Acute Small Bowel Research Articles

Novel variant of reversed midgut rotation \u2013 retro-arterial proximal jejunum and transverse colon: a case report and review of the literature

BackgroundReversed rotation of the midgut is the rarest variation of midgut malrotations, which are congenital disorders that result from aberrant rotation and fixation of the midgut during embryological development. Common complications of these disorders are small bowel obstruction by volvulus or peritoneal bands, usually occurring in early infancy.Case presentationA 23-year-old Caucasian woman presented with recurrent abdominal pain. A contrast-enhanced multidetector computed tomography study revealed a novel variant of reversed rotation of the midgut. Besides the specific finding of a retro-arterial transverse colon, we also found the proximal jejunum to cross posterior to the mesenteric root, a variation that has not been reported in the literature so far. In this case, substantial symptomatic relief was achieved with conservative management.ConclusionsThe hypothesis of a double reversed rotation of the pre-arterial segment of the umbilical loop around the superior mesenteric artery axis provides a possible explanation for this anomaly. There is no evidence-based consensus on the management of patients presenting with non-symptomatic or mildly symptomatic intestinal malrotations. In this case, radiologic and clinical presentations excluded acute small bowel obstruction, and surgical intervention was avoided.

CT Findings of Acute Small-Bowel Entities

Although a broad spectrum of entities can induce acute pathologic changes in the small bowel, there are relatively few imaging features that are characteristic of a specific diagnosis on the basis of CT findings. Specific clinical information, including time course and onset of disease, patient risk factors, and any recent pharmacologic or radiation therapy, is often instrumental in refining the differential diagnosis. A wide spectrum of disorders is reviewed in this article; however, given the breadth of disorders associated with the small bowel, neoplastic and infectious conditions affecting the small bowel that can manifest acutely are not specifically discussed. Vascular diseases that can affect the small bowel regionally or diffusely, including thromboembolic and hypoperfusion phenomena, as well as a spectrum of vasculitides, are reviewed. Iatrogenic causes of small bowel disorders are discussed, including angiotensin-converting enzyme inhibitor-induced angioedema, and chemotherapy- and radiation therapy-associated patterns of disease. Autoimmune and hereditary conditions that can affect the small bowel, including systemic lupus erythematosus and genetic C1 esterase inhibitor deficiency, respectively, are reviewed. ©RSNA, 2018.

Small bowel obstruction with gallstone. Case report

Clinical case study of a cholelithiasis rare complication — gallstone small bowel obstruction with cholecystoduodenal fistula has been presented. According to several studies, the frequency of gallstone small bowel obstruction is approximately 0.3 to 4 % of all cases of small bowel obstruction, and 0.2 to 0.6 % of patients with cholelithiasis. A patient at the age of 69 years, was admitted to the surgical department in urgently 07.11.2017 with the diagnosis of acute gallstone small bowel obstruction. The diagnosis was based on complaints, anamnesis, clinical signs, additional imaging methods (radiography and ultrasound examination of the abdominal cavity organs). The patient was operated urgently. In the lumen of the small intestine at a distance of 120 cm from the Treitz ligament a concrement up to 33 × 26 mm was found, proximal to the concrement the loops of the small intestine were expanded to 42 mm, filled with intestinal contents and gas, distal to the concrement, the small intestine collapsed. The dense infiltrate up to 6 × 4 cm, involving the gallbladder and duodenum was visualized during operation in the subhepatic space. There was no bile and intestinal content leakage in the infiltration area. Enterotomy, lithoextraction, enterorrhaphia were performed. Dissociation of the cholecystoduodenal fistula was not performed due to the severity of the patient’s condition and the presence of small bowel obstruction. The postoperative period was without complications. The patient was discharged in a satisfactory condition. An ultrasound examination of the abdominal cavity organs allowed to diagnose this pathology before the operation, demonstrating high sensitivity and specificity of the method.

Analysis of Related Factors in Elderly Patients with Strangulated Small Bowel Obstruction

Objective To investigate the surgery-related factors of strangulated small bowel obstruction in the elderly patients. Methods The clinical data of 261 elderly patients with acute small bowel obstruction treated between July 2010 and September 2016 were analyzed retrospectively. Differences of clinical data,laboratory Results ,and CT findings were compared between the elderly strangulation group(ESt group,n=139)and the elderly simple group (ESi group,n=122). The surgery-related factors of strangulated small bowel obstruction in the elderly were analyzed by univariate and multivariate Logistic regression analysis. Results The ESt group and the ESi group showed significant differences in factors including muscle guarding (χ2=102.331,P=0.000),American Society of Anesthesiologists(ASA) score≥3 (χ2=69.748,P=0.000),leukocyte count (t=7.453,P=0.000),C-reactive protein (t=2.128,P=0.034),segmental mesenteric fluid (χ2=78.655,P=0.000),thick-walled small bowel (χ2=100.806,P=0.000),intestinal wall of hyperattenuation (χ2=69.068,P=0.000),ascites (χ2=89.299,P=0.000),mesenteric fat stranding (χ2=80.255,P=0.000),bird's beak sign (χ2=84.451,P=0.000),and stranding sign (χ2=98.635,P=0.000). Univariate regression analysis indicated the above 11 factors were the surgery-related factors in elderly patients with strangulated small bowel obstruction. Multivariate Logistic regression analysis showed that the surgery-related factors included segmental mesenteric fluid (OR=3.576,95%CI:1.043-12.261,P=0.043),ASA score≥3 (OR=3.463,95%CI:1.149-10.441,P=0.027),muscle guarding (OR=3.288,95%CI:1.010-10.707,P=0.048),thick-walled small bowel (OR=3.046,95%CI:1.074-8.638,P=0.036),and increased leukocyte count (OR=1.307,95%CI:1.170-1.458,P=0.000). Conclusion Muscle guarding,ASA score≥3,segmental mesenteric fluid,thick-walled small bowel,and increased leukocyte count are the surgery-related factors of strangulated small bowel obstruction in the elderly patients.

Роль надпочечников в механизмах стрессорного влияния на патогенез развития осложнений при острой тонкокишечной непроходимости (обзор)

Роль надпочечников в механизмах стрессорного влияния на патогенез развития осложнений при острой тонкокишечной непроходимости (обзор)

Morphofunctional Changes of Blood Supply and the Glycogen Content in the Liver during Acute Strangulational Small Bowel Obstruction

Morphofunctional Changes of Blood Supply and the Glycogen Content in the Liver during Acute Strangulational Small Bowel Obstruction

Rapunzel syndrome: a tail too long to tell!

Trichobezoar leading to Rapunzel syndrome (RS) is an extremely rare entity with about 90 cases reported in literature.1 RS derives its name from the fairy tale ‘Rapunzel’, where the German...

Особливості бактеріальної контамінації перитонеуму та кишки при різних стадіях гострої злукової тонкокишкової непрохідності та її корекції

Мета дослідження: з’ясувати особливості бактеріальної контамінації перитонеуму та кишки при різних стадіях гострої злукової тонкокишкової непрохідності та її корекції.Матеріали і методи. Обстежено та прооперовано 152 хворі на гостру злукову тонкокишкову непрохідність. З них 58 (38,2 %) пацієнтів були в стадії компенсації та 94 (61,8 %) пацієнтів – у стадії декомпенсації. З метою вивчення рівня бактеріальної транслокації виконували бакпосів виділень із дренажів та назогастроінтестинального (НГІ) зонда в динаміці лікування у післяопераційному періоді.Результати досліджень та їх обговорення. У роботі вивчено кількісний і якісний склад мікрофлори тонкої кишки та перитонеального ексудату під впливом комплексного лікування із застосуванням лаважу кишечника 0,9 % розчином натрію хлориду в поєднанні з оксигенотерапією та ентеральним харчуванням розчином «Пептамен» у хворих на гостру злукову тонкокишкову непрохідність у стадії компенсації та декомпенсації. Виявлено меншу колонізацію кишечника та контамінацію черевної порожнини кишковою паличкою, умовно-патогенними мікроорганізмами, та більш швидке відновлення біоценозу тонкої кишки при застосуванні розробленого комплексу заходів дозволило знизити рівень післяопераційних ускладнень та летальності.

Small bowel obstruction due to dried fruit and vegetable bezoars in paediatric patients of northern India.

Introduction: Many foods have been implicated in bezoar obstruction especially sun dried apricots, peaches, and prunes. Dried fruits and vegetable being hygroscopic imbibe water, swell in size and cause mechanical small bowel obstruction. We hereby submit our experience of dealing with patients who presented with acute small bowel obstruction (ASBO) due to dried phytobezoars.
 Materials and methods: This was a retrospective study which was conducted from March 2017 to March 2012. Operative records of the patients with ASBO due to phytobezoars were retrieved from Hospital Records Section. The clinical details, investigative work up, operative findings and intervention and type of bezoars were noted.
 Results: Over the period of 5 years, 12 patients of phytobezoars were admitted in the department. The mean age of the patients was 1.85 years with 7(58.3%) males and 5 females (41.6.5%). Vomiting was most common and was present in all the patients, bilious in 11 (91.7%). The other features included abdominal pain in 10 (83.3%), abdominal distension in 8 (66.7%), failure to pass stools in 9 (75%), failure to pass flatus in 9 (75%), diarrhoea 16 (25%), bleeding per rectum 2 (16.6% patients). All the patients were operated in emergency settings within the period of 8 ± 3 hours of admission. There were no significant operative complications and average hospital stay was 5.2±1 days.
 Conclusion: Dry fruits and vegetables like apricot, turnip and peach can lead to bezoar formation which subsequently leads to acute small bowel obstruction in these infants and young children. We also want to impress upon the treating physicians to keep in mind the probability of phytobezoars obstruction in patients presenting with mechanical ASBO especially in patients from Himalayan regions.

Optimal time of surgery for acute adhesive small bowel obstruction

To define optimal terms of surgery for acute adhesive non-strangulatory small bowel obstruction. The analysis included 703 publications from e-LIBRARI.RU (342 works) and NCBI (361 works) databases for acute adhesive intestinal obstruction. The vast majority of articles presented retrospective analysis of single-center experience. It has been established that short course of medication is predominantly used for acute adhesive intestinal obstruction in the Russian Federation. International studies point 2-5 days for conservative treatment. The advantages and disadvantages of short and long courses of medication were analyzed. Therefore, multicenter, prospective, randomized trial 'Comparison of early operative treatment (12-hour medication) and long-term conservative treatment (48 hours) for acute adhesive small bowel obstruction' (COTACSO) was planned and registered (Unique Protocol ID: 14121729). The study protocol involves clinical, laboratory and instrumental exclusion of strangulation, randomization and conservative treatment of 2 groups of patients for 12 and 48 hours. Patients will undergo surgical interventions if obstruction will be present by that date. The main endpoint is mortality rate in both groups. The end of the study is December 2020.

Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department.

Emergency physicians frequently encounter patients with acute small bowel obstructions (SBO). Although computed tomography (CT) imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. We evaluated the accuracy of ultrasound performed in the ED by a variety of providers (physicians with various levels of training, physician assistants) compared to CT imaging in 47 patients with suspected SBOs. Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. Ultrasound can play an important role in the identification of small bowel obstructions in ED patients.

A rare cause of small bowel obstruction which should always be considered

Introduction Appendicitis has been known to cause acute small bowel obstruction through mechanical and physiological interactions with the ileum. Here a 52 year old male, who, following 3 days of lower abdominal pain, bowels not having opened and vomiting was found on computed tomography (CT) scan to have a mechanical small bowel obstruction. This was operated on via lower midline laparotomy and adhesiolysis. An inflamed appendix was found to have wrapped itself around the terminal ileum causing a focal stricture. After appendectomy the patient was discharged 6 days later and made a full recovery. Case description A 52 year old man with a past history of GORD, hypertension and peripheral vascular disease (with aorto-bifemoral bypass) was admitted onto our Surgical Triage Unit (STU) at 22:10 on a Thursday evening. He complained of a 3 day history of illness consisting of cramping lower abdominal pain, bowels not having opened and recurrent bilious vomiting. Results and Conclusions An urgent CT scan reported “High grade small bowel obstruction, with change of calibre in the distal ileum. This may be secondary to adhesions (previous bilateral femoral bypass) or internal hernia. Incidentally, the appendix also looks inflamed. No perforation or intra-abdominal collections.” At laparotomy, the appendix was inflamed with free pus in the peritoneal cavity and dilated small bowel loops in the vicinity. On closer inspection it could be seen that the inflamed appendix had wrapped itself around the terminal ileum stenosing its lumen and causing the small bowel obstruction. Take home message • Always consider a concurrent appendicitis in cases of small bowel obstruction • Do not exclude an appendicitis in cases of left sided abdominal pain as was the case here • If suspected consider performing computed tomography before proceeding to surgery • The co-existence of these two pathologies may alter operative approach

Anatomical Road Mapping Using CT and MR Enterography for Ultrasound Molecular Imaging of Small Bowel Inflammation in Swine.

To evaluate the feasibility and time saving of fusing CT and MR enterography with ultrasound for ultrasound molecular imaging (USMI) of inflammation in an acute small bowel inflammation of swine. Nine swine with ileitis were scanned with either CT (n = 3) or MR (n = 6) enterography. Imaging times to load CT/MR images onto a clinical ultrasound machine, fuse them to ultrasound with an anatomical landmark-based approach, and identify ileitis were compared to the imaging times without anatomical road mapping. Inflammation was then assessed by USMI using dual selectin-targeted (MBSelectin) and control (MBControl) contrast agents in diseased and healthy control bowel segments, followed by ex vivo histology. Cross-sectional image fusion with ultrasound was feasible with an alignment error of 13.9 ± 9.7 mm. Anatomical road mapping significantly reduced (P < 0.001) scanning times by 40%. Localising ileitis was achieved within 1.0 min. Subsequently performed USMI demonstrated significantly (P < 0.001) higher imaging signal using MBSelectin compared to MBControl and histology confirmed a significantly higher inflammation score (P = 0.006) and P- and E-selectin expression (P ≤ 0.02) in inflamed vs. healthy bowel. Fusion of CT and MR enterography data sets with ultrasound in real time is feasible and allows rapid anatomical localisation of ileitis for subsequent quantification of inflammation using USMI. • Real-time fusion of CT/MRI with ultrasound to localise ileitis is feasible. • Anatomical road mapping using CT/MRI significantly decreases the scanning time for USMI. • USMI allows quantification of inflammation in swine, verified with ex vivo histology.

Target tailoring and proton beam therapy to reduce small bowel dose in cervical cancer radiotherapy

PurposeThe aim of the study was to investigate the potential clinical benefit from both target tailoring by excluding the tumour-free proximal part of the uterus during image-guided adaptive radiotherapy (IGART) and improved dose conformity based on intensity-modulated proton therapy (IMPT).MethodsThe study included planning CTs from 11 previously treated patients with cervical cancer with a >4-cm tumour-free part of the proximal uterus on diagnostic magnetic resonance imaging (MRI). IGART and robustly optimised IMPT plans were generated for both conventional target volumes and for MRI-based target tailoring (where the non-invaded proximal part of the uterus was excluded), yielding four treatment plans per patient. For each plan, the V15Gy, V30Gy, V45Gy and Dmean for bladder, sigmoid, rectum and bowel bag were compared, and the normal tissue complication probability (NTCP) for ≥grade 2 acute small bowel toxicity was calculated.ResultsBoth IMPT and MRI-based target tailoring resulted in significant reductions in V15Gy, V30Gy, V45Gy and Dmean for bladder and small bowel. IMPT reduced the NTCP for small bowel toxicity from 25% to 18%; this was further reduced to 9% when combined with MRI-based target tailoring. In four of the 11 patients (36%), NTCP reductions of >10% were estimated by IMPT, and in six of the 11 patients (55%) when combined with MRI-based target tailoring. This >10% NTCP reduction was expected if the V45Gy for bowel bag was >275 cm3 and >200 cm3, respectively, during standard IGART alone.ConclusionsIn patients with cervical cancer, both proton therapy and MRI-based target tailoring lead to a significant reduction in the dose to surrounding organs at risk and small bowel toxicity.

Abdominal cocoon, a rare cause of intestinal obstruction: a case report and literature review

Abdominal cocoon syndrome or sclerosing encapsulating peritonitis is a rare condition that indicates that a part or whole small bowel is encased in a fibro collagenous membrane or cocoon leading to acute or chronic bowel obstruction. Approximately 50 cases have been reported in literature. Patients usually present with a picture of bowel obstruction and most cases are diagnosed during laparotomy. Herein, we present a 31 years old Indian male presented with symptoms and signs of acute small bowel obstruction that proved to be due to an abdominal cocoon intraoperatively. Our patient underwent resection with stapled side to side anastomosis. He was readmitted again with a single intraperitoneal collection; near the anastomotic site; that was managed percutaneously. He was discharged in a good condition and was seen later in the surgery clinic free of symptoms. Early diagnosis with radiological guidance and surgical intervention may reduce morbidity of the condition.

Large intra-abdominal dermoid cyst presenting as small bowel volvulus

Intestinal obstruction is one of the commonest abdominal emergencies requiring surgical intervention. Among its numerous causes, volvulus of the small and large bowel plays a less common aetiological role. This is a rare case of a large intra-abdominal dermoid cyst causing small bowel volvulus and presenting as obstruction. 46-year-old male presented with four-day history suggestive of acute small bowel obstruction, with gross abdominal distension on examination. With minimal investigations, he was explored to reveal a large 10×8 cm sized cystic mass in lower abdomen, with two vascular pedicles causing twisting of small bowel and resultant obstruction. Surgical intervention included unwinding of viable bowel, dividing pedicles and excision of the mass. The cyst was found to contain pultaceous material with hair and solid components. Patient tolerated the procedure well and was asymptomatic on discharge and subsequent follow-ups. This case illustrates an uncommon cause of a common presentation; an uncommon location of a relatively common cystic swelling; and the diagnostic surprise that was encountered during the management, thereby reiterating the need for keen observation and clinical acumen while dealing with such cases.

Nasogastric decompression not associated with a reduction in surgery or bowel ischemia for acute small bowel obstruction

ObjectivesSmall bowel obstructions (SBOs) occur 300,000 times annually leading to $1.3 billion in cost. Approximately 20% of patients require a laparotomy to manage the obstruction and either prevent or treat intestinal ischemia. Early management may play a role in reducing these complications. Nasogastric decompression is commonly used for early management. Our primary objective was to determine if NGD was associated with lower rates of surgery, bowel ischemia or length of stay. MethodsWe retrospectively enrolled 181 ED patients with SBO from 9/2013 to 9/2015 in order to determine if nasogastric decompression was associated with a reduction in rates of surgery, bowel ischemia or hospital length of stay. ResultsOur subject population was 46% female, median age of 60.27% of patients received surgery. Nasogastric decompression was used in 51% of patients. There was no association with a reduction in rates of surgery (p=0.20) or bowel resection (p=0.41) with patients receiving Nasogastric decompression, and no difference in baseline characteristics. Nasogastric decompression was associated with a two-day increase in hospital length of stay. Factors that were significantly associated with surgical exploration of SBO were: female (OR 2.32 (95% CI: 1.01–5.31)) and “definite SBO” on CT (OR 3.29 (95% CI: 1.18–9.20)). Abnormal vital signs, obstipation, and lab values were not predictors of surgery. ConclusionNasogastric decompression is not associated with a reduction in need for surgery or bowel resection, but is associated with a 2-day increase in median LOS. Women were more likely to receive surgery than men.

Migration of eroded laparoscopic adjustable gastric band causing small bowel obstruction and perforation

We present an unusual and rare complication caused by gastric band erosion into the stomach after band placement 15 years ago. The complication was only picked up after the band...

Acute small bowel obstruction caused by barbed suture on the second day after laparoscopic hysterosacropexy: A case report and literature review

ObjectiveTo report a case of small bowel obstruction caused by barbed suture applied in hysterosacropexy, and possible solutions. Case ReportA 57-year-old woman underwent laparoscopic hysterosacropexy for a Stage 2 uterine prolapse, presenting with acute abdominal pain and a bowel obstruction syndrome 2 days following the surgery. Conservative treatment was given, but the symptoms did not improve and gradually became worse. Diagnostic laparoscopy was performed on the 7th day after the hysterosacropexy, and the volvulus was found. The residual end of the barbed V-Loc adopted in the peritoneal closure was incidentally hooked to the mesentery and caused small bowel obstruction. The redundant V-Loc was released and cut off at 2 cm. Neither bowel ischemia nor significant bowel injury was noted. Two days later, she was discharged without complication. ConclusionA barbed suture has a risk of bowel obstruction when used in surgery. To avoid a grave prognosis, early diagnosis and prompt management of complication is necessary.

Imaging Evidence Demonstrating Effectiveness of Osteopathic Visceral Manipulation Techniques in Treating Pseudo-Obstruction

Abstract This report describes the case of a 66-year-old afebrile woman seen on the hospital inpatient service with nausea, vomiting, bloating, and constipation for 5 days prior to admission. The patient was diagnosed with idiopathic acute small bowel pseudo-obstruction by gastroenterology. The epidemiology of acute small-bowel pseudo-obstruction is briefly reviewed. Osteopathic manipulative treatment (OMT) was performed on the patient using mostly abdominal and visceral manipulation techniques. This case represents the first report of imaging evidence that demonstrates the effectiveness of osteopathic visceral manipulation techniques in successfully treating patients who have acute intestinal pseudo-obstruction.