic review and meta-analysis. Eur Radiol. 2015;25(6):1823–35. doi: 10.1007/s00330-014-3440-2 25850889

43. Millet I, Boutot D, Faget C, Pages-Bouic E, Molinari N, Zins M, et al. Assessment of Strangulation in Adhesive Small Bowel Obstruction on the Basis of Combined CT Findings: Implications for Clinical Care. Radiology. 2017;285(3):798–808. doi: 10.1148/radiol.2017162352 28759326

44. Takahara T, Kwee TC, Haradome H, Aoki K, Matsuoka H, Nakamura A, et al. Peristalsis gap sign at cine magnetic resonance imaging for diagnosing strangulated small bowel obstruction: feasibility study. Jpn J Radiol. 2011;29(1):11–8. doi: 10.1007/s11604-010-0508-z 21264656

45. Rubio EI, Blask AR, Badillo AT, Bulas DI. Prenatal magnetic resonance and ultrasonographic findings in small-bowel obstruction: imaging clues and postnatal outcomes. Pediatr Radiol. 2017;47(4):411–21. doi: 10.1007/s00247-016-3770-0 28116474

46. Krishna S, McInnes MDF, Schieda N, Narayanasamy S, Sheikh A, Kielar A. Diagnostic Accuracy of MRI for Diagnosis of Internal Hernia in Pregnant Women With Prior Roux-en-Y Gastric Bypass. AJR Am J Roentgenol. 2018;211(4):755–9. doi: 10.2214/AJR.17.19252 30106618

47. Halepota HF, Mateen Khan MA, Shahzad N. Sensitivity and specificity of CT scan in small bowel obstruction among children. J Pak Med Assoc. 2018;68(5):744–6. 29885174

48. He B, Gu J, Huang S, Gao X, Fan J, Sheng M, et al. Diagnostic performance of multi-slice CT angiography combined with enterography for small bowel obstruction and intestinal ischaemia. J Med Imaging Radiat Oncol. 2017;61(1):40–7. doi: 10.1111/1754-9485.12514 27709810

49. Idris M, Kashif N, Idris S, Memon WA, Tanveer UH, Haider Z. Accuracy of 64-slice multidetector computed tomography scan in detection of the point of transition of small bowel obstruction. Pediatr Radiol. 2012;30(3):235–41.

50. Jabra AA, Fishman EK. Small bowel obstruction in the pediatric patient: CT evaluation. Abdom Imaging. 1997;22(5):466–70. 9233878

51. Jabra AA, Eng J, Zaleski CG, Abdenour GE Jr, Vuong HV, Aideyan UO, et al. CT of small-bowel obstruction in children: sensitivity and specificity. AJR Am J Roentgenol. 2001;177(2):431–6. doi: 10.2214/ajr.177.2.1770431 11461877

52. Jaffe TA, Martin LC, Thomas J, Adamson AR, DeLong DM, Paulson EK. Small-bowel obstruction: coronal reformations from isotropic voxels at 16-section multi-detector row CT. Radiology. 2006;238(1):135–42. doi: 10.1148/radiol.2381050489 16293807

53. Jancelewicz T, Vu LT, Shawo AE, Yeh B, Gasper WJ, Harris HW. Predicting strangulated small bowel obstruction: an old problem revisited. J Gastrointest Surg. 2009;13(1):93–9. doi: 10.1007/s11605-008-0610-z 18685902

54. Jang KM, Min K, Kim MJ, Koh SH, Jeon EY, Kim IG, et al. Diagnostic performance of CT in the detection of intestinal ischemia associated with small-bowel obstruction using maximal attenuation of region of interest. AJR Am J Roentgenol. 2010;194(4):957–63. doi: 10.2214/AJR.09.2702 20308497

55. Kato K, Mizunuma K, Sugiyama M, Sugawara S, Suzuki T, Tomabechi M, et al. Interobserver agreement on the diagnosis of bowel ischemia: assessment using dynamic computed tomography of small bowel obstruction. Jpn J Radiol. 2010;28(10):727–32. doi: 10.1007/s11604-010-0500-7 21191737

56. Kulvatunyou N, Pandit V, Moutamn S, Inaba K, Chouliaras K, DeMoya M, et al. A multi-institution prospective observational study of small bowel obstruction: Clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393–8. doi: 10.1097/TA.0000000000000759 26307871

57. Maglinte DD, Gage SN, Harmon BH, Kelvin FM, Hage JP, Chua GT, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology. 1993;188(1):61–4. doi: 10.1148/radiology.188.1.8511318 8511318

58. Makanjuola D. Computed tomography compared with small bowel enema in clinically equivocal intestinal obstruction. Clin Radiol. 1998;53(3):203–8. doi: 10.1016/s0009-9260(98)80101-3 9528871

59. Matsushima K, Inaba K, Dollbaum R, Cheng V, Khan M, Herr K, et al. High-Density Free Fluid on Computed Tomography: a Predictor of Surgical Intervention in Patients with Adhesive Small Bowel Obstruction. J Gastrointest Surg. 2016;20(11):1861–6. doi: 10.1007/s11605-016-3244-6 27613731

60. Memon W, Khattak YJ, Alam T, Sconfienza LM, Awais M, Anwar SSM. MDCT of small bowel obstruction: How reliable are oblique reformatted images in localizing point of transition? Gastroenterol Res Pract. 2014:815802. doi: 10.1155/2014/815802 24883057

61. Obuz F, Terzi C, Sokmen S, Yilmaz E, Yildiz D, Fuzun M. The efficacy of helical CT in the diagnosis of small bowel obstruction. Eur J Radiol. 2003;48(3):299–304. doi: 10.1016/s0720-048x(02)00382-0 14652150

62. Pongpornsup S, Tarachat K, Srisajjakul S. Accuracy of 64 sliced multi-detector computed tomography in diagnosis of small bowel obstruction. J Med Assoc Thai. 2009;92(12):1651–61. 20043569

63. Scrima A, Lubner MG, King S, Pankratz J, Kennedy G, Pickhardt PJ. Value of MDCT and Clinical and Laboratory Data for Predicting the Need for Surgical Intervention in Suspected Small-Bowel Obstruction. AJR Am J Roentgenol. 2017;208(4):785–93. doi: 10.2214/AJR.16.16946 28328258

64. Shah ZK, Uppot RN, Wargo JA, Hahn PF, Sahani DV. Small bowel obstruction: the value of coronal reformatted images from 16-multidetector computed tomography—a clinicoradiological perspective. J Comput Assist Tomogr. 2008;32(1):23–31. doi: 10.1097/RCT.0b013e318063c66d 18303284

65. Taourel PG, Fabre JM, Pradel JA, Seneterre EJ, Megibow AJ, Bruel JM. Value of CT in the diagnosis and management of patients with suspected acute small-bowel obstruction. AJR Am J Roentgenol. 1995;165(5):1187–92. doi: 10.2214/ajr.165.5.7572500 7572500

66. Xu N, Li NE, Cao XL, Wang L, Li XT, Huang LY. The benefit of double-balloon enteroscopy combined with abdominal contrast-enhanced CT examination for diagnosing small-bowel obstruction. Acta Endoscopica. 2013;43(5–6):242–7.

67. Ten Broek RPG, Krielen P, Di Saverio S, Coccolini F, Biffl WL, Ansaloni L, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018;13:24. doi: 10.1186/s13017-018-0185-2 29946347

68. Maung AA, Johnson DC, Piper GL, Barbosa RR, Rowell SE, Bokhari F, et al. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S362–9.

69. Garfinkle MA, Stewart S, Basi R. Incidence of CT Contrast Agent-Induced Nephropathy: Toward a More Accurate Estimation. AJR Am J Roentgenol. 2015;204(6):1146–51. doi: 10.2214/AJR.14.13761 26001222

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