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• W1990902802 abstract "Small bowel obstruction (SBO) is a clinical condition that is often initially diagnosed and managed in the emergency department (ED). The high rates of potential complications that are associated with an SBO make it essential for the emergency physician (EP) to make a timely and accurate diagnosis. The primary objective was to perform a systematic review and meta-analysis of the history, physical examination, and imaging modalities associated with the diagnosis of SBO. The secondary objectives were to identify the prevalence of SBO in prospective ED-based studies of adult abdominal pain and to apply Pauker and Kassirer's threshold approach to clinical decision-making to the diagnosis and management of SBO. MEDLINE, EMBASE, major emergency medicine (EM) textbooks, and the bibliographies of selected articles were scanned for studies that assessed one or more components of the history, physical examination, or diagnostic imaging modalities used for the diagnosis of SBO. The selected articles underwent a quality assessment by two of the authors using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data used to compile sensitivities and specificities were obtained from these studies and a meta-analysis was performed on those that examined the same historical component, physical examination technique, or diagnostic test. Separate information on the prevalence and management of SBO was used in conjunction with the meta-analysis findings of computed tomography (CT) to determine the test and treatment threshold. The prevalence of SBO in the ED was determined to be approximately 2% of all patients who present with abdominal pain. Having a previous history of abdominal surgery, constipation, abnormal bowel sounds, and/or abdominal distention on examination were the best history and physical examination predictors of SBO. X-ray was determined to be the least useful imaging modality for the diagnosis of SBO, with a pooled positive likelihood ratio (+LR) of 1.64 (95% confidence interval [CI] = 1.07 to 2.52). On the other hand, CT and magnetic resonance imaging (MRI) were both quite accurate in diagnosing SBO with +LRs of 3.6 (5- to 10-mm slices, 95% CI = 2.3 to 5.4) and 6.77 (95% CI = 2.13 to 21.55), respectively. Although limited to only a select number of studies, the use of ultrasound (US) was determined to be superior to all other imaging modalities, with a +LR of 14.1 (95% CI = 3.57 to 55.66) and a negative likelihood ratio (–LR) of 0.13 (95% CI = 0.08 to 0.20) for formal scans and a +LR of 9.55 (95% CI = 2.16 to 42.21) and a –LR of 0.04 (95% CI = 0.01 to 0.13) for beside scans. Using the CT results of the meta-analysis for the 5- to 10-mm slice subgroup as well as information on intravenous (IV) contrast reactions and nasogastric (NG) intubation management, the pretest probability threshold for further testing was determined to be 1.5%, and the pretest probability threshold for beginning treatment was determined to be 20.7%. The potentially useful aspects of the history and physical examination were limited to a history of abdominal surgery, constipation, and the clinical examination findings of abnormal bowel sounds and abdominal distention. CT, MRI, and US are all adequate imaging modalities to make the diagnosis of SBO. Bedside US, which can be performed by EPs, had very good diagnostic accuracy and has the potential to play a larger role in the ED diagnosis of SBO. More ED-focused research into this area will be necessary to bring about this change. Obstrucción de Intestino Delgado en el Adulto La obstrucción de intestino delgado (OID) es una situación clínica que a menudo es diagnosticada y manejada inicialmente en el servicio de urgencias (SU). El alto porcentaje de complicaciones potenciales que se asocian con la OID hace necesario que el urgenciólogo realice un diagnóstico certero de forma precoz. El objetivo principal fue realizar una revisión sistématica y un metanálisis de la historia clínica, la exploración física y las modalidades de pruebas de imagen relacionadas con el diagnóstico de OID. Los objetivos secundarios fueron identificar la prevalencia de OID en los estudios prospectivos de adultos con dolor abdominal agudo en el SU, y aplicar la aproximación de Pauker and Kassirer a la toma de decisión clínica para el diagnóstico y el manejo de la OID. Se revisó MEDLINE, EMBASE, los principales libros de medicina de urgencias y emergencias y las bibliografías de los artículos seleccionados, que valoraron uno o más componentes de la historia, la exploración física y de las modalidades de pruebas de imagen utilizadas en el diagnóstico de la OID. Se llevó a cabo una valoración de la calidad de los artículos seleccionados mediante el Quality Assessment Tool for Diagnostic Accuracy Studies 2 (QUADAS-2). Los datos utilizados para compilar las sensibilidades y las especificidades se obtuvieron de estos estudios y se realizó un metanálisis en aquéllos que examinaron el mismo componente de la historia clínica, la exploración física, o la prueba diagnóstica. Una información diferente sobre la prevalencia y el manejo de la OID se utilizó junto con los hallazgos del metanálisis de la tomografía computarizada (TC) para determinar el umbral de la prueba diagnóstica y el tratamiento. La prevalencia de OID en el SU se determinó que era aproximadamente el 2% de todos los pacientes que presentan dolor abdominal agudo. Los mejores factores predictivos de OID en la historia clínica y la exploración física fueron el tener un antecedente previo de cirugía abdominal, el estreñimiento y/o la distensión abdominal en la exploración. La radiografía se determinó que era la modalidad de prueba de imagen de menor utilidad para el diagnóstico de OID, con un razón de probabilidad positiva (RP+) de 1,64 (IC 95% = 1,07 a 2,52). Por otro lado, la TC y la resonancia magnética nuclear (RMN) fueron ambas bastante certeras en el diagnóstico de OID, con una RP+ de 3,6 (cortes de 5 mm a 10 mm, IC 95% = 2,3 a 5,4) y 6,77 (IC 95% = 2,13 a 21,55), respectivamente. Aunque limitado a unos pocos estudios seleccionados, el uso de la ecografía (ECO) fue superior a todas las otras modalidades de estudios de imagen, con una RP+ de 14,1 (IC 95% = 3,57 a 55,66) y una razón de probabilidad negativa (RP-) de 0,13 (IC 95% = 0,08 a 0,20) para la evaluación estándar, y una RP+ de 9,55(IC 95% = 2,16 a 42,21) y una RP- de 0,04 (IC 95% = 0,01 a 0,13) para la evaluación a pie de cama. Usando los resultados del metanálisis de la TC para el subgrupo de 5 a 10 mm así como la información sobre las reacciones al contraste intravenoso y el manejo de la intubación nasogástrica, el umbral de la probabilidad pretest para las pruebas diagnósticas se determinó que era el 1,5%, y el umbral para la probailidad pretest para iniciar el tratamiento se estimó que era el 20,7%. Los aspectos potencialmente útiles de la historia clínica y la exploración física están limitados al antecedente de cirugía abdominal, el estreñimiento y el hallazgo en la exploración de distensión abdominal. La TC, la RMN y la ECO son todas modalidades de pruebas de imagen adecuadas para hacer el diagnóstico de OID. La ecografía a pie de cama, que puede ser realizada por los urgenciólogos, tuvo muy buena certeza diagnóstica y tiene potencial para jugar un destacado papel en el diagnóstico de OID en el SU. Será necesario investigar en el futuro en esta área en el SU para lograr este cambio. CME Editor: Hal Thomas, MD Authors: Mark R. Taylor, MD, and Nadim Lalani, MD, FRCPC Article Title: Adult Small Bowel Obstruction If you wish to receive free CME credit for this activity, please refer to the website: http://www.wileyhealthlearning.com. Accreditation and Designation Statement: Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Educational Objectives After completing this exercise the participant will be able to explain the relative roles of the various components of the diagnostic assessment for small bowel obstructions in adults. Activity Disclosures No commercial support has been accepted related to the development or publication of this activity. Faculty Disclosures: CME editor – Hal Thomas, MD: No relevant financial relationships to disclose. Authors –Mark R. Taylor, MD, and Nadim Lalani, MD, FRCPC This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Academic Emergency Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Academic Emergency Medicine is double-blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. No relevant financial relationships exist for any individual in control of the content and therefore there were no conflicts to resolve. Instructions on Receiving Free CME Credit For information on applicability and acceptance of CME credit for this activity, please consult your professional licensing board. This activity is designed to be completed within an hour; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity during the valid credit period, which is up to two years from initial publication. Follow these steps to earn credit: This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months. Small bowel obstruction (SBO) is a common clinical condition that is often initially diagnosed and managed by an emergency physician (EP). It is estimated that 300,000 hospitalizations occur annually as a result of SBO in the United States,1 with approximately 70% of these patients being admitted through an emergency department (ED).2 The diagnosis of intestinal obstruction in the ED has been estimated to be around 2% of all patients who present with the symptom of abdominal pain,3 and 15% of all patients who ultimately get admitted to a surgical unit from the ED.1 Although presentations are highly variable, primary emergency medicine (EM) textbooks teach the “classical” signs and symptoms as some combination of abdominal pain, nausea, vomiting, and abdominal distention.4, 5 The most common cause of SBO is adhesions from previous abdominal surgery, which account for approximately 75% of all cases.6 Other common etiologies include neoplasms, hernias, and Crohn's disease.7 The complication risks associated with SBO are very high, with strangulation occurring in 30% and bowel necrosis in 15%.8 Both may ultimately lead to perforation, sepsis, and death.9 Risk factors for complicated SBO included age, comorbid illness, and a delayed diagnosis of >24 hours.8 The high rate of complications and the need for urgent management make it essential for the EP to make the diagnosis as early as possible. There are several diagnostic tests available to assist in making the diagnosis of SBO. These include plain radiographs, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). There are currently no serum markers that are predictive of noncomplicated SBO, limiting any potential usefulness in the ED decision-making process.10 Patients with strangulated bowel obstruction were not the focus of this meta-analysis, but often present with metabolic acidosis11 and elevation of other potential serum markers that are not readily available to the EP, such as intestinal fatty acid–binding protein.12 An effective way to make the diagnosis of SBO in the ED as quickly as possible is with the use of likelihood ratios (LRs) as described by Hayden et al.13 Diagnosis is made from determining a pretest probability based on the history and physical examination and from a LR of the specific diagnostic test used. Historically, this information could have been plotted on the Fagan nomogram to determine a posttest probability of having the condition.14 Readily available and easy-to-use applications such as PEPID (www.pepid.com) and MedCalc (www.medcalc.org) have replaced the Fagan nomogram as quick alternatives for the EP to accomplish this task. Although this approach can be very useful, it ultimately depends on the EP's ability to determine an accurate pretest probability and to have clinically relevant LRs available for the diagnostic tests that are ordered. Unfortunately, there are few EM-specific resources that assist in this task. Core EM textbooks do not provide summarized quantitative data in regard to history, physical examination, and diagnostic test LRs for SBO and instead rely on single study findings at best.4, 5 To the best of our knowledge, no EM-specific systematic reviews for the diagnosis of SBO exist. Of the non-EM reviews that have been written regarding SBO, including those from the surgical literature, none provide a comprehensive diagnostic meta-analysis with pooled estimates for history and physical examination as well as diagnostic studies.15-18 The primary objective of this meta-analysis was to provide the EP with evidence-based reliability and pooled diagnostic accuracy estimates for history, physical examination, and imaging for SBO in ED settings. This information can then be used to develop pre- and posttest probability of SBO to facilitate Bayesian decision-making and hopefully improve diagnostic accuracy and efficiency. The second objective is to use the method described by Pauker and Kassirer19 to determine a test-treatment threshold for SBO to assist the EP in deciding when to begin treatment for SBO versus getting further testing to confirm the diagnosis. Treatment in this case involves conservative management with intravenous (IV) fluids and nasogastric (NG) intubation. One investigator (MRT) searched the medical literature using both OVID MEDLINE and EMBASE during the time periods of 1946 to November 2011 and 1947 to November 2011, respectively. The Medical Subject Headings (MeSH) term intestinal obstruction was combined individually using “and” with the MeSH terms emergency medicine, history, physical examination, sensitivity and specificity, diagnostic tests, and diagnostic imaging. The “explode” option was used for the OVID MEDLINE search. Results were limited to “humans” and “English language studies.” An additional OVID MEDLINE search was used with the above terms along with the search limitations of “Clinical Prediction Guidelines” (best balance of sensitivity and specificity—a MEDLINE clinical query option used to retrieve the largest number of high-quality studies).20 To identify the risk of IV contrast allergic reactions from CT for the test-treatment threshold, the MeSH terms IV contrast and hypersensitivity were used in a MEDLINE search. Conversely, the MeSH term gastrointestinal intubation was searched with the limit of “therapy (best balance of sensitivity and specificity)” to determine the risks and benefits of NG insertion. References from selected articles, the Cochrane database of systematic reviews, and core textbooks of EM4, 5 were searched for relevant studies. This expansive search strategy was also used to identify the studies of SBO prevalence after the above combined MeSH terms with the addition of prevalence failed to produce any articles stating these statistics. Abstract submissions to Academic Emergency Medicine (1995 to November 2011), Annals of Emergency Medicine (1993 to November 2011), and Canadian Journal of Emergency Medicine (2002 to November 2011) were also searched. The articles that provided the highest level of evidence according to the hierarchy of evidence-based medicine were selected for use in the test-treatment threshold calculations. The hierarchy of evidence-based medicine considers the relative strength of the primary types of research in the following order: systematic reviews rank above individual randomized controlled trials, which in turn rank above cohort studies, case-control studies, and expert opinion.21 The inclusion criteria for the studies selected included those that focused primarily on SBO in an adult population and with sufficient data to develop a two-by-two table for sensitivity and specificity calculations. There were a few studies included that indiscriminately assessed bowel obstruction in general, but whose study populations predominantly were diagnosed with SBO.22-26 Our exclusion criteria included case studies, studies with insufficient data to develop a two-by-two table, pediatric populations studies, those with tests not readily available to the EP, those focused on a single radiographic sign, those focused on treatment, and studies that were not primary research. Furthermore, studies that focused solely on ischemic bowel, cancer, intussusception, or Crohn's disease were not selected. Both authors independently reviewed all the titles and abstracts for selection of potential studies using the predetermined inclusion criteria. A medical librarian provided assistance when requested in the retrieval process. The authors independently used the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) to evaluate the evidence of the studies that were selected.27 When there was disagreement regarding one of the aspects of the QUADAS-2 answers, consensus was reached via discussion. Statistical agreement was determined with kappa analysis using SPSS Statistics v17.0 (SPSS, Inc., Chicago, IL).28 The QUADAS-2 tool uses four key domains to assess for bias: patient selection, index test, criterion standard, and flow and timing.27 In terms of patient selection, bias was determined to be high if a study used a case-control approach, did not have a random or consecutive sample of patients enrolled, or had inappropriate exclusions. If the majority of the patients involved were not originally assessed in the ED, then the concern that patients did not match the review question was stated as being either unclear or high. The risk of bias for the index test was determined to be high if the test was interpreted with knowledge of the criterion standard. On the other hand, bias of the use of the criterion standard was high if the criterion standard was unlikely to correctly classify the target condition. Last, bias toward study flow was stated as high if all the patients were not included in the analysis or if they were not subject to a criterion standard. The following information was independently collected from the selected studies by the two authors using a standardized collection form: type of study, setting, patient population, inclusion criteria, index test, index test properties, criterion standard, true-positives and -negatives, and false-positives and -negatives. Each of the studies had a majority of this information readily available in their methods and results sections. A “true-positive” was defined as a diagnostic test that correctly identified SBO according to previously defined criteria and was confirmed with the criterion standard. A “false-positive” was a diagnostic test that suggested SBO was present when the criterion standard did not demonstrate this. A “true-negative” was a diagnostic test that suggested the absence of SBO when the criterion standard confirmed that no SBO was present. A “false-negative” was a diagnostic test that suggested no SBO was present when the criterion standard found there to be one. Sensitivities and specificities were determined and LRs were calculated whenever possible. If there were more than two qualitatively similar studies of the same index test, we combined the results using Meta-DiSc.29 Interstudy heterogeneity of the pooled sensitivities and specificities was assessed with the I2 and chi-square test using the Dersimonian-Laird random effects model.30 Data were not combined for the history and physical examination because there were only two studies that looked at these components, and each assessed a different group of questions and physical examination maneuvers. If there was significant heterogeneity for a particular diagnostic test, single studies were sequentially removed to see if the heterogeneity could be eliminated. This was not possible for some subsets. There was tremendous variability in the equipment and techniques used in the studies that looked at CT scan for SBO. The one variable that was most likely to affect the accuracy of the studies was the thickness of slices that were taken, also known as beam collimation.31 The groups were divided into the studies that did not define slice thickness and those that were 50-, 5- to 10, or 0.75-mm slices. US studies were split into those that were formal US done by radiology and those that were bedside US done in the ED. From our selected studies we abstracted the following data for inclusion into the Pauker and Kassirer model equation for test-treatment threshold: sensitivity of test, specificity of test, false-negatives of test, false-positives of test, risk of test, risk of treatment in those without SBO, and anticipated benefit of treatment in those with SBO.19 The 5- to 10-mm subgroup of CT scans was chosen as the test of choice because 7 mm is the mean slice thickness used for abdominal pain protocols, according to the Society of Computed Body Tomography.32 These variables are highly open to interpretation and estimates were based on the best available research. A search of MEDLINE yielded 3,801 studies. An assessment of both titles and abstracts selected 207 studies for further review. A search of EMBASE yielded 3,901 studies, of which 136 were selected for further review. Twenty papers were selected that met the inclusion criteria. An additional two papers were added from a review of the bibliographies of selected articles, for a total of 22 papers (Figure 1).22-26, 33-49 Data Supplement S1 (available as supporting information in the online version of this paper) includes summaries of all the included studies. There were 12 prospective, cross-sectional studies22, 24-26, 34, 36-39, 41, 44, 46 and 10 retrospective studies.23, 33, 35, 40, 42, 43, 45-49 No case-control or randomized controlled trials were identified. Two studies looked at the history and physical examination for diagnosis of SBO.24, 33 Others looked at the different imaging modalities and often compared them head to head for the diagnosis of SBO.22, 34, 35 There were only two studies that were based on an emergency patient population exclusively, and both were ED-personnel US studies.36, 37 The rest often included patients who were first assessed in the ED, but were not explicitly limited to these patients. Table 1 shows a summary of the QUADAS-2 assessments. The purpose of the tool is to help readers judge the risk of bias in the markedly heterogeneous group of studies that make up this meta-analysis. The kappa scores ranged from 0.621 to 1. The majority of the articles selected for this meta-analysis had low risks of bias in patient selection, index test usage, criterion standard choice, and flow and timing. However, some studies did not explicitly explain how the patient selection process occurred.23, 37-39 Moreover, for several studies it was unclear whether the criterion standard results were interpreted without knowledge of the index test.22-25, 40-45 Finally, some studies did not state the interval between the reference test and the criterion standard.24, 33, 35, 41, 42, 45-47 The criterion standard for the majority of the studies was usually a combination of surgical findings, eventual clinical outcomes, or both. Unfortunately, many of the studies do not go into further detail about the specifics of the surgical diagnosis nor the timeline of the eventual clinical diagnosis. There are very few studies that state the prevalence of SBO in the ED. A study completed at the University of Virginia Hospital provided an estimate of 2% for all patients presenting with abdominal pain to the ED.3 An audit of a U.K. ED reported an intestinal obstruction prevalence-based estimate of 15% of all patients with abdominal pain who presented to the ED and were admitted to a surgical unit.1 They did not differentiate between large or SBOs. Another large population-based study out of California had 30,000 SBO admissions annually, of which 70% originally presented to an ED.2 Other sources state that SBO accounts for approximately 15% to 20% of all admissions to surgical services.50, 51 Only two articles assessed the diagnostic accuracy of history for SBO and met the inclusion criteria.24, 33 The results are shown in Table 2. Both studies used surgical findings, x-ray findings, or diagnosis at time of discharge as their criterion standard. The first study was a prospective analysis of 1,300 patients in Finland who were admitted with acute abdominal pain.33 Only 53 of these patients were ultimately found to have SBOs from operation or clinical follow-up. There were no components of the history that could reliably and accurately predict SBO. Having a history of previous abdominal surgery had the best combination (+LR = 3.86 and –LR = 0.19). The second study was also prospective and looked at 1,200 patients presenting with abdominal pain to several hospitals throughout Germany.24 Forty-eight patients ultimately were diagnosed with SBO. In this study, a history of constipation had the best combination (+LR = 8.8 and –LR = 0.59). The same two articles that assessed the history for SBO also looked at the physical examination findings.24, 33 The results are shown in Table 3. Again, there were very few components of the physical examination that could be used reliably for diagnostic accuracy. Abdominal distention was the best sign with a +LR of 16.8 and –LR of 0.34 in the study by Eskelinen et al.33 and +LR of 5.64 and –LR of 0.43 in the study by Böhner et al.24 Eskelinen et al. also found that abnormal bowel sounds had a +LR of 6.33 and a –LR of 0.27. Having a normal urine was 100% sensitive, but not very specific, and visualizing peristalsis was 100% specific but not very sensitive. Five studies were included that looked at the usefulness of plain radiography in diagnosing SBO (Table 4, Figure 2).22, 34-36, 40 Three were prospective case studies,22, 34, 36 and two were retrospective case studies.35, 40 All of the studies used the previously defined criteria of SBO on x-ray to be greater than or equal to two air fluid levels in dilated loops of bowel (>2.5 cm).52 A majority of the studies used two or more radiologists reading the images to ensure reliability. None of the studies provided kappa scores to assess reliability. All of the studies were small, with patient numbers in the range of 32 to 108. The criterion standard used was always surgical findings or eventual clinical outcome. There was some heterogeneity across the included studies with a +LR 1.64 (95% confidence interval [CI] = 1.07 to 2.52) and an I2 = 25%. With the removal of Musoke et al.,34 the +LR and –LR had an I2 = 0 and values of 1.55 (95% CI = 1.10 to 2.19) and 0.59 (95% CI = 0.43 to 0.82), respectively. Fourteen studies in total were examined that looked at the usefulness of CT for the diagnosis of SBO (Table 5, Figure 3). Six were prospective studies22, 25, 38, 41, 44, 46 and eight were retrospective studies.23, 35, 40, 42, 45, 47-49 All studies used surgical findings or diagnosis at time of discharge as the criterion standard. Due to the significant advancement in CT technology over the past 20 years, there was tremendous variability between the studies in terms of the type of CT scanner used, the thickness of slices (ranging from 50 to 0.75 mm), and the use and timing of both IV and oral contrast. The most commonly used CT scanner was the General Electric 9800CT (Fairfield, CT).42, 47, 49 Other models included the General Electric Helical44, 45, 48 and the Seimens Somatom series (Siemens Medical Solution USA, Inc., Malvern, PA).22, 38, 41 Two studies did not list the type of CT scanner used.35, 40 In terms of contrast, two studies used oral exclusively,35, 47 while two others did not mention the use of contrast.23, 40 All remaining studies used both oral and IV contrast for their CT scans. Thinner CT slices improve diagnostic accuracy in bowel obstruction,31 and therefore studies were grouped according to the thickness of slices that were taken. An SBO was diagnosed if continuous dilated loops of bowel >2.5 cm were present proximal to collapsed loops of bowel. These criteria were first described by Maglinte et al.49 and were consistent across all studies. A majority of the studies used two radiologists for image interpretation as a measure of reliability. Only the study by Atri et al.45 provided a kappa score for the reviewers, which was recorded as 0.68 to 0.80. Several studies did not state the thickness of CT slices that were taken and are listed in Table 5.23, 35, 40, 47 These studies had sensitivities ranging from 50% to 92% and specificities ranging from 78% to 94%. Makanjuola et al.42 used a very large slice size of 50 mm for their study. They reported a sensitivity and specificity of 79% (95% CI = 64% to 90%) and 67% (95% CI = 22% to 95%). There was a large range of sensitivities (63% to 100%) and specificities (57% to 100%) for the studies that used slice sizes of 5 to 10 mm. These data were pooled together because the largest proportion of studies used this range for their scans. The pooled studies had a +LR of 3.6 (95% CI" @default.
• W1990902802 created "2016-06-24" @default.
• W1990902802 creator A5056925040 @default.
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• W1990902802 date "2013-06-01" @default.
• W1990902802 modified "2023-10-18" @default.
• W1990902802 title "Adult Small Bowel Obstruction" @default.
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