;uest Editoria~

"Nonspecific Abdominal Gas Pattern": An Interpretation Whose Time Is Gone

Dean D. L Maglinte, M.D., F.A.C.R. Department of Radiology,/vlethodist Hospital of Indiana, and Indiana University School of Medicine, Indianapolis, Indiana

everal reports have addressed the need for radiologists to be clear and pertinent in their interpretation or reporting of radiologic procedures (1-5). Imprecise or poorly understood reports can adversely affect the workup and management of patients. Plain abdominal radiography (PAP,) is one of the more frequently requested examinations in emergency medicine. In our experience, emergency physicians frequently utilize the term "nonspecific abdominal gas pattern" in their preliminary interpretations when, in fact, they mean that the bowel gas pattern is normal (6). A recent survey of community-based teaching hospital radiologists showed that 70% of the radiologists used this term (7); 65% of these radiologists considered this to be "normal or probably normal," 22% interpreted this as "cannot tell if normal or abnormal," and 13% defined this term as "abnormal but cannot tell if it is mechanical obstruction or adynamic ileus." O f the referring physicians in the same survey who received the report, 44% defined it as "normal," 51% defined it as "normal or abnormal," and 5% defined it as "abnormal, representing either mechanical obstruction or adynamic ileus." Some did not know what the term meant. It is obvious that the term has a wide range of meaning for both radiologists and referring clinicians. At one extreme, it appears to signify a normal condition; whereas, at the other extreme, it is perceived as a pathologic state such as obstruction. Few other radiologic interpretations

have more consistent disagreement about their meaning both among radiologists and between radiologists and referring clinicians. Prior communications have called for the abandonment of the term "nonspecific abdominal gas pattern" (7, 8), and yet the term continues to be used. It is pertinent to consider why this is so. Is it because radiologists and emergency physicians do not read the literature, or is it because a "nonspecific" intestinal gas pattern really exists? My experience suggests that there is a group of patients whose abdominal radiographs do not fit the definition of "normal," "probable small bowel obstruction" and "definite small bowel obstruction" gas patterns. This is likely why there is difficulty in "ignoring" or abandoning this interpretation in the absence of an applicable alternative recommendation. H o w does one report this intestinal gas pattern, and what are its clinical implications? A recent report of a blinded analysis of plain radiographic abdominal examinations in the diagnosis of small bowel obstruction (SBO) by experienced gastrointestinal radiologists showed a sensitivity of 66% (9). This report differed from other studies in that the PAR patterns were defined, and a follow-up for every defined interpretive category was given. In this report, 62% of the patients clinically suspected of SBO were, in fact, not obstructed. O f "normal" plain radiographic interpretations, 21% had low-grade SBO. O f the so-called "abnormal but nonspecific" plain radiographic interpretations, 13% had low-

grade and 9% had high-grade SBO. The investigators defined the latter pattern as borderline or slightly dilated (2.5-3 cm) small bowel with more than two air fluid levels. O f the "probable" SBO plain radiographic interpretations, 37% had low-grade SBO and 16% had high-grade SBO. O f the "definite" SBO interpretations, 26% had lowgrade SBO and 23% had high-grade SBO; 13% had complete SBO. This report clearly showed that there is a pattern which is neither normal nor fits the categories of probably or definitely obstructed. Gammill and Nice (10) recognized this pattern to mean ileus (i.e., the small bowel is unable to push fluid along). Indeed, the word "ileus" means stasis and does not differentiate between mechanical and nonmechanical causes. Our acceptance of the term "ileus" to mean an adynamic etiology when, in fact, it simply means stasis that can result from any cause may be part of the problem. Plain radiographic examination has remained a mainstay in the evaluation of patients with suspected intestinal obstruction because of its ready availability, its relative cheapness, and its acceptable clinical record. It is the usual starting point in the radiologist's involvement in the workup of this group of patients. The interpretation "nonspecific abdominal gas pattern" should be avoided. I propose the term "mild small bowel stasis." If the term "nonspecific abdominal gas pattern" is used, it should be qualified as abnormal and should be followed by a specific recommendation for
Guest Editorial 93

Emergency R a d i o l o g y M a y / J u n e 1996

further workup. This interpretation satisfies a group ofplain radiographicfindings that does not fit the normal and definitely abnormal categories and has clinical implications (9). Based on the current literature, the various intestinal gas patterns are defined as follows: 1. A "normal" intestinal gas pattern is defined as either an absence of small intestinal gas (without abnormal increase in abdominal density or loss of soft tissue planes) or the presence of gas w i t h i n a few (3-4) variably shaped small intestinal loops measuring less than 2.5 cm in diameter. In addition, there is a normal gas and/or fecal distribution in a nondistended colon. 2. "Mild small bowel stasis" (abnormal but nonspecific pattern) is defined as those cases demonstrating single or multiple loops of borderline or slightly dilated small intestine (2.5-3 cm) with three or more air fluid levels on upright or decubitus radiographs. There is no disproportionate distention of the small

intestine relative to the colon. Gas a n d / o r feces is present in a nondistended colon. The term is used to indicate an abnormal gas distribution but does not allow distinction b e t w e e n mild reflex or adynamic ileus and mechanical obstruction. Some of the patients in this category have low-grade obstruction and are difficult to diagnose clinically, and others may have reflex or reactive ileus secondary to a variety of processes, e.g., trauma, critical illness, or urinary tract calculus. Some cases may be related to medication-induced hypoperistalsis and air swallowing (10). 3. A "probable" SBO pattern is defined as unequivocally dilated multiple gaseous a n d / o r fluid-filled loops o f small intestine with a moderate amount ofcoionic gas, but the degree of distention of small intestine relative to the colon is insufficient to make a definite diagnosis. Air fluid levels are generally present, but there is an element of uncertainty in diagnosing SBO.

4. A "definite" SBO pattern is defined as abnormal and clearly disproportionate gaseous and/or fluid distention of small bowel relative to the colon (or other segments of small intestine). Air fluid levels are evident, and the diagnosis of SBO is considered unequivocal. The use of precise definition of plain radiographic intestinal patterns will enable radiologists to be better understood by referring clinicians, allow us to make more cost-effective recommendations for further workup in suspected SBO, and prevent misunderstandings with referring clinicians (11). The radiologic report should include a recommendation for further imaging if this is needed, so that erroneous application of radiologic resources, which can increase the cost o f w o r k u p and management, is avoided. An algorithm is proposed for additional imaging in the workup of patients with suspected intestinal obstruction (Fig. 1). This recommendation is based on the acknowl-

--/g.re
Clinical Background History, physical and laboratory examinations

Suspected Intestinal Obstruction

Plain Abdominal Radiography

i 1

"Normal" or "Abnormal but Nonspecific" and "Probable" SBO Patterns

"Definite" SBO Pattern

Small Bowel + Colonic Distention

Acute symptoms esp. ER patient

Non-acute symptoms

Surge

:al patient vative ement

Possible colonic ileus vs. distal colonic ohst. (with incompetent ileocecal valve)

Postoperative patients or with signs of intraabdominal inflammation

info~a{ive

::

cT

Figure 1. Algorithm for additional imaging in the workup of patients with suspected intestinal obstruction.
94 Guest Editorial
Emergency RadiologT May/June 1996

edged limitations o f P A R (9), the value of c o m p u t e d t o m o g r a p h y in the e m e r gent situation (12, 13), and the problem-solving ability o f enteroclysis in the subacute or chronic setting (11, 14). It will expedite diagnosis and decrease the cost o f w o r k u p o f the patient with suspected intestinal obstruction. T h e recommendations given are not based on firm scientific evidence but on continu i n g clinical radiologic observations over the last decade (9, 11-17). As the value o f other imaging modalities are established, they can be added to the recommendations. Radiologists must understand each other if we expect other physicians to understand us. T h e lack o f a definition o f the m e a n i n g o f the various terms used in plain radiographic interpretation has resulted in confusion and prevented meaningful comparison o f different reports. It has been estimated that PAl% findings are diagnostic o f SBO in about 50-60% o f cases; "equivocal" in about 20-30%; and "normal," " n o n specific," or "misleading" in 10-20% o f cases (18, 19). A careful analysis and clear reporting o f the plain radiograph is crucial to prevent erroneous application o f imaging resources and clinical mism a n a g e m e n t . T h e "misleading" patterns in intestinal obstruction appear to be largely plain radiographic misinterpretations and miscommunication. O u r reports should be concise and as precise as possible.

"Nonspecific abdominal gas pattern" is an interpretation whose time should have been long gone. It serves no useful purpose and deserves permanent burial.

ACKNOWLEDGMENTS
The author would like to thank Frederick M. Kelvin, M.D., for his advice and Fran Shaul for secretarial assistance.

:EFERENCE~
1. Olinger NJ, Hunter TB, Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988;169: 825-6. 2. Fischer HW. Better communication between the referring physician and the radiologist [editorial]. Radiology 1983; 146:845. 3. Friedman PF. Radiologic reporting structure [editorial]. AJR Am J Roentgenol 1983;140:171. 4. Revak CS. Dictation of radiologic reports [letter]. AJR Am J Roentgenol 1983;141:210. 5. Lafortune M, Breten G, BaudoinJL. Radiological report: what is useful for the referring physician? J Can Assoc Radiol 1988;39:140-3. 6. Suh RS, Maglinte DDT, Lavonas EJ, Kelvin FM. Emergency abdominal radiography: discrepancies of preliminary and final interpretation and management relevance. Emerg RadioI 1995;2:315-8. 7. Patel NH, Lauber PR. The meaning of a nonspecific abdominal gas pattern. Acad Radiol 1995;2:667-9. 8. Bohrer SP. Nonspecific gas pattern [letter]. Radiology 1989;173:283.

9. Shrake PD, Rex DK, Lappas JC, Maglinte DDT. Radiographic evaluation of suspected small bowei obstruction. Am] Gas~roenterol 1991 ;86:175-8. 10. Gammill SL, Nice CM Jr. Air-fluid levels: their occurrence in normal patients and their role in the analysis of ileus. Surgery 1972;71:771-80. 11. Maglinte DDT, Herlinger H. Turner WWJr, Kelvin FM. Radiologic management of small bowel obstruction: a practical approach. Emerg Radiol 1994;1: 138-49. 12. Balthazar EJ. CT ofsmaii-bowel obstruction. AJR Am J Roentgenot 1994;162: 255-61. 13. Tourel PG, Fabre VM, Pradel JA, et aI. Value of CT in diagnosis and management of patients with suspected acute small-bowel obstruction. AJR Am J Roentgenol 1995;1187-92. 14. Maglinte DDT, Peterson LA, Vahey TN, et al. Enteroclysis in partial small bowel obstruction. Am] Surg 1984;147: 325-9. 15. Megibow AJ, Balthazar EJ, Cho KC, et al. Bowel obstruction: evaluation with CT. Radiology 1991;180:313-8. 16. Maglinte DDT, Gage S, Harmon B, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology 1993;186:61-4. 17. Gazelle GS, Goldberg MA, Wittenberg J, et al. Efficacy of CT in distinguishing small bowel obstruction from other causes of small bowel dilatation. AJR Am] Roentgenol 1994;162:43-7. 18. Mucha P Jr. Small intestinal obstruction. Surg Clin North Am 1987;67:597-620. 19. Laws HL, Aldrete JS. Small bowel obstruction: a review of 465 cases. South MedJ 1976;69:733-4.

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