Bilious Vomiting in a Neonate: A Diagnostic Challenge.

Abdominal cocoon syndrome, or idiopathic sclerosing encapsulating peritonitis (SEP), is an uncommon cause of small bowel obstruction marked by the encasement of bowel loops within a dense fibrocollagenous membrane. Due to its rarity and nonspecific presentation, diagnosis is frequently delayed, particularly in patients without prior abdominal surgery or known risk factors. We report a diagnostically challenging case of a 53-year-old male with an 18-month history of recurrent gastrointestinal obstruction, including bilious vomiting, oral intolerance, and epigastric pain. Multiple prior evaluations yielded inconclusive findings. Contrast-enhanced computed tomography raised suspicion for SEP, prompting exploratory laparotomy. Intraoperative findings confirmed SEP, along with a rare anatomical anomaly-hypoplasia of the greater omentum. Surgical excision of the encasing membrane and adhesiolysis resulted in complete symptom resolution, with no recurrence at six-month follow-up. This case underscores the importance of clinical vigilance in recognizing abdominal cocoon syndrome and highlights the first reported co-occurrence of SEP with greater omental hypoplasia. Surgical exploration not only confirmed the diagnosis but also achieved full recovery. The embryologic implications of omental hypoplasia may offer new insights into SEP pathophysiology and merit further investigation.

Cholecystoenteric fistulas are uncommon complications of chronic gallstone disease and may present insidiously, leading to delayed diagnosis. We describe a male patient in his early 70s who developed biliary ileus secondary to a cholecystoduodenal fistula, initially manifesting as right upper quadrant pain, bilious vomiting and progressive oral intolerance. CT imaging demonstrated pneumobilia, a large ectopic gallstone and small-bowel obstruction consistent with Rigler's triad. At laparotomy, he underwent partial cholecystectomy, closure of the duodenal defect, pyloric exclusion and decompressive procedures; however, an enteric leak required reoperation with omental patch repair, gastrojejunostomy and enterolithotomy. His recovery was complicated by intra-abdominal sepsis and ventilator-associated pneumonia but improved with intensive care management.This case highlights the diagnostic challenge of gallstone ileus from cholecystoduodenal fistula and the need for prompt CT evaluation and flexible, staged surgical decision-making in patients with significant inflammation or postoperative complications.

Presumed septic shock from small-bowel obstruction due to a vitellointestinal remnant in a 12-year-old: successful surgical management – a case report

Introduction: Pediatric pancreatic injury isuncommon but carries significant morbidity. While non-operative management is standard for low-grade injuries, the optimal approach for high-grade trauma (AAST grade III–V) remains debated. Pancreaticoduodenectomy (Whipple procedure) is rarely performed due to high procedural risks and is typically reserved for severe pancreatic head injury with concomitant duodenal damage. Case presentations: A 13-year-old boy presented three days after blunt abdominal trauma with epigastric pain and bilious vomiting. CT imaging revealed free fluid, a large retroperitoneal hematoma, and suspected pancreatic head injury. Despite initial stability and conservative management in the High Care Unit, worsening abdominal distension prompted an exploratory laparotomy. Discussion: Surgery revealed pancreatic head laceration and duodenal tears. Consequently, a pancreaticoduodenectomy with pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy wasperformed. The patient recovered steadily, resumed oral intake at two weeks, and was discharged in good condition. At the one-year follow-up, he remained asymptomatic and had resumed normal activities. Conclusion. This case demonstrates that pancreaticoduodenectomy is a definitive option for stable pediatric patients with high-grade pancreatic head and duodenal injuries when local reconstruction is unfeasible. However, due to its complexity, it should remain a last-resort strategy reserved for specialized hepatopancreatobiliary centers.

Patient: Female, 33-year-oldFinal Diagnosis: Internal herniaSymptoms: Abdominal pain nausea vomitingClinical Procedure: —Specialty: Anatomy • Gastroenterology and HepatologyObjective: Rare diseaseBackgroundParaduodenal hernia (PDH) is a rare internal hernia, accounting for 50% to 55% of internal hernias but only 0.2% to 0.9% of intestinal obstructions. Right-sided PDH is less common, occurring in approximately 25% of cases.Case ReportThis case describes a 33-year-old pregnant woman at 20 weeks 6 days gestation who was admitted with a 15-day history of abdominal distension accompanied by nausea and vomiting. The patient had postprandial exacerbation of intermittent abdominal pain, bilious vomiting, and significant weight loss (5 kg), with a history of similar symptoms during previous pregnancies. Abdominal contrast-enhanced computed tomography revealed clustered bowel loops in the right upper quadrant and medial displacement of the superior mesenteric vein, which is consistent with right-sided PDH complicated by intestinal malrotation. After conservative treatment failed, the patient opted for pregnancy termination followed by laparoscopic surgery. Intraoperative exploration confirmed complete absence of fusion between the ascending mesocolon and the posterior peritoneum, resulting in a wide hernia defect through which bowel loops had herniated into the space lateral to the ascending duodenum. The procedure included reduction of herniated contents, adhesiolysis, and fixation of the ascending mesocolon. The patient’s recovery was uneventful, and she was discharged on postoperative day 5. At 3-month follow-up, no abnormalities were noted.ConclusionsGiven its nonspecific clinical presentation, PDH is frequently misdiagnosed or diagnosed late. Abdominal computed tomography facilitates early diagnosis and timely intervention, while laparoscopic repair offers favorable outcomes.

Background: Pre-duodenal portal vein (PDPV) is a rare congenital vascular anomaly resulting from abnormal embryological development of the vitelline venous system. Although often asymptomatic, PDPV may be associated with duodenal obstruction, particularly in neonates with additional congenital anomalies such as situs inversus, intestinal malrotation, and duodenal atresia. Case Presentation: We report a four-day-old male neonate presenting with bilious vomiting and features of proximal intestinal obstruction. Imaging revealed duodenal obstruction with situs inversus abdominus. Laparotomy demonstrated a pre-duodenal portal vein crossing the second part of the duodenum with an associated intraluminal duodenal membrane. Membrane excision and gastro-duodenostomy were performed to bypass the obstruction while avoiding injury to the anomalous portal vein. The postoperative recovery was uneventful. Conclusion: The coexistence of PDPV, duodenal obstruction, and situs inversus is exceedingly rare. Intraoperative recognition of anomalous vascular anatomy and tailored surgical planning are critical to prevent catastrophic vascular injury and ensure favorable outcomes. Journal of Paediatric Surgeons of Bangladesh (2022) Vol. 13 (1 & 2): 49-51

Jejunal web as the cause of bowel obstruction in an infant: case report and brief literature review

A volvulus in cases of non-rotation in newborns is a neonatal surgical emergency that is associated with high mortality if there is a delay in diagnosis and therapy. In addition to clinical signs such as bilious vomiting, bloody stools, a tender abdomen, and a lethargic patient, the diagnosis can be quickly made by sonographic evidence showing the "whirlpool sign," allowing for the initiation of surgical therapy. We report on a full-term male newborn who was unremarkable at the routine U2 examination except for a weight loss of just under 10%. On the third day of life, the newborn began bilious vomiting and passed bloody stools. A suspected diagnosis of volvulus was made via sonography and was treated with immediate, intestine-preserving surgery.

Abstract Small bowel obstruction (SBO) without a congenital aetiology is an urgent surgical condition in children. It can result from a variety of causes, including foreign body ingestion and food impaction. This report presents the case of an 11‐year‐old male patient who was admitted with SBO due to the ingestion of a pickled pepper, to discuss the diagnostic challenges and therapeutic management of this condition. The patient presented with abdominal distention, bilious vomiting, and progressive abdominal pain. His past medical history was unremarkable. Abdominal x‐ray and computed tomography (CT) scan revealed air‐fluid levels suggestive of SBO but were not diagnostic for the underlying aetiology. Surgical exploration identified an intraluminal obstructing lesion approximately 80 cm proximal to the ileocecal valve. An enterotomy was performed, and a hot pickled pepper was extracted. The enterotomy site was primarily repaired. The patient was discharged uneventfully. SBO secondary to indigestible food material presents a significant diagnostic challenge and should be considered in the differential diagnosis for previously healthy patients presenting with intestinal obstruction. A careful and detailed history, including dietary intake, is critical for diagnosis. Surgical removal of the impacted material is an effective treatment option for children.

Abstract Strongyloidiasis, caused by Strongyloides stercoralis, is a soil-transmitted helminthiasis with the unique capacity for autoinfection, enabling chronic persistence within the host. While often asymptomatic, it may progress to hyperinfection or disseminated disease in immunocompromised individuals, particularly those on corticosteroids. Leprosy patients are especially vulnerable due to prolonged corticosteroid use for lepra reactions. We report a 42-year-old man with Hansen’s disease on long-term prednisolone for recurrent erythema nodosum leprosum, who presented with bilious vomiting, abdominal discomfort, and significant weight loss. Investigations revealed anemia, electrolyte disturbances, and imaging suggesting small bowel obstruction. Active motile larvae suggestive of Strongyloides stercoralis were observed in routine microscopic examination of stool. He was treated with ivermectin and albendazole, alongside steroid tapering and hydrocortisone replacement for adrenal insufficiency, resulting in rapid clinical recovery and parasitological clearance. This case emphasizes the need for early suspicion, routine examination before immunosuppressive therapy, and prompt treatment to avert fatal outcomes.

Background: Acute appendicitis is the most common pediatric surgical emergency, but diagnosis can be difficult when superimposed on other intra-abdominal conditions. Chronic calcific pancreatitis in children, although rare, presents with recurrent abdominal pain and imaging abnormalities that can obscure coexisting acute pathology. Clinical Description: A 13-year-old boy presented with acute-onset abdominal pain and bilious vomiting. He had a 6-year history of chronic calcific pancreatitis and had undergone endoscopic retrograde cholangiopancreatography 3 days prior. A computed tomography (CT) 2 weeks ago had shown an atrophic pancreas with a pseudocyst. On examination, child was hemodynamically stable with tenderness in right hypochondrium. Management and Outcome: Laboratory investigations were normal, including serum amylase and lipase. Despite ultrasound-guided pigtail catheter drainage of the pseudocyst, symptoms persisted. A CT showed right-sided loculated intraperitoneal collection extending into the paracolic gutter, in addition to pancreatic pseudocyst. Exploratory laparotomy revealed a necrotic, gangrenous appendix with intraperitoneal pus. Appendectomy was performed and symptoms gradually abated. He was discharged in the stable condition with plans for the elective surgical management of chronic pancreatitis. Conclusion: This case highlights the diagnostic challenges posed by overlapping clinical features of chronic pancreatitis and acute appendicitis. Vigilance and timely surgical intervention is crucial to prevent complications, particularly when acute appendicitis presents in the background of chronic pancreatic disease or any other chronic abdominal pathology.

Pediatric intestinal pseudo-obstruction (PIPO) is a severe bowel motility disorder characterized by impaired propulsion of gastrointestinal contents without mechanical obstruction. PIPO encompasses congenital and acquired disorders, including neuropathies, myopathies, and mesenchymopathies. PIPO presents with abdominal distension, bilious vomiting, and severe constipation. Diagnosis is based on objective measures of neuromuscular dysfunction, dilated bowel on imaging, parenteral and/or enteral nutrition dependence, and genetic or metabolic testing. Antroduodenal manometry permits objective assessment of proximal bowel neuromuscular function. Genetic testing is increasingly valuable although causes of PIPO often remain incompletely defined. Understanding genotype-phenotype correlations is essential for clarifying disease mechanisms and guiding therapies. This study aimed to characterize the clinical and genetic profiles of children with PIPO, utilizing manometric data for subtype classification. A retrospective chart review was conducted at a tertiary care pediatric medical center, with inclusion criteria of PIPO diagnosis, completed manometry testing, and genetic evaluation. Nineteen children met inclusion criteria. Antroduodenal manometry classified 59% as neuropathic, 35% as myopathic, and one with mixed neuropathic and myopathic dysfunction. Genetic testing revealed pathogenic ACTG2 mutations in all myopathic cases, while neuropathic PIPO exhibited more genetic variability. Histopathology was inconsistent and often nonspecific. Therapeutic approaches focused on nutritional support and promotility agents, with surgical intervention more common in myopathic cases. This study highlights the association of ACTG2 mutations with a myopathic phenotype, and genetic diversity in neuropathic PIPO, emphasizing the need for further research to improve phenotyping to enhance diagnosis and treatment.

Gastroduodenal fistulas are uncommon complications of peptic ulcer disease, and those involving the distal duodenum are particularly rare today. We describe an elderly man with a history of alcohol use and prior abdominal surgery who presented with longstanding upper abdominal pain, recurrent bilious vomiting, and significant weight loss. Evaluation revealed a fistulous tract between the posterior stomach and the fourth part of the duodenum, along with duodenojejunal narrowing. Definitive surgical management involved excision of the tract and reconstruction with Roux-en-Y gastrojejunostomy and duodenojejunostomy, leading to a satisfactory outcome.

Abstract Introduction Gallstone ileus is a rare complication of cholelithiasis, responsible for 1–4% of small bowel obstructions. Impaction of the stone in the jejunum is exceptionally uncommon. This case report highlights a rare presentation of gallstone ileus complicated by sealed perforated jejunal diverticulum, presenting a diagnostic and therapeutic challenge. Case Presentation A 61-year-old male presented with progressive abdominal pain, bilious vomiting, and abdominal distension. Examination revealed a distended, tender abdomen with exaggerated bowel sounds. Initial CT interpretation suggested adhesive small bowel obstruction without intraluminal pathology. However, review of the images identified a hyperdense lesion consistent with an ectopic gallstone, raising suspicion for gallstone ileus and prompting operative management. Intraoperatively, a large gallstone was found impacted in the jejunum approximately 2.5 meters from the duodenojejunal flexure, with evidence of extensive jejunal diverticulosis and a sealed perforation. The patient underwent segmental resection of the jejunum and side-to-side hand-sewn anastomosis. He developed postoperative ileus, which was managed conservatively, and was discharged in good condition on postoperative day 11. Discussion This case illustrates a rare form of gallstone ileus in the setting of enteric diverticulosis, complicated by sealed perforation. high clinical suspicion is required to diagnose gallstones ileus when history of gallstones and classical imaging findings are not present. Segmental resection was required due to local inflammation and potential perforation, highlighting the importance of intraoperative judgement. Conclusions Gallstone ileus, though rare, should be considered in patients with small bowel obstruction, even when classical imaging findings are absent. Enteric diverticulosis may complicate such cases and may warrant surgical resection.

Meckel’s diverticulum is a congenital gastrointestinal anomaly that is usually asymptomatic but may lead to complications such as obstruction, bleeding, diverticulitis, or perforation [1-4]. Intestinal obstruction is the most common complication in adults [3]. We report the case of a 37-year-old man who presented with acute abdominal pain, bilious vomiting, cessation of stool and gas passage, and abdominal distension. Abdominal CT revealed small bowel obstruction without a clearly identifiable cause. Emergency laparotomy revealed a bowel volvulus caused by a fibrous band extending from an inflamed Meckel’s diverticulum to the umbilicus. The diverticulum was resected, and a functional end-to-end bowel anastomosis was performed. Although preoperative diagnosis can be challenging, imaging may aid in identifying bowel obstruction, and surgical resection remains the definitive treatment in symptomatic cases [12-14]. This case highlights the importance of considering Meckel’s diverticulum in adult patients with small bowel obstruction and the need for prompt surgical intervention.

The paper reports the case of a ten-day-old infant presenting to a primary care paediatric clinic with bilious vomiting, abdominal distension and inadequate weight gain. Initial evaluations and daily rectal irrigations led to clinical improvement, while rectal suction biopsies confirmed Hirschsprung disease. Intraoperative biopsies revealed an unexpected ileocolic aganglionosis, diagnosing a rare ‘total colonic aganglionosis’, which required the creation of a temporary ileostomy. This case highlights the importance of early recognition of neonatal intestinal obstruction, timely diagnosis of Hirschsprung disease and the need to consider extensive forms when clinical and preoperative findings are inconclusive.

Rivaroxaban is a direct oral anticoagulant that selectively inhibits factor Xa by blocking thrombin production. It is mainly indicated for the treatment and prevention of venous thromboembolism and in patients with non-valvular atrial fibrillation. We present a 74- year-old female patient with complaints of abdominal pain, nausea, and 3 episodes of non- bilious vomiting and dyspnea. She is a known case of type 2 DM, SHTN, HFpEF, and paroxysmal atrial fibrillation, for which she has been taking tablet Rivaroxaban 15mg for 3 years. Computed tomography of the abdomen demonstrated a splenic hemostasis, due to which an emergency splenectomy was conducted without stopping rivaroxaban, which led to a major complication during the surgery.

We report the case of a man in his 60s presenting with 2 days of persistent bilious vomiting, with mild abdominal tenderness. His history was significant for a gastric surgery 40 years earlier, although no operative records or indications were available. There was no history of obesity, malignancy or weight change before or after the index procedure. CT and upper gastrointestinal endoscopy findings were suggestive of retrograde gastroenteric intussusception. Given the concern for bowel ischaemia due to the duration of complaints, an exploratory laparotomy was performed, with intraoperative confirmation of a Roux-en-Y gastrojejunostomy (RYGJ). Following adhesiolysis, the intussusceptum-an unusually long, retrocolic Roux limb (approximately 80 cm) anastomosed to an unresected stomach-was reduced and fixed to the mesocolon to avoid recurrence. Postoperative recovery was uneventful, and monthly follow-up showed no recurrence of symptoms or complications. This is, to our knowledge, the first reported case of retrograde jejunogastric intussusception following a non-bariatric RYGJ.

Jejunal atresia type 3B (Apple peel variant) is a rare congenital anomaly of the small intestine associated with high mortality and morbidity, mainly due to complications following surgery and loss of functional bowel segment. We describe a preterm neonate presenting on day of life (DOI) 1 with abdominal distension and bilious vomiting, who was operated on DOI 2. No resection of bowel segment was performed; side to side anastomosis done. Post-operatively, the neonate was started on enteral feeds on DOI 10, tolerated well, and was discharged on DOI 18 in a stable condition.