G a s t r o i n t e s t i n a l I m a g i n g • R ev i ew

Somwaru and Philips

Uncommon Causes of Large-Bowel Obstruction

Gastrointestinal Imaging
Review
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Imaging of Uncommon Causes of

Large-Bowel Obstruction
Alexander S. Somwaru1 OBJECTIVE. The most common causes of large-bowel obstruction (LBO) are colon car-
Shaile Philips 2 cinoma and volvulus. Nevertheless, the increased frequency of the condition and widespread
use of diagnostic imaging have revealed uncommon causes of LBO. We review the imaging
Somwaru AS, Philips S features of the unusual causes of LBO on several imaging modalities, with particular empha-
sis on CT, along with the current literature.
CONCLUSION. We propose an algorithmic approach to the radiologic evaluation of the
uncommon causes of LBO.

arge-bowel obstruction (LBO) is (Fig. 1) for imaging workup of uncommon

L approximately five to six times

less common than small-bowel
obstruction (SBO) and is more
causes of LBO that is based on a review of the
current literature and the current approach to
this entity, key CT findings, and location of
common in elderly patients [1]. The causes of the underlying process in the large bowel: ex-
LBO and SBO differ substantially. Patients trinsic, mural, or luminal (Table 1).
with LBO typically present with abdominal
pain, distention, and constipation [1]. LBO Diagnostic Algorithmic Approach
uncommonly may also present acutely, such When a patient presents acutely with ab-
as in cases of volvulus. Untreated LBO can dominal pain, abdominal distention, nausea,
lead to mucosal edema and ischemia proxi- and vomiting, bowel obstruction is a leading
mal to the site of obstruction, which if un- consideration. A dilemma that physicians of
treated leads to infarction and colonic perfo- medical, surgical, and radiologic specialties
ration [2, 3]. Emergency colonoscopy, encounter when confronted with a patient
surgery, or both can be required to relieve with a possible LBO is the decision of which
LBO [4]. The left colon is the most common imaging examination to use to confirm the
Keywords: bowel, colon, large bowel, large-bowel site for LBO [4–6]. Primary colon carcinoma LBO, assess the presence of concomitant
obstruction (60–80%) and volvulus (10–15%) are the SBO, and help determine the best therapeutic
most frequent causes of LBO [4–6]. Less approach. An algorithmic approach, based
DOI:10.2214/AJR.16.17621
common causes of LBO include diverticuli- on CT findings, is shown in Figure 1.
Received November 2, 2016; accepted after revision tis (5–10%), inflammatory bowel disease
March 24, 2017. (IBD), bowel ischemia (4–8%), fecal Key Findings on Radiography
1
impaction, and other uncommon and unusual Although many patients now directly un-
Department of Radiology, MedStar Georgetown
diagnoses (fewer than 5%) [4–6]. dergo CT, radiography may be a useful mo-
University Hospital, 3800 Reservoir Rd NW, CG201,
Washington, DC 20007. Address correspondence to Imaging plays an important role in the de- dality in the detection of LBO. The reported
A. S. Somwaru (alex.somwaru@gmail.com). tection of LBO and its underlying causes. diagnostic sensitivity of radiography for the
Radiologic evaluation of the lower gastroin- detection of LBO is 84%, but the reported
testinal tract has evolved from fluoroscopic specificity is 72% [1]. Despite its relatively
2
Department of Radiology, University of Louisville,
Louisville, KY.
barium studies to advanced cross-sectional low sensitivity and specificity, radiography
WEB imaging. This review will focus on imaging provides a basis for triage for further imag-
This is a web exclusive article. findings of these uncommon causes of LBO. ing workup and assists in the therapeutic de-
Recognition of the typical imaging findings cision-making process [1]. Inherent pitfalls
AJR 2017; 209:W1–W10 for these uncommon causes of LBO is impor- in radiography of patients who are suspected
0361–803X/17/2095–W1
tant to make an accurate and timely diagno- of having LBO are other causes of colonic
sis and to assist in patient management. We dilation, particularly adynamic ileus and co-
© American Roentgen Ray Society therefore propose an algorithmic approach lonic pseudoobstruction [1].

AJR:209, November 2017 W1

 Somwaru and Philips

TABLE 1: Causes of Large-Bowel Obstruction by Location is in the lumen of the large bowel, unusual
causes of LBO are foreign bodies, stercoral
Location Entities
colitis, and intussusception. Imaging, partic-
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Luminal Intussusception, stercoral colitis, foreign body ularly CT, may allow detection of an obstruc-
Mural tive foreign body, depending on its composi-
Acute inflammation or infiltration Inflammatory bowel disease, acute diverticulitis tion and associated complications. However,
the foreign body may be inconspicuous on
Fixed stenosis Anastomosis, radiation, inflammatory bowel disease, diverticular
CT because of its composition or an associ-
stricture, NSAID colopathy, ischemia, rare causes
ated reactive process that obscures visualiza-
Extrinsic Serosal metastases, endometriosis, hernias tion. If no foreign body is present and feces
Note—NSAID = nonsteroidal antiinflammatory drug. impacts the dilated large bowel with associ-
ated mural thickening, then stercoral colitis
Anteroposterior projections of the abdomen or suspected LBO. It is readily available, is is the inciting cause. However, if the cause is
in the supine position are performed to deter- performed quickly, allows assessment of po- in the lumen and the dilated colon contains
mine whether LBO is present and to exclude tential complications, and permits visualiza- an intraluminal intussusceptum, then intus-
SBO. The key radiographic findings of LBO tion of extracolonic structures. The advent susception is the cause.
are the presence of large-bowel distention, di- of MDCT scanners with improved techni- If an obstruction is in the wall of the large
lated loops greater than 9 cm in diameter in the cal protocols has resulted in faster and more bowel, the presence of acute inflammation or
cecum, and dilated loops greater than 6 cm in available imaging, particularly in the acute fixed stenosis should be determined. If in-
diameter in the remainder of the colon [1]. A setting. Multiplanar and thin-section recon- flammation is present in the setting of colon-
transition point may be detected as an abrupt struction capability may allow identification ic diverticular disease, then the cause is acute
change in luminal caliber or lack of luminal of sites of obstruction in the large bowel and diverticulitis. However, incidental diverticu-
gas in the large bowel distal to the transition delineation of large-bowel morphology. CT losis may be present without acute or chronic
[1]. Unusual findings that can be associated has a reported sensitivity of 96% and speci- diverticulitis. Moreover, a diverticular stric-
with LBO are foreign bodies, malpositioned ficity of 93% for the correct identification of ture from chronic diverticular disease may
medical devices, and luminal fecalomas [7]. LBO [1]. Additional benefits of CT are vis- cause LBO without mural inflammation. If
Occasionally, a large-bowel loop within a her- ualization of complications associated with inflammation is present and diverticular dis-
nia may be detected as ectopic bowel gas ab- LBO (particularly ischemia and perforation) ease is absent, IBD is a likely cause. Howev-
normally located external to the expected ana- as well as comorbid conditions in other or- er, colitis and other causes of wall thicken-
tomic boundaries of the abdomen and pelvis. gan systems, such as inflammation, metastat- ing may be encountered. Fibrostenotic Crohn
Radiography is helpful to assess the pres- ic disease, and sites of extracolonic tumor [1]. disease (CD) and ulcerative colitis (UC) are
ence of complications associated with LBO. Both common and uncommon causes of types of IBD that may cause a fixed steno-
Nondependent views of the abdomen in the LBO may be associated with SBO. If the il- sis without inflammation. If a fixed stenosis
upright or left lateral decubitus positions may eocecal valve is competent, then the LBO is seen, the causes may be anastomosis, ra-
also be used for assessment of free air. Bow- will result in a closed-loop obstruction, diation, or other rare entities. Surgical and
el ischemia and infarction may be manifest- which cannot decompress into the small treatment history may reveal that the fixed
ed on radiographs as pneumatosis, air within bowel [1]. If the ileocecal valve is incompe- stenosis is likely due to scarring from a sur-
the bowel wall, portal venous gas that projects tent, the LBO may decompress into the small gical anastomosis or radiation. If the fixed
over the silhouette of the liver, or some combi- bowel [1]. The dilated small bowel may mim- stenosis is associated with impacted hyper-
nation of those findings. Pneumoperitoneum ic a distal SBO on imaging [1]. Moreover, if dense pills and the patient has a history of
from bowel perforation can be detected on ra- the small bowel contains an additional site of using nonsteroidal antiinflammatory drugs
diography by air external to the bowel wall, obstruction, a concomitant SBO may occur (NSAIDs), NSAID colopathy is the suspect-
air along the peritoneal ligaments, and air in [1]. The presence or absence of an associated ed cause. Ischemia, diverticular stricture, ca-
the right upper abdominal quadrant [1]. If a SBO in the setting of an LBO is a pertinent thartic colitis, and prior necrotizing entero-
surgical emergency is suspected on radiog- finding and may alter management. colitis may also cause fixed stenoses.
raphy, emergent surgical consultation is rec- CT may have a substantial impact on the Finally, if the source of the obstruction is
ommended. However, if surgery is not immi- clinical management of the patient by helping neither mural nor luminal but is rather exter-
nently planned or other treatment options are to answer major questions: Is the large bow- nal to the large bowel, then an extrinsic cause
being considered, assessment of the severity el obstructed? Is the small bowel obstructed? is the source. If an anatomic cause is not clear-
and cause of the obstruction with cross-sec- Can the cause of the obstruction be identified, ly identified, specifically an external or inter-
tional imaging becomes a priority. CT is the as well as its exact location? More specifical- nal hernia, and the source remains extrinsic
preferred imaging modality because of its su- ly, is the cause of the obstruction in the lumen to both the lumen and wall of the large bow-
perior sensitivity and specificity and because of the large bowel (luminal cause), in the wall el, examination of the serosa may reveal the
it can lead to treatment modifications. of the large bowel (mural cause), or external to probable cause. If the patient has a history of
the large bowel (extrinsic cause)? malignancy, a serosal metastasis may be the
Key Findings on CT We propose an algorithmic approach that cause. However, in the setting of endometrio-
CT is the most important imaging modal- is based on CT findings and site in the large sis, serosal endometriosis is a potential, albeit
ity in the evaluation of patients with known bowel (Fig. 1). If the cause of the obstruction uncommon, cause and may result in LBO.

W2 AJR:209, November 2017

 Uncommon Causes of Large-Bowel Obstruction

CT colonography (CTC) has been reliably discrimination of a mass, specifically adeno- as discontinuous colonic mural enhancement
proven to have comparable sensitivity and carcinoma, in the colon that causes intussus- [1, 2]. Additional complications are perfora-
specificity to optical colonoscopy in the de- ception can be difficult on CT and remains a tion, fecal peritonitis, and sepsis with a mortal-
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tection of colorectal polyps and cancer [8]. An diagnostic challenge. ity rate that approaches 50% [15] (Fig. 3).
added advantage of this modality is multipla-
nar reformations that provide anatomic corre- Stercoral Colitis Foreign Body
lations between a specific mass and a selected Stercoral colitis usually afflicts elderly Rarely, LBO results from a foreign body.
landmark in the large bowel. CTC is far less debilitated patients, including institutional- Foreign bodies may enter the large bowel
prone to intrinsic limitations that plague MRI, ized patients in nursing homes or those who by ingestion, insertion, migration, surgery,
such as luminal underdistention, bowel peri- are chronically hospitalized, who often have or trauma. Fewer than 1% of foreign bod-
stalsis, and feces [9]. multiple and chronic medical comorbidi- ies cause perforation; perforation associated
ties, and take cholinergic, opiate, and certain with obstruction occurs even less frequent-
Key Findings on MRI psychiatric medications [14–18]. The patho- ly [7]. Ingested foreign bodies can also af-
Although MRI is not typically performed physiologic course of stercoral colitis begins fect the colon. Objects may lodge at areas
in the imaging assessment of the obstructed with chronic constipation, which leads to fe- of normal anatomic narrowing (particularly
large bowel, the emergence of MR enterogra- cal impaction and fecaloma formation, in- the ileocecal valve), the appendix, and at ar-
phy (MRE) has enabled advanced cross-sec- creased colonic or rectal transmural pressure eas of pathologic narrowing. The most com-
tional characterization of the bowel and ob- that can lead to LBO, decreased transmural mon site of inserted foreign bodies is in the
structive disease, particularly serosal lesions perfusion, and ischemia, resulting in colon- rectum [7]. Obstruction is most commonly
and IBD. MRE has been shown to correlate ic or rectal necrosis and perforation [14–16]. caused by antecedent perforation and chron-
well with endoscopy and colonoscopy in dis- Patients usually present with constipation, ic inflammation of the bowel by the foreign
ease detection [10]. Challenges to MRI of acute abdominal pain, or both. Fecal stasis body. These perforations are typically partial
the large bowel are luminal underdistention, results from bowel hypomotility, drugs (opi- and indolent and produce a chronic inflam-
bowel peristalsis, and the presence of feces, ates, tricyclic antidepressants, anticholiner- matory process rather than acute symptoms
which may obscure visualization of the bow- gics), prior colorectal surgery, neurologic im- [7]. Metallic and sharp objects are the most
el wall. Preparation and scan times are longer pairment, and psychologic disorders [16–18]. likely to penetrate or perforate the bowel [7].
for MRI examinations than CT examinations. Commonly, patients with stercoral colitis may Perforations from ingested foreign bodies
manifest symptoms of paradoxic diarrhea: are more common in the terminal ileum, the
Luminal Causes overflow around impacted stool. Hemorrhage ileocecal region, or the appendix [7].
Intussusception is another potential, relatively common com- Radiography typically reveals malposi-
Intussusception accounts for less than plication, in association with ulceration. Se- tioned foreign bodies if they are metallic, but
1–2% of all LBO in adults. The most com- rologic tests and physical examination are if the foreign body is radiolucent, radiography
mon cause (>  50%) of large-bowel intus- nonspecific [16–18]. The distal colon and may be very limited [7]. CT is the modality
susceptions is malignancy (primary colon proximal rectum are the most common sites of choice to detect migration or displacement
carcinoma and very rarely lymphoma and for stercoral colitis because they are the nar- of the foreign body and potential complica-
metastatic disease), but benign or low-grade rowest points in the colon, making it difficult tions [7]. However, the foreign body may not
causes, such as lipoma, adenomatous polyp, for dehydrated stool to pass the Sudeck point, be visible on CT because of its composition,
and appendiceal mucoceles, can also some- and the rectosigmoid vascular watershed re- its size, associated inflammatory changes that
times cause intussusception [11, 12]. gion is prone to is­chemia [1, 2, 17, 18]. Loca- may obscure detection, or some combination
Abdominal radiographs may show only tions above and beyond the distal colon and of these factors [1–3]. The malpositioned for-
an LBO. Imaging findings on CT include a proximal rectum are highly unusual but re- eign body is typically accompanied by lo-
distended colon—the intussuscipiens—with ported sites of stercoral ulceration. cal inflammatory changes and, depending on
an intraluminal intussusceptum resembling The importance of CT is not only in estab- time course, a local granulomatous reaction
a target on cross-sectional imaging [13] lishing or suggesting the diagnosis but also, [7] (Fig. 4). Associated complications include
(Fig. 2). An intervening layer of fat from more importantly, in assessing potentially fa- stricture leading to obstruction, fistula, infec-
the mesentery or mesocolon with associat- tal complications. All patients with stercoral tion, and transmural perforation.
ed vasculature is almost always identified colitis show a fecaloma: solid bulk of dehy-
on CT [13] (Fig. 2). Although identification drated, compacted stool [16–18] (Fig. 3). Co- Mural Causes
of the intussusceptum is typically possible lonic mural thickening greater than 3 mm, Mural causes of LBO can be subdivided
on CT, the cause is not always easily deter- which is usually asymmetric, is another char- into acute inflammation or infiltration and
mined. If a lead mass is a lipoma, which is acteristic feature (Fig. 3). Stercoral colitis with fixed stenosis. However, some entities, par-
the most common benign cause of large- obstruction will present with proximal colon- ticularly CD and colonic diverticular disease,
bowel intussusception, it is visualized as a ic distention of greater than 6 cm [16–18]. may cause LBO by acute inflammation, fixed
circumscribed mass with fat attenuation. If CT will also depict complications associat- stenosis, or both in this classification system.
the mass is an adenocarcinoma, which is the ed with a high rate of mortality, including isch-
most common malignant cause, it is usual- emia and ulceration manifested by increased Inflammatory Bowel Disease
ly associated with a greater caliber of large- mucosal density, which reflects intramural IBD is a group of chronic gastrointestinal
bowel lumen [13]. Nevertheless, prospective hemorrhage and perfusion defects that appear disorders with two broad subtypes: CD and

AJR:209, November 2017 W3

 Somwaru and Philips

UC. CD is a transmural chronic inflamma- ticulitis will experience recurrent symptoms, significant finding to exclude the presence of
tory disorder that can affect any part of the and another third will have a subsequent epi- malignancy [8, 25]. Other reliable morpho-
gastrointestinal tract in a discontinuous dis- sode [23]. A smaller number of these patients logic features that indicate chronic diverticu-
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tribution. CD may be classified into active may develop chronic diverticulitis, which litis are length of colonic segment involved
inflammatory fistulizing and perforating, fi- includes obstructive symptoms or abdomi- (over 10 cm), absence of overhanging edg-
brostenotic, and reparative and regenerative nal pain of at least 2 months’ duration, fre- es or shouldering, thick fascia sign (lateral
phases of disease based on clinical presen- quently without fever or leukocytosis [23]. conal fascial thickening), absence of lym-
tation, serology, endoscopy, histology, and Because of its clinical presentation and find- phadenopathy, and distorted but preserved
imaging [10, 19, 20]. Although all phases of ings on imaging, diagnosing chronic diver- mucosal folds [8, 25]. The degree of luminal
CD may result in LBO, the fibrostenotic sub- ticulitis is a challenge. Moreover, a particular narrowing is not a significant discriminator
type is associated with the highest incidence challenge on CT of the colon is discriminat- between chronic diverticulitis and colorectal
of obstructions, more commonly in the small ing acute and chronic diverticulitis from co- cancer, however [8, 25].
bowel but also in the large bowel [21]. The lon cancer [23].
fibrostenotic subtype of CD is characterized An uncommon presentation and complica- NSAID Colopathy
by progressive, transmural fibrosis, followed tion of colonic diverticular disease and acute, NSAID colopathy is a rare cause of LBO
by scar contraction, luminal narrowing, and recurrent, and subacute to chronic diverticu- (fewer than 1% of all cases). NSAIDs affect
stricture formation from unregulated normal litis is LBO, which occurs in approximately the large bowel by damaging the protective
healing response to tissue injury and inflam- 10% of all cases of diverticulitis, most com- mucosal lining of the gut, decreasing prosta-
mation [21]. Thus, CD is a mural cause that monly in the setting of chronic diverticulitis glandin synthesis, and impairing angiogen-
may cause LBO from acute inflammation, [23]. Typically, in the acute setting, the ob- esis [26]. Ulceration and inflammation oc-
fixed stenosis, or both. struction is related to extensive inflammation cur acutely with subsequent progression to
Imaging findings of LBO from CD are or segmental mural edema and thickening. chronic development of diaphragmlike fi-
based on the stage of disease. Fibrostenotic LBO can also occur from strictures that are brous strictures that may result in obstruc-
disease results in endoluminal narrowing, ob- caused by multiple episodes of acute divertic- tion [26]. Typical locations are the cecum,
struction, and upstream bowel dilation [10, 19] ulitis or by chronic diverticular disease with- ascending colon, and rectum [26].
(Fig. 5). When active inflammation is present out any antecedent episode of acute divertic- NSAID colopathy manifests two patterns
in conjunction with fibrostenotic disease, CT ulitis [23]. Thus, colonic diverticular disease, of findings on CT. In the early phase, the af-
may display mucosal hyperemia and vasa rec- a mural cause of LBO, may occur. Less com- fected colon features nonspecific inflamma-
ta engorgement associated with the stenosis monly, LBO is caused by complications of di- tory changes. In the late or chronic phase,
(Fig. 5). If active inflammation occurs in the verticulitis, such as air and fluid in the perito- multiple annular smooth strictures of both
setting of reparative or regenerative disease, neal cavity, sinus tract formation, and fistula short and long segments are seen with as-
the involved colon features a loss of mural formation that result in extensive mural in- sociated impacted hyperdense endoluminal
stratification and thickened bowel wall, which flammation [1]. Thus, colonic diverticular dis- NSAID tablets [26] (Fig. 6). Additional find-
is homogeneous in attenuation [10, 20]. ease is a mural entity that may cause LBO by ings of obstruction will be present.
On MRE, fibrostenotic disease appears as acute inflammation, fixed stenosis, or both.
focal short- or long-segment mural thickening CT is the imaging modality of choice for Anastomotic or Postsurgical Stricture
that is hypointense on T2-weighted sequences diagnosis and staging of diverticulitis. It is Anastomotic or postsurgical stricture is an
[10, 20]. Depending on the degree of luminal the most sensitive imaging technique be- equally infrequent cause of LBO (fewer than
narrowing caused by the stricture, proximal cause of its ability to show classic features of 1%). Patients who undergo partial large-bow-
bowel dilation may be present [10, 20]. The diverticulitis that include colonic wall thick- el resections are at risk for development of
enhancement in fibrostenotic disease is usual- ening, pericolonic inflammatory stranding, strictures near the anastomosis. Low rectal
ly restricted to the mucosa, but other patterns and associated inflammatory collections anastomoses are particularly vulnerable to
of enhancement, including layered and homo- [23]. These findings may be seen in the set- ischemia, stricture, leak, and fistula forma-
geneous patterns, can be seen [10, 20, 22]. Un- ting of macroperforation, abscess formation tion [27]. End-to-end anastomoses are the
restricted diffusion is typically seen on DWI, (seen in up to 30% of cases), sinus tract, and most physiologic type but also the most prone
but lowering of apparent diffusion coefficient fistula formation to regional small bowel, co- to anastomotic stricture. End-to-side or side-
values has been associated with the degree of lon, bladder, or vagina [23, 24]. Upstream to-side anastomoses incur a lower prevalence
fibrosis [22]. Interpretation of these findings dilatation of proximal colon is seen when an of stricture or obstruction but a higher rate of
may be difficult, and close correlation with obstruction is present [23]. stasis within blind segments [27]. Any resec-
symptoms, inflammatory markers, and endo- Colonic wall thickening from diverticu- tion and anastomosis surgically performed
scopic findings may be needed in many cases. litis, particularly chronic, can be masslike, in the setting of peritoneal contamination or
and differentiating it from colorectal carci- borderline viability of bowel are prone to de-
Colonic Diverticular Disease noma can be difficult. Several morpholog- hiscence or stricture.
Inflammation, infection, and microper- ic features have been described on CT and CT shows abrupt transition or focal narrow-
foration of an obstructed colonic diverticu- CTC, which can be used to relatively reli- ing of large-bowel caliber at the site of anasto-
lum result in acute diverticulitis [23]. Nearly ably discriminate chronic diverticulitis from mosis, dilatation of large bowel proximal to the
one-third of patients with colonic diverticu- colorectal cancer. The presence of diverticu- anastomosis, and decompression of large-bow-
lar disease who are afflicted by acute diver- la in the involved segment is the single most el loops distal to the anastomosis [27] (Fig. 7).

W4 AJR:209, November 2017

 Uncommon Causes of Large-Bowel Obstruction

Rare Causes cularis propria and the mucosa. Similar find- 6. Drożdż W, Budzyński P. Change in mechanical
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Fig. 1—Algorithmic approach for imaging workup

Is the cause external to the bowel?
of uncommon causes of large-bowel obstruction.
NSAID = nonsteroid antiinflammatory drug.
Yes No

Extrinsic causes: Is the cause endoluminal?

Serosal metastases
Endometriosis hernias Yes No

Mural
Luminal causes:
Is there inflammation?
Intussusception
Stercoral colitis
Foreign body Yes No

Acute inflammation: Fixed stenosis:

Inflammatory bowel disease Anastomosis

Acute diverticulitis Radiation
Inflammatory bowel disease
Diverticular stricture
NSAID colopathy
Ischemia
Rare causes

A B C
Fig. 2—49-year-old woman with abdominal pain.
A and B, Axial (A) and coronal (B) abdominal CT images with IV and oral contrast enhancement show dilated cecum (intussuscipiens) with luminal mass (intussusceptum,
arrow) surrounded by intervening layer of mesocolonic and mesenteric fat, fluid, and associated vasculature that create “target” (arrowhead). Large, complex mass
(asterisk, B) is seen in pelvis.
C, Photograph of colonic luminal mass, which caused intussusception and consequent large-bowel obstruction, was resected along with ovarian mass and uterus.
Colonic mass was metastasis from ovarian carcinoma diagnosed after surgery.

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A B C
Fig. 3—98-year-old woman with constipation and abdominal pain.
A, Scout coronal contrast-enhanced CT image shows multiple dilated large-bowel loops (arrow) with transition in sigmoid colon, which is impacted with large amount of
feces (arrowhead).
B and C, Axial (B) and sagittal (C) unenhanced abdominopelvic CT images show significant dilatation and fecal impaction of sigmoid colon (arrowhead), which features
asymmetric mural thickening (arrow). Despite fecal disimpaction, colon perforated. Stercoral colitis was diagnosed during emergent surgery.

A B
Fig. 4—43-year-old man with abdominal distention.
A and B, Axial contrast-enhanced abdominal CT images show migration and perforation of strut from inferior vena cava filter (arrow) into transverse colon with
pericolonic fat stranding, colonic mural thickening, and regional inflammatory changes (arrowhead). Inferior vena cava is substantially collapsed. Case is highly unusual
complication of inferior vena cava filter and very unusual cause of large-bowel obstruction from foreign body.

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 Somwaru and Philips
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A B
Fig. 5—34-year-old man with Crohn disease who complained of recurrent bouts of abdominal distention, nausea, and vomiting.
A, Axial contrast-enhanced pelvic CT image shows long-segment stricture in sigmoid colon (arrow) with proximal large-bowel dilation (asterisk).
B, Coronal contrast-enhanced abdominal CT image shows obstructed large bowel (asterisk) from sigmoid colonic stricture, which is associated with active inflammation,
manifested by hyperemia, mural thickening, vascular and vasa recta engorgement, and mesenteric fat proliferation (arrow). Inflamed large bowel adheres and fistulizes
with small bowel (arrowhead).

A B C
Fig. 6—63-year-old man with diffuse distention from chronic nonsteroidal antiinflammatory drug therapy for osteoarthritis.
A and B, Axial pelvic CT images with IV and oral contrast enhancement shows long-segment, smooth stricture of sigmoid colon (arrows) with consequent large-bowel
obstruction and impacted high-density pills (arrowheads). Measurement (line, B) is length of long-segment smooth stricture in sigmoid colon.
C, Axial abdominal CT image with IV contrast enhancement shows multiple dilated loops of small and large bowel from obstruction due to sigmoid stricture.

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A B
Fig. 7—32-year-old man with diffuse acute-on-chronic abdominal pain. One year earlier, he had undergone prior laparoscopic
cholecystectomy that was converted to open surgery due to complications.
A and B, Axial and coronal abdominal CT images with IV contrast enhancement show stricture at hepatic flexure (arrowhead, B) with dilated
loops of cecum (arrows) and ascending colon. Large-bowel obstruction is due to stricture at right colonic flexure from adhesions from prior
cholecystectomy.

A B
Fig. 8—32-year-old man with cystic fibrosis and diffuse abdominal pain.
A, Axial abdominal CT image with IV contrast enhancement shows dilated loops of transverse colon and left colic flexure (arrow). There is
also diffuse fat replacement of pancreas (asterisk).
B, Axial pelvic CT image with IV contrast enhancement shows large entrapped thick fecal plugs in sigmoid colon (arrow) and nodular colonic
mural thickening with distal short-segment stricture (arrowhead) due to fibrosing colopathy from cystic fibrosis.

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Fig. 9—45-year-old woman with abdominal

pain and history of endometriosis. Patient had
history of laparoscopic cystectomy for bilateral
endometriomas.
A, Abdominal radiograph shows dilated loops of large
bowel consistent with ileus or distal large-bowel
obstruction. Diameter of colon is 93.9 mm.
B, Axial abdominal CT image with oral and IV contrast
enhancement shows transition point in sigmoid colon
with infiltrative mass (crossed lines). Measurements
are measurements of “infiltrative mass” that is
endometriosis.

A B

Fig. 10—72-year-old man with

abdominal pain.
A, Scout abdominopelvic CT image
with IV and oral contrast enhancement
shows dilated and obstructed large
bowel and gas within bowel loop in left
groin (arrow).
B, Axial pelvic CT image with IV
and oral contrast enhancement
confirms indirect hernia on left that
contains obstructed sigmoid colon
(arrow). Small-bowel loops that are
unobstructed and not strangulated are
also seen in indirect inguinal hernia
on right.
A B

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