When Surgery meets Autoimmunity: A Case of Pneumatosis Cystoides Intestinalis mimicking mesenteric infarct in systemic sclerosis

49-Year-Old Woman With Acute Abdominal Pain and Nausea

The relevance of free fluid between intestinal loops detected by sonography in the clinical assessment of small bowel obstruction in adults

Objective The objectives of the study are to discuss the usefulness of multidetector computed tomography (CT) in the evaluation of intestinal obstruction and the underlying causes. Background CT has become a mainstay in diagnosing bowel obstruction. Since the management of obstruction has dramatically changed with a decrease in the proportion of patients who need surgery, a precise CT evaluation is now both the gold standard and the common approach in patients with suspected bowel obstruction. Materials and methods Twenty patients were included in this study. They were referred to the Radiology Department, Menoufia University, in the period from July 2014 to November 2015. These patients were referred for multidetector CT assessment complaining of one or more of the following symptoms: inability to pass stools, constipation, acute abdomen, vomiting, and nausea. Results Mechanical causes were the dominant (95%) in the referred patients with bowel obstruction. The dilated bowel loops in the referred patients were: 11/20 patients with small bowel dilatation (55%), 8/20 patients with large bowel dilatation (40%), and 1/20 patient with small and large bowel dilatation (5%). Adhesive intestinal obstruction and obstructed hernias are the main causes of small bowel obstruction in our study. Cancer sigmoid is the main cause of large bowel obstruction in our study. Conclusion Our results showed a very high sensitivity and specificity which had been at 100% mark. This study has confidently ascertained the role of MSCT in diagnosing and altering the treatment plans of a wide range of bowel obstruction causes.

Case Report: Patient is a 75-year-old female who presented with 3-week history of nausea, vomiting and diffuse abdominal pain. On physical exam, her abdomen was distended and tender in the RUQ. CT scan of the abdomen and pelvis revealed marked dilation of the stomach with fluid, pneumobilia, and poor gallbladder visualization. The patient had no history of an abdominal surgery or ERCP. EGD showed Grade D esophagitis, excessive fluid in stomach and a large ulcerated area in second part of duodenum. Biopsies were negative for malignancy. A PET scan was suggestive of acute cholecystitis versus a cholocystoenteric fistula or malignancy. Repeat EGD a week later showed total resolution of the ulcerated area in the duodenum. EUS revealed peri-pancreatic inflammation and poor visualization of the gallbladder. Repeat CT scan revealed dilated proximal jejunal small bowel loops with transition zone and a 1.5 cm rounded structure in the jejunum. Patient was thought to have chronic cholecystitis causing perforation of the gallbladder with formation of a cholecystoenteric fistula resulting in gallstone impaction and small bowel obstruction. She underwent laparoscopic small bowel enterotomy with removal of gallstones from distal jejunum and proximal ileum. Patient slowly began eating and was discharged with uneventful post-operative course.Figure 1Figure 2Discussion: Bouveret syndrome is a rare cause of gastric outlet obstruction. It is a variant of gallstone ileus resulting in gastroduodenal obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The average size is 4.6 cm compared to 2.5 cm for gallstone ileus. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test is EGD although CT scan, abdominal ultrasound and plain X-ray can be very helpful. Rigler's triad of pneumobilia, an ectopic gallstone, and dilated small bowel on abdominal x-ray is classic but is only seen in 30-35 % of cases. Classic CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. Although the gastric outlet obstruction is almost always seen on EGD, the obstructing gallstone is seen only in 69 % of cases. Our patient, initially, presented with Bouveret's syndrome which then complicated by gallstone ileus. She was found to have several large stones causing her small bowel obstruction. Treatment options are endoscopic, open surgery or laparoscopic removal of the stones.

An Unusual Cause of Intestinal Obstruction in a Young Female

We describe a case of a 61-year-old Caucasian man who presented to the emergency department because of severe periumbilical pain associated with nausea and vomiting. On examination, there was gross...

Pneumatosis cystoides intestinalis (PCI) is a rare condition for which autopsy studies have reported a prevalence of 0.03% in the general population. Although PCI can be associated with pneumoperitoneum, many cases are benign and do not reflect viscus perforation. Coexistence with tuberculous pleurisy and recurrent pneumoperitoneum is rare and may be underrecognized. In this report, we present the case of a 38-year-old Tibetan male who experienced tuberculous pleurisy accompanied by recurrent pneumoperitoneum with PCI. Despite the presence of free air, he remained minimally symptomatic. Comprehensive imaging failed to reveal evidence of intestinal perforation, ischemia, or necrosis. Consequently, a nonoperative management strategy was successfully employed, leading to the patient's recovery and discharge. The patient denied any clinical symptoms other than mild abdominal distension. Computed tomography demonstrated PCI involving the transverse colon and hepatic flexure with scattered intraperitoneal free air and no evidence of perforation, ischemia, or necrosis. Nonoperative management comprised close hemodynamic and abdominal monitoring, bowel rest, low-flow oxygen, and scheduled computed tomography reexamination. Standard antituberculosis therapy was continued. In our case, recurrent benign pneumoperitoneum improved with conservative care alone, supporting a standardized, threshold-based, individualized nonoperative approach with ongoing surveillance. Clinically stable PCI patients with pneumoperitoneum and no radiologic or clinical signs of perforation, ischemia, or necrosis are best managed nonoperatively; surgery is reserved for high-risk features. Pneumoperitoneum secondary to PCI is often benign, may not require surgical intervention, and can recur. Tuberculous pleurisy may contribute to PCI with pneumoperitoneum via altered thoracoabdominal pressures. Characteristic computed tomographic findings are instrumental in recognizing PCI and distinguishing it from other causes of pneumoperitoneum.

Cricket Ball, Rectum Foreign Body: Case Report And Review Of The Literatures

Introduction. Pneumatosis intestinalis (PI) is an uncommon pathology characterised by the presence of gas within the intestinal wall. It has been associated with various conditions, including connective tissue diseases. This is the first report of PI being the initial presentation of systemic sclerosis. Case Presentation. The patient, a 75-year-old female, presented with an 8-month history of worsening dysphagia and epigastric pain, as well as other nonspecific symptoms. Initial investigations with an oesophagogastroduodenoscopy diagnosed Candida oesophagitis and also identified an extrinsic compression of the gastric antrum. Subsequently a CT scan of the abdomen and pelvis showed moderately dilated small bowel loops and PI. Due to the patient's stability, non-critical clinical condition, conservative management was instituted. More detailed investigations confirmed the diagnosis of systemic sclerosis with positive anticentromeric and antinuclear antibodies. The patient improved on methotrexate and was discharged with appropriate outpatient follow-up. Discussion. PI is a rare but well-documented pathology associated with connective tissue diseases, such as systemic sclerosis. In most cases, conservative management is preferable to surgical intervention, depending on the patient's clinical presentation and progress. This is the first report of PI being the initial presentation of a patient with systemic sclerosis responsive to conservative management.

BackgroundAcute abdomen is a medical emergency with a wide spectrum of etiologies. Point-of-care ultrasound (POCUS) can help in early identification and management of the causes. The ACUTE–ABDOMEN protocol was created by the authors to aid in the evaluation of acute abdominal pain using a systematic sonographic approach, integrating the same core ultrasound techniques already in use—into one mnemonic. This mnemonic ACUTE means: A: abdominal aortic aneurysm; C: collapsed inferior vena cava; U: ulcer (perforated viscus); T: trauma (free fluid); E: ectopic pregnancy, followed by ABDOMEN which stands: A: appendicitis; B: biliary tract; D: distended bowel loop; O: obstructive uropathy; Men: testicular torsion/Women: ovarian torsion. The article discusses two cases of abdominal pain the diagnosis and management of which were directed and expedited as a result of using the ACUTE–ABDOMEN protocol. The first case was of a 33-year-old male, who presented with a 3-day history of abdominal pain, vomiting and constipation. Physical exam revealed a soft abdomen with generalized tenderness and normal bowel sounds. Laboratory tests were normal. A bedside ultrasound done using the ACUTE–ABDOMEN protocol showed signs of intussusception. This was confirmed by CT-abdomen. The second case was of a 70-year-old female, a known case of diabetes and hypertension, who presented with a 3-hour history of abdominal pain, vomiting and diarrhea. She had a normal physical exam and laboratory studies. Her symptoms mimicking simple gastroenteritis had improved. However, bedside ultrasound, using the ACUTE–ABDOMEN protocol showed localized free fluid with dilated small bowel loop in right lower quadrant with absent peristalsis. A CT abdomen confirmed a diagnosis of intestinal obstruction. These two cases demonstrate that the usefulness of applying POCUS in a systematic method—like the “ACUTE–ABDOMEN” approach—can aid in patient diagnosis and management.Case presentationWe are presenting two cases of undifferentiated acute abdomen pain, where ACUTE ABDOMEN sonographic approach was applied and facilitated the accurate patient management and disposition.ConclusionACUTE ABDOMEN sonographic approach in acute abdomen can play an important role in ruling out critical diagnosis, and can guide emergency physician or any critical care physician in patient management.

Internal hernia is a rare condition. We report a case where computed tomography (CT) demonstrated a saclike encapsulation of small bowel loops which suggested a diagnosis of internal hernia. A 76-year-old woman presented with abdominal pain and vomiting. Ultrasound examination revealed a 10 cm heterogenous mass posterior to the bladder, close to the ovaries, associated with bilateral hydronephrosis affecting mainly the left side. Contrast-enhanced CT showed a large pelvic mass Fig. 1), behind the bladder, of fluid density and containing septations. The appearance suggested dilated loops of small bowel. Both ureters were dilated, and a plain film of the abdomen 24 h after injection of contrast medium (Fig. 2) showed marked left hydronephrosis and less severe dilatation the right renal tract. Forty-eight hours after injection Fig. 3) the left ureter was still opacified. At laparotomy a cluster of dilated and congested loops of small bowel were found posterior to the bladder and these were strangulated in the pouch of Douglas. Resection of 50 cm of ileum was necessary, following which the patient made a full recovery.

INTRODUCTION: Fever, cough and shortness of breath have become the classic COVID-19 symptoms. But, abdominal symptoms; pain, diarrhea, and vomiting, should alert for possible COVID-19 infection, in addition to respiratory symptoms. We are present a case of a young man who presented with intestinal obstruction without respiratory symptoms who tested positive for COVID-19. CASE DESCRIPTION/METHODS: A 30-year-old male presented with abdominal pain, distension, and absolute constipation for two days. He had severe epigastric & Right upper quadrant crampy pains associated with nausea and few episodes of vomiting, but denied any diarrhea, fever, chills or shortness of breath. He has no known medical history. His blood pressure was 120/66 mmHg, pulse was 107 BPM, and body temperature was 37.5°C and the oxygen saturation was 97% on room air. Abdomen was diffusely tender with no rebound tenderness or guarding and bowel sounds were noted in all four quadrants. Leukocyte count was 8300/μL, CRP was 4.0 mg/dL, and LDH was 166 units/L, while the rest of the hemogram and metabolic panel were within normal range. Because of nausea and vomiting, he was tested for COVID-19. RT-PCR testing confirmed COVID-19 infection. The chest X-ray was normal, while the abdominal X-ray revealed dilated loops of small bowel suggesting ileus or small bowel obstruction. Non-contrast abdominal CT showed Fluid-filled distended stomach and proximal small bowel with Transition to normal caliber small bowels in the right lower quadrant, suggestive of a partial small bowel obstruction without perforation or pneumatosis intestinalis. Conservative management with NG tube suction, IV fluid, and pain control was followed by rapid symptom resolution. On the second day of admission after a small bowel follow through test showed no obstruction, he tolerated diet and was discharged to home for self-quarantine. DISCUSSION: It's important to maintain a level of suspicion of COVID-19 infection in the setting of abdominal symptoms. Anorexia, nausea, and diarrhea have been increasingly reported with this novel illness. However, it is even more important to not have a false sense of security whenever intestinal obstruction is the presenting symptoms, especially in a young otherwise healthy person. Although GI presentation takes the form for anorexia, nausea, and diarrhea in COVID-19 infection, small bowel obstruction can rarely be the only presenting finding for COVID-19 infection.Figure 1.: Axial CT scan through the lower abdomen shows multiple fluid-filled and dilated loops of small bowel.Figure 2.: Plain film of the abdomen.

Adult intussusception (AI) following blunt abdominal trauma (BAT) is a rare surgical condition. We present a case of delayed diagnosis of ileocecal junction intussusception with a perforation of small bowel in a 34-year-old male with a history of fall from height. Initial exploratory laparotomy revealed shattered spleen requiring splenectomy. Initial abdominal computerized tomography scanning (CT) scan showed dilated small bowel with no organic obstruction. Patient started to improve with partial distention and was shifted to rehabilitation unit. On the next day, he experienced severe abdominal distention and vomiting. Abdominal CT showed characteristic intussusception at the distal ileum. Secondary exploratory laparotomy revealed severe adhesions of stomach and small bowel to the anterior abdominal wall with dilated small bowel loops and intussusception near the ileocecal junction with perforation of small bowel. The affected area was resected and side-to-side stapled anastomosis was performed. Though small bowel intussusception is a rare event, BAT patients with delayed symptoms of bowel obstruction should be carefully evaluated for missed intussusception.

INTRODUCTION: Portal venous gas is a rare radiological finding that demonstrates the accumulation of gas in the portal vein and its branches. It is associated with multiple pathological conditions some of which have grave prognosis and need immediate intervention. We report a case in which extensive gas was found within the hepatic portal venous and mesenteric vessels in a patient with gastric distention secondary to a bezoar. CASE DESCRIPTION/METHODS: The patient was a 53 year old male with a history of schizophrenia, maintained on psychiatric medications, who presented with complaints of vomiting and abdominal pain after binging hot dogs. Patient was found to be hypotensive, tachycardia and anemic. There was no blood noted on the rectal exam but NGT lavage produced large amounts of coffee grounds. CT abdomen displayed a distended stomach, extensive portal venous air, foci of air in multiple mesenteric vessels with dilated small bowel loops (C). Patient underwent a diagnostic laparoscopy which showed viable bowel without ischemia or incarceration. Subsequent EGD performed for hematemesis showed an ulcerating mass lesion starting in the cardia and extending into the gastric fundus (A). Biopsy revealed squamous epithelium with food particles and without malignant cells. Of note, the patient had an EGD two months prior and no mass was noted. Patient symptoms improved with NGT decompression and metoclopramide. Repeat CT showed complete resolution of previous findings (D) while repeat EGD revealed no mass lesion. With gastric distention and motility improvement all of the patients concerning findings had resolved. DISCUSSION: It has been postulated that disruption in mucosal integrity, intraluminal pressure and intestinal microflora contribute to the pathogenesis of hepatic venous gas. It is most commonly associated with bowel necrosis and very few case reports exist of a bezoar causing such findings. Bezoars can cause gastrointestinal complications like bleeding, gastric outlet obstruction or perforation. Our patient was on psychiatric medications which is known to cause slowing of gastric motility thus leading to the development of the gastric bezoar and gastric dilation. We believe that this resulted in an increase in intra-luminal pressure thus leading to the development of hepatic portal venous and mesenteric gas. This case illustrates not only how a bezoar can lead to bleeding and diffuse portal venous air but how history and prior records can help avoid unnecessary work up.Figure 1.: Ulcerating mass lesion starting in the cardia and extending into the gastric fundus.Figure 2.: Extensive portal venous air, foci of air in multiple mesenteric vessels with dilated small bowel loops.Figure 3.: Complete resolution of air in the portal and mesenteric vessels after disappearance of mass in the cardia.

An acute abdomen is a complex case with multiple possible etiologies and requires the help of many different disciplines. We present the case of a two-year-old female who presented to the emergency department in acute distress, pale in complexion, and continuously guarding her abdomen. Physical examination revealed a distended, rigid abdomen with tenderness to palpation of the abdomen in all four quadrants. A computed tomography scan illustrated markedly dilated loops of small bowel but unclear etiology of obstruction with no evidence of perforation. Stat diagnostic laparotomy showed a strangulated internal hernia secondary to a congenital mesenteric defect. The mesenteric defect was repaired laparoscopically, and 25 cm of necrotic bowel was resected with an end-to-end anastomosis. Internal hernias secondary to mesenteric defects are the most common forms of internal hernias in pediatric patients and present with a 100% mortality rate if left untreated. This case illustrates the importance of a high index of suspicion, thorough physical examination, prompt diagnosis, and treatment in preventing a fatal outcome in these patients.