Bowel obstruction X-ray

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]


An X-ray is the initial investigation performed in the diagnosis of bowel obstruction. Findings on an X-ray suggestive of bowel obstruction include dilated bowel loops with air-fluid level, distal collapsed bowel, absence of gas in the abdomen or alternatively, "string of pearls" sign indicating trapped flatus.

X Ray

  • A plain X-ray is recommended as the initial investigation of choice when bowel obstruction is suspected.[1][2][1][3][4]
  • The X-ray should be performed when:
  • The following result of plain X-ray is confirmatory of bowel obstruction:
    • Dilated bowel loops with air-fluid level
      • In the supine postion, an estimate of bowel distension is made based on the width of the bowel loops
      • In the lateral postion, air fluid levels are seen more clearly
    • Distal collapsed bowel
      • Small bowel obstruction must cause a dilation of more than 2.5cm to be visible on X-ray
    • Gasless abdomen or alternatively, "string of pearls" sign
      • A "gasless abdomen" indicates that the bowel loop is filled with fluid with no room for gas to occupy the bowel loop
      • "String of pearls" sign indicates that a bowel loop is partially filled with fluid and that air bubbles are accumulating along the surface
X-ray in the upright position demonstrating multiple fluid levels in bowel obstruction by James Heilman, MD - Own work, CC BY-SA 3.0,

Limitations of plain X-ray

  • The site and etiology of obstruction usually cannot be determined especially in the area between the dilated proximal and the nondilated distal loop of the small bowel.
  • It is also limited in distinguishing small from large bowel impactions.
  • X-rays are not sensitive in differentiating partial obstructions from paralytic ileus.

The comparison table for diagnostic studies of choice for bowel obstruction[5]

Sensitivity Specificity
CT 93% 100%
X-ray 50% 75%


  1. 1.0 1.1 Thompson WM, Kilani RK, Smith BB, Thomas J, Jaffe TA, Delong DM, Paulson EK (2007). "Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?". AJR Am J Roentgenol. 188 (3): W233–8. doi:10.2214/AJR.06.0817. PMID 17312028.
  2. Mullan CP, Siewert B, Eisenberg RL (2012). "Small bowel obstruction". AJR Am J Roentgenol. 198 (2): W105–17. doi:10.2214/AJR.10.4998. PMID 22268199.
  3. Maglinte DD, Reyes BL, Harmon BH, Kelvin FM, Turner WW, Hage JE, Ng AC, Chua GT, Gage SN (1996). "Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction". AJR Am J Roentgenol. 167 (6): 1451–5. doi:10.2214/ajr.167.6.8956576. PMID 8956576.
  4. Maglinte DD, Heitkamp DE, Howard TJ, Kelvin FM, Lappas JC (2003). "Current concepts in imaging of small bowel obstruction". Radiol. Clin. North Am. 41 (2): 263–83, vi. PMID 12659338.
  5. Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD (1999). "Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction". Acta Radiol. 40 (4): 422–8. PMID 10394872.

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