|Year : 2019 | Volume
| Issue : 4 | Page : 321-330
Role of computerized tomography in the management of intestinal obstruction in adults
Ahmad F El-Hossainy1, Fawzy M Mustafa1, Mohamad A Shazly2, Yousef A Yousef Selim3
1 Department of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2 Department of Diagnostic Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
3 Department of Diagnostic Radiology, Faculty of Medicine, Misr University for Sciences and Technology, 6th of October, Egypt
|Date of Submission||23-Jul-2018|
|Date of Decision||14-Aug-2019|
|Date of Acceptance||19-Nov-2019|
|Date of Web Publication||14-Feb-2020|
Ahmad F El-Hossainy
Source of Support: None, Conflict of Interest: None
Background Computed tomography (CT) has become the most important noninvasive imaging tool to diagnose small and large bowel diseases as it has the potential to provide significant information that leads to timely appropriate treatment and thus positively affect the outcome, morbidity, and mortality of patients.
Patients and methods Fifty five adult patients who presented with clinical manifestations of intestinal obstruction were registered in the study. CT findings were based on dilated bowel, complete obstruction, partial obstruction, transition point, ascites, closed loop, free air, and other factors as and when required. Patients who had features suggestive of complete or complicated obstruction (strangulation, ischemia) were taken up for surgery on an emergency basis. Patients who showed improvement on conservative management and clinicoradiological features suggestive of uncomplicated partial obstruction were kept on conservative management.
Results Complete obstruction was seen in 44% of patients (22 cases) and all of them underwent surgery. Partial obstruction was seen in 56% (28 cases), of which 71.4% (20 cases) were operated upon. Postoperative adhesions were the most common etiology in the study group (26%). Out of 42 patients who were treated by surgery, majority of patients (88%) matched with preoperative CT findings, whereas in 12% of patients, CT findings did not match with intraoperative findings. CT sensitivity was 76.6%, specificity was 75%, positive predictive value was 94.2%, negative predictive value was 40%, and accuracy was 78%.
Conclusion Clinical sense still the mainstay for deciding the line of management in cases of intestinal obstruction. CT in this category of patients can help surgeons to perform surgery early and prevent complications. It also helps in preventing unnecessary surgeries in patient who can be treated conservatively.
Keywords: computed tomography, conservative management, intestinal obstruction, laparotomy
|How to cite this article:|
El-Hossainy AF, Mustafa FM, Shazly MA, Yousef Selim YA. Role of computerized tomography in the management of intestinal obstruction in adults. Al-Azhar Assiut Med J 2019;17:321-30
|How to cite this URL:|
El-Hossainy AF, Mustafa FM, Shazly MA, Yousef Selim YA. Role of computerized tomography in the management of intestinal obstruction in adults. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Feb 29];17:321-30. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/321/278398
| Introduction|| |
Bowel obstruction was first described and managed by Hippocrates. The first recorded operation for management was performed by Praxagoras circa (350 BC). He created an enterocutaneous fistula to alleviate the obstruction of a bowel segment . Mortality of cases with bowel obstruction has been greatly reduced through better conception of bowel obstruction pathology, resuscitation with isotonic fluid, intestinal decompression, and antibiotics. However, patients who present with bowel obstruction represent troublesome and difficult problems for surgeons in terms of the proper diagnosis, perfect time for definitive therapy, and convenient treatment. Ultimate clinical decisions on the management of these cases depend on an inclusive approach that includes clinical background, patient history, results of physical examination, and laboratory tests .
Intestinal obstruction represents 20% of surgical flow of patients with acute abdomen. The early discovery of bowel obstruction is critical in preventing complications, particularly perforation and gangrene. The morbidity and mortality of acute bowel obstruction are responsible for 12–16% of all surgical ward admissions in cases with acute abdomen. Postoperative adhesive bowel obstruction accounts for 70% of small-bowel obstruction cases. Mechanical colonic obstruction is fivefold less than small intestinal obstruction; neoplasms are the most common cause .
Imaging plays a vital role in the decision making of patients with suspected intestinal obstruction because it provides very important anatomical and functional information. The first imaging procedure used in cases with intestinal obstruction is conventional radiography, with 50–80% accuracy in the detection of obstruction. Accuracy in the detection of the site and actual cause of obstruction, and strangulation is lower. The next investigation in cases with equivocal radiographic signs is radiography using intraluminal perfusion of contrast material. It should be precluded in cases with reduced bowel peristalsis . Enteroclysis is helpful in drawing and grading of the severity of partial bowel obstruction and detecting the exact sites of multifocal incomplete obstructions. However, it is absolutely forbidden in cases with acute or complete intestinal obstruction, and in those patients with strangulation or expected perforation. It should not be used in cases with scanty bowel peristalsis .
Bowel obstruction is considered to be present on ultrasonography when dilated loop diameter exceeds 2.5 cm and the length of the affected segment exceeds 10 cm . The clinical efficacy of MRI in this field is still limited; however, favorable results have been reported . Unlike radiography with oral contrast that provides imaging of the luminal surface, computed tomography (CT) permits imaging of other contents outside the lumen.
Recently, the role of CT in the estimation of visceral obstruction has been expanded. It is recommended when initial and clinical radiographic findings remain indeterminate or strangulation is suspected. It distinctly demonstrates involved bowel wall as well as its mesentery (including its vessels), and the rest of the peritoneal cavity. CT should be perfected with an intravenous injection of contrast, and the use of thin sections is highly recommended to evaluate the specific region of interest .
Studies have shown superior results of CT in detecting the exact site and the cause of bowel obstruction, and in demonstrating signs of intestinal and mesenteric viability. CT proved to be beneficial in the detection of extrinsic, intrinsic, and intraluminal causes of bowel obstruction and also intestinal malrotation ,.
In a recent study, multislice CT had a sensitivity of 85% and a specificity of 70% in detecting complete bowel obstruction. Injected contrast was helpful in the diagnosis of strangulation, in identification of the specific cause of intestinal obstruction, and in the detection of other pathologies such as superior mesenteric artery or vein thrombosis, which produce ileus that fake mechanical obstruction .
The new technique of progressive interest in the disclosure of intestinal obstruction is multiplanar reformatted imaging at a workstation. Abdominal volume data are obtained with a helical technique (during a single breath hold − usually with 5 mm collimation). A multidetector CT scanner allows better spatial resolution through thinner collimation. Axial, coronal, sagittal, and curved reformatted images are generated at a workstation from the obtained volume data. Multiplanar views may help in the identification of the site and cause of bowel obstruction when axial findings are indeterminate .
The present work will evaluate the efficacy of multislice CT in different causes of bowel obstruction, correlating with their clinical presentation and operative findings.
| Patients and methods|| |
This prospective hospital-based study was carried in the Department of Surgery, and Department of Diagnostic Radiology, Faculty of Medicine, Al-Azhar University and Faculty of Medicine, MUST (Misr University for Sciences and Technology). Fifty five adult patients who presented with clinical manifestations of intestinal obstruction were enrolled in the study after providing an informed consent. Exclusion criteria were decompensated patients, and patients with radiological findings suggestive of perforation, impaired renal function, and pregnancy. Five patients were excluded due to patient noncompliance. A total of 50 cases were included during the period of study. A pretested prestructured questionnaire was performed after obtaining permission from the Ethical Committee and after consent from eligible study participants was obtained.
Ryle’s tube insertion and Foley’s catheterization were performed in all patients. Isotonic fluid was administered intravenously. A detailed history was assessed under the heading of present medical history and history with a special focus on previous surgical intervention. Patients were examined fully under the heading of general physical examination and systemic and local examinations. All the patients were referred for a battery of investigations that included routine investigations such as complete blood picture, liver function tests, renal function tests, serum amylase and lipase, serum electrolytes, and radiological investigations that included plain abdominal radiographs, ultrasonography, and contrast-enhanced CT abdomen. Patients with stable vitals and normal renal function tests were referred for CT abdomen in which water-soluble oral contrast medium was administered 2 h before scanning. Then, a bolus dose of intravenous contrast medium was administered and a triphasic-contrast study was carried out. Rectal contrast is administered if large bowel pathology is suspected. CT scanning of the abdomen and pelvis was performed with contiguous axial 5 mm sections (with pitch of 1.5). In overdistension of abdomen and vomiting, oral contrast was not administered. One mm reconstructions were acquired to generate axial, sagittal, and coronal reformatted images on a workstation. Images were saved for future re-evaluation. Clinical, surgical, histopathological, and other pertinent follow-ups were obtained.
CT findings were based on dilated bowel, complete obstruction, partial obstruction, transition point, ascites, closed loop, free air, and other factors as and when required. Patients who had features suggestive of complete or complicated obstruction (strangulation, ischemia) were taken up for surgery on an emergency basis. Patients who showed improvement on conservative management and clinicoradiological features suggestive of uncomplicated partial obstruction were maintained on conservative management.
Manifestations suggestive of a complicated obstruction included fever, tachycardia, leukocytosis, localized rebound, continuous abdominal pain, and peritonitis. The presence of any three of the following signs: continuous pain, tachycardia, leukocytosis, peritoneal signs, and fever, has an 82% predictive value for strangulation obstruction. Similarly, the presence of any four of the above signs has a near 100% predictive value for strangulation obstruction. 
The collected data were analyzed using SPSS 22.0 software (IBM = SPSS Incorporation, Chicago, Illinois, USA) in terms of mean and SD for continuous variables and percentages for categorical variables. Cross tabulation was performed for all the variables of interest. McNemar’s χ2-test was performed to test the significance of proportions of CT with surgical findings. The sensitivity, specificity, positive, and negative predictive values were computed. P less than 0.05 was considered to be statistically significant.
| Results|| |
The study was carried out in an adult age group ranging from 16 to 65 years, with a mean age of 36.2 years. The occurrence of intestinal obstruction was more common in males (62%) in comparison with females (38%). There were 31 male and 19 females, with a male to female ratio of 1.6 : 1. The most common symptoms or complaints with which the patients presented were abdominal pain, distension, vomiting, and constipation. [Table 1] shows the signs and symptoms of the participants. The results of CT findings observed in the study were categorized individually according to the positivity and negativity in the patient and need for surgery ([Table 2]).
Free air was seen in 12% of patients and all of these patients underwent surgery. Free air fluid level in conventional plain radiology is less sensitive indicator for diagnosis of IO than CT because it is only seen in 12% of cases submitted to surgery. A transition point was seen in 70% (35 cases), of whom 71.4% (25 cases) underwent surgery. It has a high sensitivity. A transition point was not seen in 30% of cases, of whom 53.3% were operated upon; this implies that it is a less specific indicator for surgery alone.
Complete obstruction was seen in 8% of cases and all of them underwent surgery. It has high sensitivity as an indicator for surgery as in cases of complete obstruction, complication rates are high. The lower specificity (47.8%) perhaps can be explained by the fact that the majority of patients with complete obstruction also develop features of strangulation and other complications and surgery is not delayed in those patients. Closed loop was found in 4% of cases and was seen in patients with hernia and multiple strictures forming the closed loop.
Free fluid was seen in 76% (38 cases) and 57.9% (22 cases) of these patients were operated upon. It has a high sensitivity in cases of obstruction as free fluid is seen in most of the cases. The free fluid in the peritoneal cavity indicates complication in cases of obstruction. However, free fluid can also be seen without complication and in cases of infectious pathologies.
Partial obstruction was seen in 56% (28 cases), of whom 64.3% (18 cases) were operated upon. It has medium sensitivity and specificity in cases of obstruction as partial obstructions show good response to conservative management. Clinically, partial obstruction was diagnosed in 46 patients and four patients with complete obstruction; however, radiologically, only 28 patients had features of partial obstruction.
In the present study, 84% of patients were referred for surgical management and the rest were managed conservatively. Seventy percent of the patients in our study had simple obstruction and 30% of the patients had features of strangulation. The patients who were referred for surgery were planned according to clinical and radiological findings. Sixty-four percent of the patients operated on were taken for emergency surgery and 20% were operated as elective surgery ([Table 3]).
Postoperative adhesions were the most common etiology in the study group (26%). Bands, perforations, and stricture were diagnosed in 10, 12, and 8% of the cases, respectively. Six percent of the cases were tumors (one gastrointestinal stromal tumor ([Figure 1] and [Figure 2]), one duodenal ([Figure 3]), and one ascending colon cancer ([Figure 4]). Volvulus was found in 4% of cases ([Figure 5]). Mesenteric vascular occlusion was diagnosed in 4% of cases ([Figure 6]). Internal hernia and intussusception ([Figure 7]) each was diagnosed in 2% of the cases.
|Figure 1 Computed tomography of gastrointestinal stromal tumor of the duodeno–jujenal junction.|
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|Figure 2 Operative findings of gastrointestinal stromal tumor of the duodeno–jujenal junction.|
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|Figure 3 Contrast-enhanced computed tomography abdomen (with coronal reformat) shows a well-defined oval-shaped hypodense eccentric soft tissue mass on the second part of the duodenum. It measures 4×5 cm with a contour bulge. Note the large gallbladder stone.|
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|Figure 5 Contrast-enhanced computed tomography shows dilated stomach and proximal small bowel with a reversed position or superior mesenteric artery and vein (artery to right and vein to left), congested mesenteric vessels, and characteristic Swriling sign of mid-gut volvulus.|
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|Figure 7 Contrast-enhanced computed tomography shows dilated small and large bowel loops secondary to fatty soft tissue mass lesion (3×4 cm) of average density − 80 HU at the proximal part of the descending colon (intussusception).|
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Paralytic ileus was found in 2% (one case), who were managed conservatively by prompt correction of hypovolemia and serum electrolyte correction. Sixteen percent (eight cases) had infectious and inflammatory pathology. Eight (16%) patients were managed conservatively by prompt and timely management. Gall stone ileus was diagnosed in one case ([Figure 8] and [Figure 9]). Three cases were recovered on conservative measures and the exact cause of obstruction was not identified. Forty-two percent (42 cases) underwent surgery ([Table 4]).
|Figure 8 Contrast-enhanced computed tomography abdomen and pelvis shows a large laminated gallstone at the terminal ileum (gallstone ileus) measuring 3×4 cm with dilated small and large bowel loops as well as airobilia.|
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[Table 5] shows that out of 42 patients who were treated by surgery, the majority of patients (88%) matched with preoperative CT findings, whereas in 12% of patients, CT findings did not match with intraoperative findings. [Table 6] shows how accurate CT findings were helpful in guiding patient management (operative/conservative); sensitivity was 76.6%, specificity was 75%, positive predictive value was 94.2%, negative predictive value was 40%, and accuracy was 78%. Also, the difference between the two management lines was also found to be statistically significant (P<0.05). CT suggested level of obstruction to be in the small bowel in 44/50 cases and in the large bowel in 6/50 cases. CT was found to be correct in identifying the level in 88% of the cases and incorrect in identifying the level in 12% of cases.
|Table 5 Matching of computed tomography findings with intra-operative findings|
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|Table 6 Sensitivity and specificity of computed tomography in the diagnosis of intestinal obstruction.|
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[Table 7] shows the sensitivity, specificity, positive and negative predictive values, and accuracy of all parameters of CT findings. Free fluid and transition point have the highest sensitivity, respectively. The specificity was the highest and the same for free air, complete obstruction, and closed loop. Accuracy was the highest for a transition point, followed by partial obstruction, free air, and free fluid.
| Discussion|| |
Intestinal obstruction is a commonly encountered clinical entity. There is probably not a day that goes by where a clinical surgeon does not at least once face the possible presentation of intestinal obstruction. Intestinal obstruction is a frequent emergency that surgeons encounter (1–4% of emergency surgeries) . During the current study period, the incidence of intestinal obstruction out of all the abdominal surgeries was about 3.6%. Small bowel obstruction is much more common than colonic obstruction . Treatment delay will lead to unacceptable high mortality. The mortality has reduced significantly by instituting treatment at the earliest period. One to four percent of mortality in emergency abdominal surgeries is contributed by acute bowel obstruction .
Many studies have proven the accuracy of CT scan in the diagnosis of intestinal obstruction. However, the role and impact of CT in accurate diagnosis and treatment of intestinal obstruction still need further exploration. It should be kept in mind that exploratory laparotomy is the gold standard. Jones et al.  stated that CT scans are useful in patients who have not had previous surgery, but present with signs of infection, intestinal infarction, or palpable abdominal mass.
Our study group comprised of 50 patients, all of whom had pain in the abdomen, whereas vomiting, distention, constipation, and obstipation were present in 68, 76, 84, and 52% of patients, respectively. On clinical examination, tenderness was found in 64% of patients, guarding in 54%, rigidity in 38% of patients, and tachycardia in 64%. These presentations were consistent with those observed by Jain et al.  and Saini et al. .
All patients underwent plain radiography and CT scan. On applying the χ2 test, the P value was 0.008, which suggests an association between radiography interpretation and CT scan findings for the presence of obstruction. Findings of the radiography correlated with CT in 68%, whereas there was no such correlation in 32%. These figures are close to those of Saini et al. .
Out of a total of 50 patients, 42 needed laparotomy and 12 patients were managed conservatively. Thirty-four of these 42 patients who underwent exploratory laparotomy had preoperative clinical manifestations of intestinal obstruction proved by CT, whereas the remaining eight patients underwent laparotomy as they showed no symptomatic improvement with conservative treatment, although CT performed preoperatively was not coordinated with the diagnosis of intestinal obstruction.
On statistical analysis, intraoperative findings were in agreement with CT scan only in 88% of cases. The P value for this association is 0.01, which is significant. In two out of two patients, the signs of ischemia as seen on CT scan were found to be present on exploration. Strangulation is more common with adhesions, and internal or external hernias. Sometimes, it may develop as a sequel of idiopathic small intestinal volvulus without obvious intraperitoneal abnormality. A definite uniqueness should always be found between ischemia and closed-loop obstruction. These are related entities, but separate pathologies. Strangulation almost develops as a complication of a closed loop, but, a closed loop may not be correlated with strangulation and may show spontaneous resolution.
In the current work, 88% of patients underwent surgical management and the rest were managed conservatively. Taylor et al. , in their study, reported that a conservative approach resulted in 55% resolution of obstruction, with no significant increase in mortality or in the rate of strangulation. In a search carried out by Maung et al. , it was concluded that non-operative conservative treatment has a 65% succession rate in patients with partial obstruction or patients without radiological or clinical signs of bowel ischemia. The high incidence of surgical interference in the present series may be assigned to delayed presentation of patients seeking medical advice and patients who improved temporarily on conservative measures, but later needed elective surgical interference. The summation of emergency operated patients with those of delayed surgical intervention due to temporary improvement (sub-acute Obstruction) were calculated with those underwent emergency surgery.
In the present study, 13 (26%) patients showed adhesions as a cause of obstruction on CT scan. Four of them were managed conservatively, whereas peroperatively, impassable stricture was seen in four patients; adhesions without causing obstruction were seen during laparotomy. For the proper diagnosis of bowel obstruction resulting from adhesions, indirect suspicion of adhesive obstruction should be entertained when a mass or an evident cause is not noted in the transition zone from dilated to nondilated bowel. ten Broek et al.  found adhesions to be a cause of suspected intestinal obstruction in 75% of cases. In developing countries, adhesions as a cause of intestinal obstruction are less common compared with developed countries. In one (2%) patient, hernia was found as a cause of obstruction on CT scan. On laparotomy, band was the cause of obstruction in this patient. Patrick et al. , in their study, found hernia as a definite cause of bowel obstruction in 6% of patients. The incidence of hernia as a possible cause of obstruction is declining due to increased trend of early surgical interference in hernia cases.
In two patients, small bowel volvulus was diagnosed on CT due to the presence of Swirling sign. One case was recognized preoperatively as intussusception; lipoma was the leading point on CT scan. Exploratory laparotomy detected findings consistent with CT scan. Adult intussusception is a comparatively rare condition that is responsible for less than 5% of bowel obstruction cases . In contrast to cases involving infants, 80% of the cases are associated with underlying causes such as neoplasm, adhesion, inverted Meckel’s diverticulum, foreign body, and previous history of abdominal operation . CT characterized the collapsed, intussuscepted proximal bowel with vessels and mesenteric fat present within the wall of the distal bowel. On cross-sectional images, intussusception has a target-like look. The causative lesion may be detected as the leading point .
In the present study, sensitivity was 76.6%, specificity was 75%, positive predictive value was 94.2%, negative predictive value was 40%, and accuracy was 78%. In a study by Saini et al. , the sensitivity of diagnosing bowel obstruction by CT scan was 85%, specificity was 70%, positive predictive value was 85%, negative predictive value was 70%, and accuracy was 78%. Mallo et al.  stated in their review that the sensitivity of CT scan in the detection of bowel obstruction ranged between 81and 100% and specificity was between 68 and 100%, which is consistent with the results of the present study. However, other researchers have recorded CT scan sensitivity and specificity in the diagnosis of intestinal obstruction up to 94 and 96%, respectively ,. Discrepancy of these results may be because of selection of patients with higher grades of obstruction. Significance of mild or localized dilatation may be overlooked in low-grade obstruction, which adversely affects CT scan sensitivity and specificity in the diagnosis of bowel obstruction. Attention to this relatively superfine finding should increase the overall accuracy of CT scan in the diagnosis of intestinal obstruction.
In the Baid et al.  study, CT had a sensitivity of 86.67%, a specificity of 75%, a positive predictive value of 81.87%, and a negative predictive value of 65.21%. Similar figures were described by Mallo et al. , who carried out a systemic review. This review was originally designed to assess the diagnostic performance of CT in bowel ischemia and complete bowel obstruction. They described fifteen studies representing CT diagnosis of complete obstruction and ischemia. Ischemia was specified by operative findings. Also, complete obstruction was specified by operative findings or enteroclysis. Aggregated values of sensitivity and specificity, plus positive and negative predictive rates were calculated. Eleven of the 15 studies reported on the CT diagnosis of bowel ischemia performed on 743 patients. CT in ischemic bowel obstruction had 83% sensitivity (63–100%), 92% specificity (61–100%), 79% positive predictive value (69–100%), and 93% negative predictive value (33.3–100%). Evaluation of CT classification of complete obstruction was performed in seven of the 15 studies (408 patients). CT in complete obstruction had 92% sensitivity (81–100%), 93% specificity (68–100%), 91% positive predictive value (84–100%), and 93% negative predictive value (76–100%). This review clearly demonstrates that CT is highly sensitive for ischemic bowel obstruction and suggests that CT finding of partial obstruction is likely to reflect a clinical syndrome that will resolve without surgical intervention. These results are in line with our study results.A retrospective study was carried out by Peck et al.  over a 1-year period. Fifty-five patients underwent small bowel follow-through and CT. Laparotomy in 42 patients and follow-up in 13 patients were the gold standard for diagnosis. Proven intestinal obstruction in 36 out of 42 patients at the time of laparotomy was detected. Thirty-two out of the 36 patients were identified to have high-grade and complete mechanical obstruction in CT scan. CT proved to be superior to small bowel follow-through in the identification of features of strangulation and masses.
Maglinte et al.  detected accuracy of abdominal CT in the evaluation of partial and complete small bowel obstruction by using clinical outcome and enteroclysis as standards of diagnosis. Retrospective analysis was initiated on the 55 patients of the study who underwent both CT and enteroclysis. Nine patients were proven to have no obstruction, adhesive obstruction was detected in 40 patients, and tumor-related obstruction was detected in 6 patients. CT showed sensitivity in 63% (29 of 46) of patients who had small bowel obstruction and specificity in 78% (seven of nine) of patients who did not. The overall accuracy of the CT interpretations to help establish a diagnosis was 65% (36 of 55).
Coe et al.  documented that radiographic films are a less sensitive and less specific diagnostic tool of bowel obstruction. They advised that abdominal CT should be highly considered as the prime test for the diagnosis of suspected bowel obstruction.
| Conclusion|| |
Management decisions in intestinal obstruction are still notoriously intractable depending on the clinical grounds and different investigations for stratification of patients into conservative or surgical management. CT abdomen can predict the need for surgery early in the majority of patients with bowel obstruction with high sensitivity and specificity. It demonstrates the site and cause of obstruction and prevents delayed surgery with reduced morbidity and mortality. Its sensitivity is high in detecting high-grade obstructions, but low in low-grade ones.
It also helps in preventing negative laparotomies in patients when there is the surgeon faces a dilemma of whether to opt for a conservative or a surgical approach. Nowadays, CT scan facility is available round-the-clock in almost all hospitals and it does not place too much of financial burden on the patient. Hence, it should be included as a protocol investigation in patients with intestinal obstruction for early diagnosis and timely management. It should be stressed that clinical sense still remains the mainstay for deciding on the line of management in cases of intestinal obstruction.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]