Closing the loop on internal hernias: CT of complex small bowel obstructions
Everlearning Webinar
Click here to view the webinar (online lecture)
The following cases are intended to supplement your learning experience by giving you the opportunity to review the actual images and conceptualize the three-dimensional anatomy related to the various types of obstructions presented. These cases can be reviewed before, during, and after the conference to supplement your learning.
These cases are based on an educational philosophy that promotes review of multiple variations of the same diagnosis in full case form to maximize your understanding, create a paradigm for pattern recognition, and increase your confidence when making these diagnoses independently.
Performance tips:
Google Chrome or safari; works well on phone and tablet with finger scrolling (pinch to zoom)
Consider using an external mouse with middle scroll wheel
If using a trackpad select the "Stack Scroll" button (it is defaulted when you open the case), click with one finger (index) and scroll with a second (middle) for a smoother, slower scroll than with two fingers alone
Round 1 : Closed-loop obstructions due to adhesions
Case 1 - adhesive band
Case 2 - "internal hernia"
Case 3 - hemorrhage
Case 4 - single isolated loop
Round 2 : Internal hernias
Case 1 - Neprectomy bed
Case 2 - Transmesenteric
Case 3 - Left paraduodenal
Case 4 - Foramen of Winslow
Challenge cases
Case 1 - CLO adhesions
Case 2 - Petersen internal hernia
Case 3 - CLO adhesions
Case 4 - CLO early/late
Supplemental : Additional key examples of internal hernias
Case 1 - Transomental
Case 2 - "internal hernia"
Case 3 - Right paraduodenal
Case 4- RYGB-related
Oral contrast for Abdominal CT
In response to questions about the use of oral contrast during the webinar, below is a simplified version of my institution's guidelines for oral contrast for CT abdomen/pelvis:
Outpatients:
800 mL flavored water with 16 mL of Iohexol
Additional dose on the CT table of 200 mL water + 8 mL Iohexol
Inpatients:
800 mL water with 16 mL of Iohexol in 4 doses 20-30 minutes apart
ED:
Oral contrast is indicated for patients with:
recent surgery
known cancer
suspected fistula or abscess
unable to get IV contrast
CT without oral contrast in the last 7 days
BMI <25
Practically we prefer most patients to get oral contrast in the ED setting, but the ordering provider can influence if this happens
We have found the biggest "bang for your buck" is "thinner" patients with a BMI <25
For additional reading:
Perry J. Pickhardt. Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy. (2020) American Journal of Roentgenology. https://doi.org/10.2214/AJR.19.21989