Bowel Diameter Research Articles

International expert guidance for defining and monitoring small bowel strictures in Crohn's disease on intestinal ultrasound: a consensus statement

Diagnostic imaging using CT enterography, magnetic resonance enterography, and intestinal ultrasound are important tools in evaluating stricturing Crohn's disease. Definitions of strictures have been developed for CT enterography and magnetic resonance enterography. However, expert recommendations for definitions and treatment response of strictures on intestinal ultrasound are not available. The aim of this study was to standardise definitions, diagnosis, and treatment response criteria in small bowel stricturing Crohn's disease on intestinal ultrasound. Using modified RAND-University of California Los Angeles Appropriateness Method, a diverse expert panel of 13 gastroenterologists, seven radiologists, and two patient representatives was assembled. A total of 466 statements on definitions and response to therapy of stricturing Crohn's disease on intestinal ultrasound were generated from a systematic review and from expert opinion, with subsequent rating for appropriateness. Two rounds of voting with an interposed survey result discussion were performed. Statements were classified as inappropriate, uncertain, or appropriate based on the median panel rating and degree of disagreement. Appropriateness was rated using a nine-point Likert scale (1 being inappropriate, 9 being highly appropriate). A naive or anastomotic small bowel Crohn's disease stricture on intestinal ultrasound is defined by the combination of bowel wall thickening, luminal narrowing, and pre-stenotic dilation. Bowel wall thickness is defined as being more than 3 mm. Luminal narrowing is defined as either a luminal diameter reduction of more than 50% in the narrowest area and relative to a normal adjacent bowel loop, or a luminal diameter of less than 1 cm. Pre-stenotic dilation is defined as more than 2·5 cm or an increase in bowel diameter relative to a normal adjacent bowel loop. Definitions for grading hyperaemia, inflammatory fat, wall stratification, intestinal ultrasound machine technical parameters, and image acquisition were also devised. Treatment response of strictures was defined as reduction in stricture length, bowel wall thickening, luminal narrowing, pre-stenotic dilation, and motility abnormalities. To our knowledge, this is the first intestinal ultrasound appropriateness rating exercise conducted for defining, diagnosing, and measuring response to therapy in small bowel stricturing Crohn's disease and informs future clinical use and intestinal ultrasound index development for clinical trials. Leona M and Harry B Helmsley Charitable Trust.

Determining the need for surgery in small bowel obstructions based on clinical, laboratory, and radiological parameters.

Small bowel obstruction (SBO) is a common and important surgical emergency. Our aim in this study is to describe the clinical, laboratory, and computed tomography (CT) findings to facilitate the objective identification of SBO patients in need of operative treatment in this patient population. This retrospective study included 340 patients hospitalized due to a preliminary diagnosis of ileus. Retrieved data of patients included age, gender, comorbidities, previous hospitalization due to ileus, surgical history, physical examination findings, complete blood count and biochemistry test results, and CT findings at admission. The study included 180 (52.9%) male and 160 (47.1%) female patients. Treatment was conservative in 216 patients and surgery in 124 patients. Of the patients included in the study, 36.4% needed surgery. Of the female patients, 38.90% received conservative treatment and 61.30% underwent surgery. Adhesions were the most common cause of obstruction in operated patients (43.50%). We have found that female gender, vomiting, guarding, rebound, C-reactive protein levels above 75 mg/L, increased bowel diameter, and a transition zone on CT images indicate a strong need for surgery, but a history of previous hospitalization for ileus may show that surgery may not be the best option.

Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound

ObjectivesA bowel diameter threshold of ≥2.5 cm, originally derived from the research using computed tomography, is frequently used for diagnosing small bowel obstruction (SBO) with point-of-care ultrasound (POCUS). We sought to determine the optimal bowel diameter threshold for diagnosing SBO using POCUS and its accuracy in predicting surgical intervention. MethodsWe conducted a secondary analysis using individual patient-level data from a previous systematic review on POCUS for SBO diagnosis across five academic EDs. Patient data were collected, including imaging results, surgical findings, and final diagnosis. The measured diameter of the small bowel using POCUS was recorded. ROC area under the receiver operating characteristic curves (AUC) were constructed to determine the optimal threshold for bowel diameter in predicting SBO diagnosis and surgical intervention. Subgroup analyses were performed based on sex and age. ResultsA total of 403 patients had individual patient-level data available, with 367 patients included in the final analysis. The most accurate bowel diameter overall for predicting SBO was 2.75 cm (AUC = 0.76, 95% CI 0.71–0.81). A bowel diameter of ≤1.7 cm had 100% sensitivity with no miss rate, while a bowel diameter of ≥4 cm had 90.7% specificity in confirming SBO. Patients under 65 had an optimal threshold of 2.75 cm versus 2.95 cm in patients over 65. Females had an optimal threshold of 2.75 cm, while males had a value of 2.95 cm. There was no significant correlation between bowel diameter thresholds and surgical intervention. ConclusionA bowel diameter threshold of 2.75 cm on POCUS is more discriminative diagnostic accuracy for diagnosing SBO. Patients' age and sex may impact diagnostic accuracy, suggesting that tailored approaches may be needed.

Study of Correlation between Fetal Bowel Dilation and Congenital Gastrointestinal Malformation.

Ultrasound serves as a valuable tool for the early detection of fetal bowel dilatation, yet the correlation between fetal bowel dilatation and gastrointestinal malformations remains to be further investigated. This study aims to explore the relationship by conducting a follow-up and analysis of fetuses with bowel dilation. A retrospective analysis was conducted on 113 fetuses with bowel dilatation at our center from July 2014 to December 2019. The location and degree of bowel dilatation were analyzed. ROC curves were constructed based on the diameter of the bowel and its ratio to fetal gestational age. In total, 40 of 41 cases (97.6%) with upper gastrointestinal dilatation (double-bubble sign) and 46 of 72 cases (63.9%) with lower gastrointestinal dilatation were diagnosed with gastrointestinal malformations postnatally. The AUC of the dilatation diameter was 0.854 with a cutoff value of 18.05 mm in patients with lower gastrointestinal dilatation. The ratio of the diameter to gestational age (D/GA) showed a higher AUC of 0.906 with a cutoff value of 0.4931. The presence of the double-bubble sign in fetuses indicates a close association with duodenal obstruction. The risk of gastrointestinal malformations increases when the bowel diameter exceeds 18.05 mm, particularly when the D/GA surpasses 0.4931.

Early Initiation of Adalimumab Significantly Diminishes Postoperative Crohn's Disease Endoscopic Recurrence and Is Superior to 6-Mercaptopurine Therapy: An Open-Label, Randomized Controlled Study.

Postoperative recurrence (POR) is the rule in patients with Crohn's disease (CD), mitigated with prophylactic therapy. The evidence for therapeutic choice and timing of intervention is lacking. We aimed to compare the rates of POR in patients treated early with prophylactic 6-mercaptopurine (6-MP) or adalimumab. We conducted a prospective single-center randomized open-label clinical study in which patients in surgical remission following their first ileocecectomy were randomized to receive early treatment with 6-MP or adalimumab. Patients were followed up clinically every 3 months and underwent endoscopy at weeks 32 and 58 postoperatively. The primary endpoint was endoscopic recurrence (ePOR) at 1 year (week 58), defined as a Rutgeerts score ≥ i2. We enrolled 35 patients (25 males, mean age 35 ± 1.4 years, median disease duration 5 ± 6.1 years) following ileocecectomy. Of these, seven (20%) were current smokers and nine (26%) biologics-experienced. Patients allocated to adalimumab had significantly less ePOR than patients treated with 6MP at week 32 (21% vs. 69%, p = 0.004) and 58 (47% vs. 75%), (p = 0.03, HR = 0.39, 95% CI = 0.16-0.93). POR was associated with an increased diameter of the resected small bowel surgical specimen, lower baseline body mass index (BMI), increased week 18 fecal calprotectin, increased week 18 serum alanine aminotransferase and decreased week 18 hemoglobin level. Adalimumab was more effective than 6-MP in preventing ePOR. Increased operative small bowel diameter and lower postoperative BMI were associated with ePOR. At eighteen weeks, serum hemoglobin, ALT and fecal calprotectin levels were predictive of endoscopic disease recurrence. (ClinicalTrials.gov ID NCT01629628).

Cutoffs and Characteristics of Abnormal Bowel Dilatation in Pediatric Short Bowel Syndrome.

Although excessive intestinal dilatation associates with worsened outcomes in pediatric short bowel syndrome (SBS), little is known about the natural history and definition of pathological dilatation. We addressed fore-, mid-, and hind-gut dilatation in children with SBS, who had not undergone autologous intestinal reconstructive (AIR) surgery, in relation to controls. SBS children without history of AIR surgery (n = 59) and age-matched controls without any disclosed intestinal pathology (n = 140) were included. Maximum diameter of duodenum, small bowel (SB), and colon were measured in each intestinal contrast series during 2002 to 2020 and expressed as diameter ratio (DR) to L5 vertebrae height. Predictive ability of DR for weaning off parenteral nutrition (PN) was analyzed with Cox proportional hazards regression models using multiple cutoffs. Duodenum (DDR), SB (SBDR), and colon (CDR) DR were 53%, 183%, and 23% higher in SBS patients compared to controls ( P < 0.01 for all). The maximal DDR and SBDR measured during follow-up is associated with current PN dependence and young age. DDR correlated with SBDR ( r = 0.586, P < 0.01). Patients with maximal DDR less than 1.5, which was also the 99th percentile for controls, were 2.5-fold more likely to wean off PN ( P = 0.005), whereas SBDR and CDR were not predictive for PN duration. All segments of remaining bowel, especially SB, dilate above normal levels in children with SBS. In SBS children without AIR surgery, PN dependence and young age is associated with duodenal and small intestinal dilatation, while duodenal dilatation also predicted prolonged PN.

Intra- and interobserver reproducibility of transvaginal ultrasound for the detection and measurement of endometriotic lesions of the bowel.

The number and invasion depth of endometriotic bowel lesions, total length of bowel affected by endometriosis, lesion-to-anal verge distance, and extent of pouch of Douglas obliteration are important factors in preoperatively determining risk and complexity of endometriosis surgery. The intra- and interobserver reproducibility of transvaginal ultrasound in the evaluation of many of these parameters has not yet been investigated. Our study aimed to assess the intra- and interobserver reproducibility of transvaginal ultrasound between an experienced and less experienced examiner for all of these parameters. This prospective observational cross-sectional study was conducted between July 2019 and November 2020. Fifty consecutive premenopausal women who underwent transvaginal ultrasound examination in our clinic for the first time, were examined by the same two operators during the same attendance. Outcomes of interest were the inter-rater reproducibility of transvaginal ultrasound for detecting the presence, number, depth and size of bowel endometriotic nodules, lesion-to-anal-verge distance, total length of bowel affected, and pouch of Douglas obliteration. The intraobserver reproducibility was assessed for the continuous parameters. Cohen's kappa (κ) statistic, Cohen's weighted kappa (κ), proportions of agreement, intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement were used to assess the reproducibility of the parameters. The inter-rater agreement and reliability were very good for identifying bowel endometriosis, the number and invasion depth of bowel nodules, determining whether the maximum nodule length was <3 cm, and lesion-to-anal-verge distance <8 cm (proportion of agreement 0.92, 0.94, 0.97, 0.94, 0.96; κ 0.92, 0.91, 0.92, 0.82, 0.89). The inter-rater agreement and reliability were good for assessing pouch of Douglas obliteration (proportion of agreement 0.86, κ 0.80). The intra-rater reliability for the mean nodule diameter (ICC 0.93 and 0.97) and total length of bowel affected (ICC 0.94 and 0.91) were excellent for operators A and B, respectively. The inter-rater reliability for the mean nodule diameter was good (ICC 0.80), and moderate for the total length of bowel affected (ICC 0.70). The Bland-Altman limits of agreement demonstrated clinically acceptable ranges for these two parameters. This study demonstrated a high intra- and inter-rater reproducibility of transvaginal ultrasound in the diagnosis of bowel endometriosis and measurement of its various components.

Accurately evaluating for a small bowel obstruction using an abdominal radiograph, by a new method: The Bowel-Spine Ratio

IntroductionA well-established method does not exist to rule out a small bowel obstruction using an abdominal xray series with significant accuracy. The hypothesis of the study is that the ratio of an average small bowel diameter to lumbar spine diameter over 0.5 is most likely a small bowel obstruction. MethodsAn x-ray abdominal series measurement technique was applied to 41 subjects with a chief complaint of “abdominal pain” as part of a randomized retrospective case review to predict an obstruction v. non obstruction. A total number of 81 abdominal pain subjects with a mean age of 46.7 years were selected with 40 excluded due to normal small bowel gas pattern. The subject's medical information was unknown to the authors when reading their images. The measurement technique involved averaging the largest and smallest small bowel short axis diameters with comparison to the lowest clearly visible lumbar body width. The subjects' medical course as described in the medical chart or subsequent computed tomography scans were used as the referencing standard to determine presence of obstruction vs non-obstruction. ResultsThis method, called the Bowel-Spine Ratio (BSR), resulted in a sensitivity of 0.882 (0.622–0.979; 95% CI), specificity of 0.957 (0.760–0.998; 95% CI), accuracy of 94.7% (80.9%–99.1%; 95% CI) and a positive likelihood ratio of 21 for predicting a small bowel obstruction. ConclusionThe abdominal series Bowel-Spine Ratio is a simple yet effective technique to screen for a small bowel obstruction using limited resources and to avoid unnecessary computed tomography scans with the potential to reduce health care costs. Implications for practice: Clinicians could have increased confidence in utilizing abdominal radiographs to evaluate for small bowel obstruction.

Application of jejunal turnover and bowel plication technique in neonatal high intestinal atresia: a retrospective study.

To evaluate the outcomes of jejunal turnover and bowel plication (JTBP) in high jejunal atresia of neonates. The clinical data of neonates met the criteria were retrospectively analyzed from January 2012 to December 2021.The neonates were divided into the JTBP group and control group according to the surgical procedure.Demographics, postoperative morphology of the duodenum and proximal jejunum,intestinal recovery time and complications were compared. 75 patients were allocated to the JTBP (n=30) and control (n=45) groups, respectively. There was no significant difference between the two groups in terms of gestational age, birth weight, age at surgery,the pathological classification,and concomitant disease. UGCS showed that the diameter of the proximal bowel of the anastomotic stoma was normal and the duodenum and proximal jejunumin streamline shape in the JTBP group.While the duodenum dilated, and the shape of Trojan angle was classified into sharp angle and blunt round angle in the control group.The duration of total parenteral nutrition, postoperative oral feeding time and oral feeding time of 40 mL/3 h was significantly different between the JTBP group and control group(sharp and blunt round type): 9.0±3.5d,7.0±2.1d and 11.0±6.0d vs 16.9±4.2 d, 14.0±5.0 d and 19.0±7.4 d vs 11.9±8.3 d, 8.2±3.9d and 15.8±3.6d(P<0.05). JTBP for neonatal high jejunal atresia can significantly change the diameter of the proximal bowel and the course of duodenum jejunum flexure. Postoperative bowel movement was more in line with fluid dynamics, which was conducive to the recovery of the intestinal function and resulted in fewer complications.

Ten good reasons to consider gastrointestinal function after acute brain injury.

The brain-gut axis represents a bidirectional communication linking brain function with the gastrointestinal (GI) system. This interaction comprises a top-down communication from the brain to the gut, and a bottom-up communication from the gut to the brain, including neural, endocrine, immune, and humoral signaling. Acute brain injury (ABI) can lead to systemic complications including GI dysfunction. Techniques for monitoring GI function are currently few, neglected, and many under investigation. The use of ultrasound could provide a measure of gastric emptying, bowel peristalsis, bowel diameter, bowel wall thickness and tissue perfusion. Despite novel biomarkers represent a limitation in clinical practice, intra-abdominal pressure (IAP) is easy-to-use and measurable at bedside. Increased IAP can be both cause and consequence of GI dysfunction, and it can influence cerebral perfusion pressure and intracranial pressure via physiological mechanisms. Here, we address ten good reasons to consider GI function in patients with ABI, highlighting the importance of its assessment in neurocritical care.

Visual Image Annotation for Bowel Obstruction: Repeatability and Agreement with Manual Annotation and Neural Networks

Bowel obstruction is a common cause of acute abdominal pain. The development of algorithms for automated detection and characterization of bowel obstruction on CT has been limited by the effort required for manual annotation. Visual image annotation with an eye tracking device may mitigate that limitation. The purpose of this study is to assess the agreement between visual and manual annotations for bowel segmentation and diameter measurement, and to assess agreement with convolutional neural networks (CNNs) trained using that data. Sixty CT scans of 50 patients with bowel obstruction from March to June 2022 were retrospectively included and partitioned into training and test data sets. An eye tracking device was used to record 3-dimensional coordinates within the scans, while a radiologist cast their gaze at the centerline of the bowel, and adjusted the size of a superimposed ROI to approximate the diameter of the bowel. For each scan, 59.4 ± 15.1 segments, 847.9 ± 228.1 gaze locations, and 5.8 ± 1.2 m of bowel were recorded. 2d and 3d CNNs were trained using this data to predict bowel segmentation and diameter maps from the CT scans. For comparisons between two repetitions of visual annotation, CNN predictions, and manual annotations, Dice scores for bowel segmentation ranged from 0.69 ± 0.17 to 0.81 ± 0.04 and intraclass correlations [95% CI] for diameter measurement ranged from 0.672 [0.490–0.782] to 0.940 [0.933–0.947]. Thus, visual image annotation is a promising technique for training CNNs to perform bowel segmentation and diameter measurement in CT scans of patients with bowel obstruction.

Efficacy and safety of mucous fistula refeeding in preterm infants: an exploratory randomized controlled trial

BackgroundThis study aimed to evaluate whether mucous fistula refeeding (MFR) is safe and beneficial for the growth and intestinal adaptation of preterm infants with enterostomies.MethodsThis exploratory randomized controlled trial enrolled infants born before 35 weeks’ gestation with enterostomy. If the stomal output was ≥ 40 mL/kg/day, infants were assigned to the high-output MFR group and received MFR. If the stoma output was < 40 mL/kg/day, infants were randomized to the normal-output MFR group or the control group. Growth, serum citrulline levels, and bowel diameter in loopograms were compared. The safety of MFR was evaluated.ResultsTwenty infants were included. The growth rate increased considerably, and the colon diameter was significantly larger after MFR. However, the citrulline levels did not significantly differ between the normal-output MFR and the control group. One case of bowel perforation occurred during the manual reduction for stoma prolapse. Although the association with MFR was unclear, two cases of culture-proven sepsis during MFR were noted.ConclusionsMFR benefits the growth and intestinal adaptation of preterm infants with enterostomy and can be safely implemented with a standardized protocol. However, infectious complications need to be investigated further.Trial registrationclinicaltrials.gov NCT02812095, retrospectively registered on June 6, 2016.

Ogilvie Syndrome - summary of knowledge, diagnostics and treatment

Introduction and purpose: Ogilvie's syndrome is an acute pseudo-obstruction of the colon characterized by massive dilatation of the large intestine without mechanical obstruction. The aim of this publication is to review publications and case reports concerning this disease and therapeutic management.&#x0D; A brief description of the state of knowledge: Ogilvie's syndrome was first described in 1948. The assumed pathogenesis of the disease is increased activity of the sympathetic nervous system and/or decreased activity of the parasympathetic nervous system. Most often it concerns hospitalized patients, in a serious general condition, after major injuries, operations, and pregnant or postpartum women. The importance of viral infections in the pathogenesis, including COVID-19 in recent years, is also indicated. It is important to eliminate possible organic causes of obstruction and to assess the diameter of the dilated bowel. Therapeutic options include conservative treatment, pharmacological treatment with acetylcholinesterase inhibitors, endoscopic bowel decompression and surgical treatment. Lack of medical intervention can lead to ischemia and intestinal perforation.&#x0D; Conclusion: Ogilvie's syndrome is a rare condition in which complications can be minimized with proper assessment, care and treatment. The progress of pharmacological and endoscopic therapy allows to reduce the need for surgical intervention, and thus - the patient's unnecessary burden.

Closed loop obstruction of small bowel: CT signs predicting successful non-surgical treatment

PurposeTo clarify the computed tomography (CT) findings related to successful conservative treatments in patients with closed-loop small bowel obstruction (CL-SBO) without evidence of bowel strangulation. MethodsSixty-four patients (71 CT scans) diagnosed with CL-SBO by CT and received initial conservative treatments from May 2010 to August 2020 were retrospectively included. Two blinded radiologists reviewed the CT findings, including the transition zone (number, distance, and location), maximum bowel diameter, mesenteric haziness, mesenteric fluid, increased unenhanced bowel wall attenuation, decreased bowel wall enhancement, small bowel feces sign, whirl sign, bowel wall thickening, ascites, and degree of obstruction. The findings of the success and failure groups of conservative treatment were compared. Interobserver agreement was assessed for all findings. ResultsAmong the 71 cases, conservative treatments were successful in 42 cases (59 %) but failed in 29 cases (41 %). In multivariable analyses, the distance between the transition zones (>1 cm) and low-degree obstruction were independently associated with successful conservative treatments, with odds ratios of 6.23 and 3.52, respectively. The combination of these two CT findings exhibited a specificity of 89.7 % with a positive likelihood ratio of 3.01. Interobserver agreement of the degree of obstruction and the distance between the transition zones was almost perfect (ĸ = 0.814 and 0.914, respectively). ConclusionsThe distance between the transition zones (>1 cm) and low-grade obstruction are independent CT predictors of successful conservative treatments in CL-SBO patients. Initial conservative treatments are recommended for patients with both CT findings.

Broad ligament hernia: A rare condition causing small bowel obstruction

Dear Editor, Small bowel obstruction (SBO) is a condition characterized by intraluminal flow blockage caused by several etiologies. Postlaparotomy adhesion, incarcerated hernia, and neoplasm are the top 3 causes of SBO. Internal herniation, though rare, accounts for approximately 1% of SBO. Broad ligament hernia is an even more unusual form of internal herniation, reported in 4%–5% of internal herniation cases. Here, we report a case of broad ligament herniation, leading to strangulated SBO. A 68-year-old multiparity woman without history of abdominal surgery presented to the emergency department with acute onset of lower abdominal pain. The pain was intermittent, colicky, located on the infraumbilical region, lasting for 6 hours before she sought medical attention, and did not respond to analgesics. At triage, vital signs were relatively stable, except blood pressure of 188/81 mm Hg. Physical examination showed tenderness over the left lower quadrant and hypoactive bowel sound. Hemogram, liver function, and renal function were within normal limits, except for a slightly elevated serum lactate level of 13.2 mg/dL. Supine kidney, ureter, and bladder radiograph showed a mildly dilated bowel loop. The initial impression was ileus, and she was kept on bowel rest with intravenous fluid repletion after an enema. After 24 hours of medical treatment, her symptoms persisted with several vomiting bouts. Muscle guarding over the left lower quadrant of abdomen was noted. Contrast-enhanced computed tomography showed disclosing diffuse loop dilatation of the small intestine with the transitional zone in the pelvic region and a moderate amount of ascites. Under the impression of SBO, she underwent emergent exploratory laparotomy. Internal herniation of the small intestine into a 3-cm defect in the left broad ligament was found, resulting in strangulation of the small bowel measured approximately 40 cm in length. The nonviable segment of the small intestine was resected and anastomosed via hand-sewn method. In addition, the defect of the left broad ligament was repaired, and the right-sided broad ligament was examined as well. The patient had an uneventful postoperative recovery and was discharged on postoperative day 9. There are several classification systems regarding broad ligament herniation, which is summarized in Supplementary Data, https://links.lww.com/FJSS/A4. Computed tomography is the imaging modality of choice. Mechanical SBO with double transitional zone, bowel loops herniated beside the uterus with slight deviation of uterus to the contralateral side, enlargement of the distance between the uterus and one of the ovaries, and presence of free fluid in the pelvis would lead to suspicion of broad ligament herniation.[1] A standard therapeutic intervention has not yet been established.[2] Diagnostic laparoscopy could be performed if the preoperative diagnosis is uncertain. Once the broad ligament defect with internal herniation has been found, it can be managed with the laparoscopic approach. However, laparoscopic surgery is contraindicated in the following situations: when the diameter of small bowel is greater than 4 cm, there is evidence of bowel ischemia, history of severe adhesion, or presence of inflammatory bowel disease.[3] In conclusion, broad ligament hernia should be considered one of the differential diagnoses in a multiparity woman without previous surgical history, presenting with SBO. Early diagnosis and timely surgical intervention may reduce the likelihood of morbidity and mortality.

Preoperative small bowel dilation is associated with ileus after right colectomy

• Existing prediction models for postoperative ileus are suboptimal. • The relationship between preoperative bowel dysfunction and ileus is unclear. • Small bowel dilation significantly increases the risk of postoperative ileus. • Future prediction models for ileus should incorporate small bowel diameter. • Consider earlier parenteral nutrition in affected patients with malnutrition. The relationship between preoperative bowel dysfunction and postoperative ileus has not been explored clinically. We hypothesized chronic partial obstruction, based on preoperative small bowel diameter, is associated with ileus after colon surgery. This was a retrospective case-control study of patients undergoing right colectomy or ileocolic resection with primary anastomosis. Patients who developed ileus were compared to those who did not. Postoperative ileus occurred in 22 of 69 patients (32%). Preoperative small bowel dilation with maximum diameter >3 cm was present in 13 patients (19%) with 7 developing ileus (54%; p=0.06). In a multivariable model, small bowel dilation >3 cm (OR 4.6; 95% CI: 1.3-16.6) and preoperative weight loss >10 pounds (OR 9.8; 95% CI: 1.6-57.9) were independently associated with ileus. Colorectal surgery patients with preoperative bowel dilation have an increased risk of postoperative ileus. This knowledge can better inform patient expectations for recovery and help guide perioperative nutritional management, particularly with patient selection for parenteral nutrition.

Predicting the Need for Surgery in Uncomplicated Adhesive Small Bowel Obstruction: A Scoring Tool

IntroductionNonoperative treatment can be attempted for uncomplicated adhesive small bowel obstruction (ASBO), but carries a risk of delayed surgery. Highlighting initial parameters predicting risk of failure of nonoperative management would be of great interest. MethodsPatients initially managed conservatively for uncomplicated ASBO were retrospectively analyzed. Univariate and multivariate analysis were performed to identify predictive failure's factors. Based on the risk factors, a score was created and then prospectively validated in a different patients' population. ResultsAmong 171 patients included, 98 (57.3%) were successfully managed conservatively. In a multivariate analysis, three independent nonoperative management failure's factors were identified: Charlson Index ≥4 (P = 0.016), distal obstruction (P = 0.009), and maximum small bowel diameter over vertical abdominal diameter ratio >0.34 (P = 0.023). A score of two or three was associated with a risk of surgery of 51.4% or 70.3% in the retrospective analysis and 62.2% or 75% in the validation cohort, respectively. ConclusionsThis clinical-radiological score may help guide surgical decision-making in uncomplicated ASBO. A high score (≥2) was predictive of failure of nonoperative management. This tool could assist surgeons to determine who would benefit from early surgery.

Ultrasonographic detection of gastroschisis in the first trimester: Actualities in pregnancy management and outcome

Gastroschisis is a congenital anterior abdominal wall defect that occurs in 4 to 5 in 10,000 births, consisting in the evisceration of bowel in the amniotic cavity without a membranous covering. Gastroschisis cases can be detected during the first trimester using ultrasonography or at the beginning of the second trimester with a detection rate of 100%. Although an isolated condition in most of the cases, further complications such as malrotation, atresia, stenosis, perforation or volvulus can be associated. Periodic monitoring is required to assess the progress of the pregnancy with measurements of the level of amniotic fluid, fetal biometry and bowel diameters at every ultrasound examination. Gastroschisis is most frequently associated with oligohydramnios, intrauterine fetal growth restriction, increased bowel wall thickness and bowel dilatation. The outcome of the disease is favorable with a survival rate of around 90% for born infants. The long time on ventilator and multiple intestinal surgeries that delay the moment of oral feeding with a long-term use of total parental nutrition and short bowel syndrome are the most important comorbidities. Delivery is recommended at 38 weeks of gestation, preserving caesarean delivery for complicated gastroschisis. Although a complex pathology, gastroschisis is associated with normal intellectual development and few to none long-term complications.

Double-barreled enterostomy with compression anastomosis in newborns and infants

BACKGROUND: Staged treatment of small bowel diseases involves the formation of an enterostomy. BishopKoop T-anastomosis and Mikulicz double-barreled enterostomy with compression clamp are widely applied. The disadvantages of Mikuliczs can be eliminated using a clip of titanium nickelide with shape memory instead of a clamp.&#x0D; AIM: This study aimed to evaluate the efficacy and safety of a titanium nickelide device in double-barreled enterostomy and compare the results of treatment with a T-anastomosis.&#x0D; MATERIALS AND METHODS: The study included newborns and infants. The clip was applied on 958 days postoperatively. Differences were accepted as significant at p 0.05.&#x0D; RESULTS: Since 2000, enterostomy was performed in 79 children: 12 (15.2%) had T-anastomoses, 44 (55.7%) had double-barreled stomas, and 18 (40.9%) had a titanium nickelide clip. In the study groups, stomas were applied for ileus, atresia, and aganglionosis. In the group of double-barreled enterostomies with a clip, the stoma was closed later (p = 0.027) and the operation time was short (p = 0.013). In the T-anastomosis group, parenteral nutrition was required for a longer period (p = 0.018). Self-removal of the clip and appearance of the stool occurred on days 5 and 13. Compression anastomosis was obtained in 83.3% and stoma closure outside in 73.3%. With a double-barreled enterostomy, hepatic failure (p = 0.018) and anastomosis dysfunction (p = 0.046) were less common. T-anastomosis revealed an increase in the incidence of CDC II (p = 0.013) and III (p = 0.015) complications.&#x0D; DISCUSSION: The results reflect the safety of the presented method in comparison with the T-anastomosis, since the operation time and duration of the parenteral nutrition are reduced, invasive treatment is less often required for complications, and anastomosis dysfunction rarely occurs.&#x0D; CONCLUSIONS: Double-barreled enterostomy with a compression clip is an effective and safe alternative to T-anastomosis in children aged 1 year. The formed compression anastomosis allows closure of the stoma by suturing its outer part. The conditions for the formation of the anastomosis are the patency of the distal sections and bowel diameter 1 cm.

S1948 Toxic Megacolon as a Potential Complication Associated With COVID-19

Introduction: Coronavirus-2019 (COVID-19) presents with a wide spectrum of clinical manifestations and can affect various organ systems. Common gastrointestinal symptoms of the virus include diarrhea, nausea, and vomiting. Toxic megacolon, however, has not been cited in medical literature to be a side effect of the virus. We present a case of toxic megacolon that progressed in the setting of active COVID-19 infection. Case description/methods: A 62 year old, Hispanic male with a past medical history of hypertension, hyperlipidemia, Insulin dependent type 2 diabetes mellitus and COPD presented to the emergency room with a chief complaint of acute dyspnea with hypoxemia. Initial chest x-ray demonstrated extensive interstitial and alveolar airspace opacities suspicious for COVID-19 pneumonia. A COVID-19 PCR test was positive and the patient was admitted for acute hypoxic respiratory failure. The patient was given Tocilizumab for COVID-19, however, his oxygen requirement continued to increase on heated high flow nasal cannula. On day 10 of admission, the patient began to have about ten, loose, watery bowel movements a day. An abdominal x-ray revealed large bowel gas with dilation and a peak bowel diameter of 16.3 cm. This was confirmed with a computed tomography abdomen and pelvis with and without contrast. He then developed a fever of 101.3 degrees Fahrenheit, tachycardia in the 120s, hypotension, and a leukocytosis of 29,100 confirming the diagnosis of toxic megacolon. Testing for clostridium difficile (C diff) toxin was negative x2. He did not have a known history of inflammatory bowel disease, occupational exposures, HIV, recent medication use that may cause toxic megacolon, or recent travel prior to his hospitalization. Pre-emptive treatment of C. diff was initiated without resolution of his symptoms. The patient had a cardiopulmonary arrest soon after and his family requested cessation of CPR. Discussion: Both the short and long-term manifestations of COVID-19 have not been well-studied given the unexpected progression of the pandemic. Although GI symptoms are well known to be associated with the virus, toxic megacolon is not. This case report aims to emphasize the importance of appropriate abdominal imaging if GI symptoms begin to manifest with COVID-19. Early diagnosis will allow early symptomatic treatment as well as early surgical evaluation to decrease the likelihood of perforation.Figure 1.: Endoscopic findings and histology of colon. (a, b) Colonoscopy images demonstrating moderate inflammation with altered vascularity, erosions, friability and aphthous ulcerations. (c, d). H&E staining of colon demonstrated focal active colitis (yellow arrow) with cryptitis and abscess formation (red arrow). There were no architectural changes to suggest inflammatory bowel disease.