B. L. Johnson1, J. M. Hyak2, G. A. Campagna2, Z. T. Stone2, B. J. Naik-Mathuria1 1Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Houston, TX, USA
Introduction: In children with adhesive small bowel obstruction (ASBO), abdominal radiographs (KUBs) with gaseous, distended small bowel loops are generally utilized for diagnostic and monitoring purposes. Our purpose was to determine the significance of gasless small bowel loops on the initial KUB in patients who ultimately required operation.
Methods: Retrospective chart review of children treated for ASBO who required operation between 2011- 2014 at a tertiary care pediatric hospital. Imaging characteristics, time to operation, operative findings and length of bowel resected were recorded. Data were analyzed using descriptive statistics, chi-square, and non-parametric tests.
Results: Of 99 patients, the median age was 5 and 69% were male. Almost half (48%) had previous episodes of ASBO. The median time to operation was 27 hours (IQR: 11 – 63 hours). Bowel resection was required in 35%, and 31% had closed loop obstruction. Requirement of bowel resection was similar in patients with or without closed loop obstruction (52% vs 49%, p = 0.096); however, patients with closed loop obstruction lost more bowel length than those without (median 30 cm vs 10 cm, p = 0.032). Prior to operation, the majority of patients (53%) were evaluated with serial KUB only, 36% had KUB and computerized tomography (CT scan), and 7% had KUB and small bowel follow through (SBFT). Initial KUB with a partially or completely gasless (non-visualized) portion of the small intestine was noted in 38% of patients. At operation, the majority (71%) of patients with initial gasless KUB had either closed loop or high-grade obstruction; however, the incidence of gasless KUB was similar in patients with and without closed loop obstruction (58% vs 46%, p = 0.25). Follow-up CT scan was obtained more often in patients with a gasless KUB, compared to KUB with visible gaseous distended loops (68% vs 32%, p = 0.003). Five patients with gasless KUB were further evaluated with a SBFT study. CT was superior to KUB for predicting closed loop obstruction (69% vs 7%, p = <0.001). In patients with closed loop obstruction, more bowel length was resected when CT was not obtained (38 cm KUB only vs 15 cm KUB+CT, p = 0.004). Time to operation was longer when follow-up CT was obtained (20 vs 8 hours, p = 0.111); however when CT was obtained the decision to operate was made faster (16 vs 7 hours p = 0.002).
Conclusion: For children with adhesive small bowel obstruction with a partially/completely gasless initial KUB, closed loop obstruction or high-grade obstruction should be considered and obtaining additional imaging with CT or SBFT, rather than following serial KUBs, may hasten time to operation and minimize bowel length loss.