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.

13.

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.

7-month old female

Interpretasi
Gas Distribution
:
poorly distributed.

There is a definite paucity of gas which is

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.

Interpretasi

22-month old

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.

Interpretasi

6-1/2 year old male

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.

References
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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.