Dilated Bowel Research Articles

Diagnosis and Management of Simple and Complicated Meconium Ileus in Cystic Fibrosis, a Systematic Review.

The early management of neonates with meconium ileus (MI) and cystic fibrosis (CF) is highly variable across countries and is not standardized. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The protocol was registered in PROSPERO (CRD42024522838). Studies from three providers of academic search engines were checked for inclusion criteria, using the following search terms: meconium ileus AND cystic fibrosis OR mucoviscidosis. Regarding the patient population studied, the inclusion criteria were defined using our predefined PICOT framework: studies on neonates with simple or complicated meconium which were confirmed to have cystic fibrosis and were conservatively managed or surgically treated. Results: A total of 566 publications from the last 10 years were verified by the authors of this review to find the most recent and relevant data, and only 8 met the inclusion criteria. Prenatally diagnosed meconium pseudocysts, bowel dilation, and ascites on ultrasound are predictors of neonatal surgery and risk factor for negative 12-month clinical outcomes in MI-CF newborns. For simple MI, conservative treatment with hypertonic solutions enemas can be effective in more than 25% of cases. If repeated enemas fail to disimpact the bowels, the Bishop-Koop stoma is a safe option. No comprehensive research has been conducted so far to determine the ideal surgical protocol for complicated MI. We only found three studies that reported the types of stomas performed and another study comparing the outcomes of patients depending on the surgical management; the conclusions are contradictory especially since the number of cases analyzed in each study was small. Between 18% and 38% of patients with complicated MI will require reoperation for various complications and the mortality rate varies between 0% and 8%. Conclusion: This study reveals a lack of strong data to support management decisions, unequivocally shows that the care of infants with MI is not standardized, and suggests a great need for international collaborative studies.

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.

The utility of a CT grading scale in deciding on surgical intervention for patients with suspected small bowel obstruction

BackgroundA grading system was developed for computerized tomography (CT) scans evaluating patients with suspected small bowel obstruction (SBO). We hypothesized that patients with a higher grade of suspected SBO on CT scan would be more likely to require surgical intervention. MethodsRetrospective chart review of patients who presented to the Emergency Room (ER) who had a CT of the abdomen and pelvis for suspected SBO. Patients were divided into 5 groups: Grade 1 (SBO unlikely), Grade 2 (probable partial or early SBO), Grade 3 (probable high grade SBO), Grade 4 (SBO with changes concerning for ischemia) and Not Graded. ResultsThe CT scans of 655 patients were graded. Of the 22 patients with a grade 1 SBO, only 1 went for surgery (4.5 %). For grade 2 patients, 23 out of 299 had an operation (7.7 %), for grade 3 it was 84 out of 299 (28.1 %) and for grade 4 SBO, 25 out of 35 patients (71.4 %) had surgery. The p value is <0.00001. The three most common intraoperative findings were SBO obstruction from adhesions alone (48 % of cases), followed by incarcerated hernias (12 %) and ischemic bowel (9 %). Only 8 cases out of 133 operations (6 % of total) had no findings at time of surgery other than dilated bowel. ConclusionsThe CT grading scale for SBO developed at our institution shows excellent correlation between grade and going for surgery, with few negative results, and can be a useful tool among other factors for general surgeons when deciding whether or not to operate on a patient with suspected SBO.

TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE

Abstract Case Report A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF. Discussion We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.

Congenital chloride diarrhoea in a Chinese infant with a compound heterozygous SLC26A3 mutation

IntroductionCongenital chloride diarrhoea (CCD) is an autosomal recessive condition that causes secretory diarrhoea and potentially deadly electrolyte imbalances in infants because of solute carrier family 26 member 3 (SLC26A3) gene mutations.Case presentationA 7-month-old Chinese infant with a history of maternal polyhydramnios presented with frequent watery diarrhoea, severe dehydration, hypokalaemia, hyponatraemia, failure to thrive, metabolic alkalosis, hyperreninaemia, and hyperaldosteronaemia. Genetic testing revealed a compound heterozygous SLC26A3 gene mutation in this patient (c.269_270dup and c.2006 C > A). Therapy was administered in the form of oral sodium and potassium chloride supplements, which decreased stool frequency.ConclusionsCCD should be considered when an infant presents with prolonged diarrhoea during infancy, particularly in the context of maternal polyhydramnios and dilated foetal bowel loops.

Adult ileal duplication cyst acting as lead point of ileo-caecal intussusception a rare case of complete bowel obstruction in adults

Enteric duplication cyst presenting as intussusception in adult and causing complete small bowel obstruction is a rare phenomenon. A 19 year old female presented with complaints of abdominal pain, bilious vomiting, abdomen distension and constipation for 2 days. Patient had similar episodes in the past. Computed tomography of abdomen showed dilated small bowels with “Target Sign” suggestive of Ileo caecal intussusception. Patients was taken for surgery and intraoperatively it was noted to have thick walled cystic swelling in the terminall ileum. Segmental resection done along with cyst and primary anastamosis was done. Histopathological confirmation was done as Duplication cyst.

Probabilistic Prediction of Gastrointestinal Ischemia after Cardiothoracic Surgery.

Gastrointestinal ischemia (GIisch) is challenging to diagnose in patients after cardiothoracic surgery. Computed tomography angiography (CTA) carries substantial false-negative and false-positive rates. The aim of the study was to evaluate if a combination of readily available variables improves the diagnosis of GIisch after cardiothoracic surgery. This retrospective study included patients receiving intensive care after cardiothoracic surgery. GIisch was confirmed by surgical and/or endoscopic findings. A GIisch prediction score was developed using the Spiegelhalter-Knill-Jones system in a training cohort then tested in a validation cohort (patients without obvious signs of GIisch on CTA). The training cohort comprised 125 consecutive patients with suspected GIisch in 2008 to 2019, including 85 with confirmed GIisch. CTA, performed in 92 patients, had a high false-negative rate of 17/60 (28%) and a lower false-positive rate of 7/32 (22%). The score included cardiopulmonary bypass, negatively associated with GIisch, and six variables positively associated with GIisch: intraoperative mean arterial pressure < 50 mm Hg, aspartate aminotransferase > 15 N, lactate increase in 24 hour > 20%, and 3 CTA findings, namely, bowel dilation, bowel wall thickening, and mesenteric vasoconstriction. The area under the receiver operating characteristic was 0.82 (95% confidence interval [CI], 0.51-0.93) in the training cohort and 0.82 (95% CI, 0.68-0.96) in the validation cohort (n = 34 patients). Reliability of the predicted probabilities was greatest for probabilities ≤ 30% or ≥ 70%. In patients receiving intensive care after cardiothoracic surgery, GIisch cannot be ruled out based solely on CTA findings. A scoring system combining CTA findings with other variables may improve the diagnosis of GIisch in this population.

Is Necrotizing Enterocolitis and Spontaneous Intestinal Perforation Part of Same Disease Spectrum - New Insights?

The diagnosis of NEC is based on the presence of pneumatosis, dilated bowel loops, portal venous gas, or pneumoperitoneum on the abdominal x-ray. Published studies suggest that the appearance of pneumatosis most likely depends on the gestational age, with a shift occurring between 27-28 weeks. For infants of gestational age under 27 weeks, pneumoperitoneum is the most likely presentation of bowel injury due to the thin bowel wall and the colonization of the gut with the non-gas-producing bacteria. Assessment of postoperative morbidity and white matter injury on the brain MRI at term equivalent age in a cohort of preterm infants failed to identify differences between SIP and NEC groups when confirmed by histology. These findings illustrate the difficulty in conclusively identifying cases as SIP or NEC, particularly when gestational age is considered and raise speculation that both conditions lie on the same spectrum of intestinal injury.

Cytomegalovirus colitis as intestinal obstruction in an immunocompetent adolescent: a case report and literature review

BackgroundCytomegalovirus infection manifests varying clinical characteristics and severity in diverse populations with different immune statuses. The signs and symptoms of gastrointestinal involvement are nonspecific. Here, we present a case of cytomegalovirus colitis in an immunocompetent adolescent, which manifested as intestinal pseud-obstruction.Case presentationA 15-year-old man who had contracted novel coronavirus infection one month earlier was admitted to our hospital with fever, abdominal pain, and hematochezia. His abdomen was distended, and laboratory evaluation revealed a decrease in the blood count, an increase in inflammatory indicators and hepatic impairment. Imaging shows bowel wall thickening and dilatation of the colon. A diagnosis of intestinal infection combined with acute intestinal pseud-obstruction was made. Diarrhea persisted despite conservative treatment with empirical antibiotics. A colonoscopy was performed. Pathology confirmed cytomegalovirus infection. Ganciclovir therapy was initiated, and subsequent review showed a good recovery.ConclusionsThe case was diagnosed as cytomegalovirus colitis. We reviewed the reports of 9 cases of bowel obstruction, including our own, and found that the majority of the adult patients were elderly with underlying disease. Clinical and endoscopic manifestations are typically nonspecific, and imaging shows typical signs of intestinal obstruction. The final diagnosis was confirmed by pathology. Most of them have a good prognosis. We suggest that cytomegalovirus colitis can also lead to intestinal obstruction and that viral reactivation in immunocompetent individuals may be associated with inflammatory conditions and viral coinfection, particularly with the novel coronavirus.

Delineating Gastrointestinal Dysfunction Variants in Severe Burn Injury Cases: A Retrospective Case Series with Literature Review

Background: Severe burns can significantly impact various organ systems, including the gastrointestinal (GI) system. GI complications are frequently observed in patients with over 20% total body surface area (TBSA) burn. Objectives: This case series delves into the intricate phenomenology of post-burn GI dysfunction, challenging conventional cause-and-effect paradigms. Our aim is to discern, comprehend, and explore variables influencing positive and negative outcomes, laying the foundation for further research given the current heterogeneity in the literature. Methods: Severe burn patients with GI dysfunction identified between April 1, 2022, and July 31, 2022, from the institutional database are included in this retrospective case-series, and comparisons were made across baseline and treatment conditions across participants. Data were collected on demographics, burn characteristics, complications, and treatment outcomes. Results: We analysed 12 patients with severe burns and GI dysfunction and categorized them into two patterns: Pattern A, characterised by early onset symptoms, gastric and small bowel dilatation, and a relatively benign course with high recovery rates was observed in 6 patients; and Pattern B, characterised by late-onset symptoms, colonic dilatation, shock, and a high mortality rate due to megacolon was seen in 6 patients. Conclusion: The post-burn GI dysfunction observed in our study is a complex interplay of multiple factors. Adequate fluid resuscitation, timely excision of necrotic tissue, staged food ingestion, specific nutrient administration, and appropriate use of antibiotics and judicious use of selective digestive decontamination (SDD) are essential strategies to prevent and treat this syndrome.

The role of multimodal ultrasound in diagnosis of fetal bowel dilatation and prediction of adverse neonatal outcomes: A study of 86 cases in a series of 43,562 births

ObjectiveTo investigate the diagnostic utility of multimodal ultrasound for fetal bowel dilatation (FBD) in different parts of the bowel and to examine its prognostic potential in FBD. MethodsThis retrospective study analyzed 86 fetuses with a dilated bowel identified via ultrasound in a 10-month postnatal follow-up. Both two- and three dimensional (2D and 3D, respectively) ultrasound volume imaging were used to characterize dilation across different bowel sections. The optimal intestinal diameter cut-off values for pathological bowel dilatation were determined and a predictive model for neonatal surgery was developed. ResultsThe 86 cases of dilatation were distributed as follows: duodenal (n = 36); jejunum/ileum (n = 35); and colonic (n = 15). Duodenal dilatations presented the earliest during pregnancy compared to the other 2 groups (24.4 versus [vs.] 29 vs. 33.7 weeks respectively; p < 0.05). Cases with small intestinal dilatation were delivered earlier than those with colonic dilatation (p < 0.05). Infants with duodenal dilatation had the lowest birth weight and the highest rate of multi-system abnormalities (30.6% vs. 5.7% vs. 20%; p < 0.001). More than one-half of the multi-system abnormalities had chromosomal abnormalities (multiple, 54% vs. single, 12.5%; p = 0.015). There were 2 stillbirths, 24 induced labors, 44 postnatal surgeries, and 18 normal cases after birth. In predicting adverse neonatal outcomes of jejunum/ileum dilatation using a cut-off value of 15.5 mm small intestine diameter, sensitivity was 81.5%, specificity was 62.5%, and the area under the receiver operating characteristic curve (AUC) was 0.762 (p < 0.05). For colonic dilatation, using a cut-off value of 21.5 mm colon diameter: sensitivity was 83.3%, specificity was 77.8%, and AUC was 0.861 (p < 0.05). In detecting jejunum/ileum and colonic obstruction, 3D ultrasound demonstrated significantly better diagnostic efficiency than 2D ultrasound (p < 0.05). Using the backward stepwise selection method, a predictive model for neonatal surgery in patients with jejunum/ileum and colonic dilatation was established: logit (P) = −1.58 + (2.32 × polyhydramnios) +(2.0 × ascites) +(1.14 × hyperechogenic bowel). The AUC for the prediction model was 0.874 (p < 0.05), with 76% sensitivity and 94.1% specificity. ConclusionsDuodenal dilatation occurred earlier, with a higher incidence of chromosomal abnormalities and multi-system abnormalities than dilatation of other parts of the bowel. 3D ultrasound played an important role in the detection of jejunum/ileum and colon obstructions. Clinical signs, including polyhydramnios, ascites, and strong echoes in the intestine, can be used to predict neonatal surgery.

Retroperitoneal hernia following laparoscopic living-donor nephrectomy: a case report and review of literature

BackgroundThe laparoscopic approach is the standard of care for living-donor nephrectomy. A rare postoperative complication is small bowel obstruction due to a retroperitoneal hernia. We present a case of an incidental finding of a retroperitoneal hernia in a patient with a history of laparoscopic donor nephrectomy.Case presentationAn adult male presented with diffuse abdominal pain, vomiting, and obstipation for 12 h. He had undergone laparoscopic donor nephrectomy two months prior. Plain abdominal radiograph revealed a dilated small bowel with homogenous opacity in the left lumbar region. Due to worsening diffuse abdominal pain and a high clinical suspicion of intestinal strangulation and ischemia after conservative management, an exploratory laparotomy was performed. Intraoperatively, an incarcerated small bowel segment herniating through an 8 cm descending mesocolon defect into the retroperitoneal space was discovered, forming a closed-loop obstruction. The bowel segment was reduced, and the mesocolon defect was repaired. The patient was discharged five days postoperatively with good recovery.ConclusionRetroperitoneal hernia following laparoscopic living-donor nephrectomy is a rare but significant complication. Mitigation to prevent mesenteric defect creation, routine inspection, and closure of the defect can reduce the risk of hernia. Non-specific abdominal pain in patients with a history of laparoscopic donor nephrectomy prompts rapid imaging evaluation to aid in the early diagnosis of possible retroperitoneal hernia and its intervention.

Towards an EKG for SBO: A Neural Network for Detection and Characterization of Bowel Obstruction on CT.

A neural network was developed to detect and characterize bowel obstruction, a common cause of acute abdominal pain. In this retrospective study, 202 CT scans of 165 patients with bowel obstruction from March to June 2022 were included and partitioned into training and test data sets. A multi-channel neural network was trained to segment the gastrointestinal tract, and to predict the diameter and the longitudinal position ("longitude") along the gastrointestinal tract using a novel embedding. Its performance was compared to manual segmentations using the Dice score, and to manual measurements of the diameter and longitude using intraclass correlation coefficients (ICC). ROC curves as well as sensitivity and specificity were calculated for diameters above a clinical threshold for obstruction, and for longitudes corresponding to small bowel. In the test data set, Dice score for segmentation of the gastrointestinal tract was 78 ± 8%. ICC between measured and predicted diameters was 0.72, indicating moderate agreement. ICC between measured and predicted longitude was 0.85, indicating good agreement. AUROC was 0.90 for detection of dilated bowel, and was 0.95 and 0.90 for differentiation of the proximal and distal gastrointestinal tract respectively. Overall sensitivity and specificity for dilated small bowel were 0.83 and 0.90. Since obstruction is diagnosed based on the diameter and longitude of the bowel, this neural network and embedding may enable detection and characterization of this important disease on CT.

A103 A COMPREHENSIVE REVIEW OF ENTEROLITH ILEUS SECONDARY TO COMPLICATIONS OF ILEAL DIVERTICULA AND INVESTIGATIONS INTO OPTIMAL MANAGEMENT

Abstract Background Acquired ileal diverticula are rarely found in adults and are only apparent in 1.9% of small bowel contrast studies. Even more rarely, these diverticula can lead to enterolith formation which can obstruct the bowel, a term coined “enterolith ileus”. Both surgical and non-surgical approaches have been espoused in tackling this complication but definitive literature on optimal management is lacking and is limited to scattered case reports and case series. With this phenomenon carrying significant morbidity and mortality, we have conducted a comprehensive review of all available case reports to summarize our understanding of enterolith ileus secondary to ileal diverticula. Aims To understand the varying clinical presentations of enterolith ileus from ileal diverticula complications and understanding optimal management for the pathology. Methods A comprehensive search of PubMed, OVID, CINAHL, and Cochrane databases up to February 2023 was conducted to identify all studies reporting clinical information on enterolith formation in ileal diverticula leading to small bowel obstruction. Relevant data were extracted from selected studies to determine clinical courses and optimal management. Results Our literature review identified 61 case reports of enterolith ileus secondary to complications of ileal diverticula. The mean age of the patients was 51.64 years (SD 20.9), with 27% of them being female. The most common symptoms reported were abdominal pain (87%), nausea, and vomiting (51%), followed by constipation (18%) and melena (5%). Notably, localized abdominal tenderness was a common finding, observed in 74% of cases across 29 out of 34 studies reporting physical examination findings. Diagnostic investigations, including abdominal X-rays and CT scans, consistently revealed dilated bowel loops and signs of bowel obstruction. Surgical intervention was eventually required for almost all patients (97%), with diverticulectomy performed in 47%, enterectomy in 12%, and surgical resection of the bowel in 32% of cases respectively. These surgical interventions demonstrated high success rates, effectively resolving the condition in most cases. Complications, such as wound infection (2 cases), postoperative ileus (3 cases), anastomotic leak, and wound dehiscence (1 case each) were observed in a limited number of patients. Conclusions Our findings highlight the critical importance of prompt diagnosis and management of enterolith ileus secondary to complications of ileal diverticula. We recommend avoidance of initial conservative management as surgical intervention has proven almost always necessary and is highly successful in tackling this pathology. Early recognition and intervention can help minimize the risk of morbidity and mortality associated with this condition. Funding Agencies None

The learning curve for using intestinal ultrasonography

Background and aimsIntestinal ultrasonography (IUS) is challenging to learn. This prospective study examined how the accuracy of IUS increases with operator experience (“learning curve”) and if prior abdominal ultrasound experience facilitates the learning process. MethodsThe study included two trainees with limited abdominal ultrasound experience (< 50 exams) and two with extensive experience (> 500 exams). Each trainee performed 99 examinations and reported four IUS findings. An expert sonographer repeated the exam, and concordance (k) between the expert and trainees was assessed in three consecutive testing periods of 33 exams each. ResultsA progressive improvement in concordance was observed for all IUS findings from Period 1 to Period 3, overall and for both groups of trainees, although those with experience in abdominal ultrasound had faster learning curves. The minimum number of examinations required to achieve concordance with the expert operator for detecting increased bowel wall thickness was 84 and detecting bowel dilatation was 79. However, a minimum of 97 examinations was necessary to achieve concordance for detecting intra-abdominal complications, considered an advanced IUS competence. ConclusionBasic competence in IUS can be acquired with relatively few examinations, while advanced competence requires more extensive training, particularly for gastroenterologists without abdominal ultrasound experience.

Acute Mesenteric Ischemia: Imaging Findings and Mimics

Acute mesenteric ischemia is a rapidly life-threatening condition in which the radiologist may play a crucial role in early diagnosis and thus improve patient outcomes. Acute mesenteric ischemia can occur from arterial embolism or thrombosis, venous occlusive, or nonocclusive etiologies. Key findings for acute arterial occlusion include hypoenhancing bowel, which is usually not thickened or dilated. Venous occlusion often results in a hyperenhancing, thickened, and dilated bowel. Nonocclusive mesenteric ischemia should be considered in the appropriate clinical context, when there is no vascular occlusion on CT, and when there is involvement of watershed regions without specific vascular territory abnormalities. Venous congestion and increased vascular permeability can result in mesenteric edema and ascites; however, it is not predictive of mesenteric ischemia severity. Pneumatosis alone may not indicate presence of nonviable bowel; however, pneumatosis with portal venous gas or pneumoperitoneum has high sensitivity for nonviable bowel. Clinical history and laboratory results can often help differentiate between acute mesenteric ischemia and its mimics, such as inflammatory bowel disease, enteritis, and radiation injury.

MRI AND BLOOD-BASED BIOMARKERS ASSOCIATED WITH SURGICAL MANAGEMENT IN CHILDREN AND ADULTS WITH SMALL BOWEL CROHN'S DISEASE

Abstract BACKGROUND Despite advances in medical therapy, many children and adults with ileal Crohn’s Disease (CD) progress to fibrostenosis requiring surgery. Prior studies have identified circulating and imaging biomarkers associated with strictures, although their associations with need for surgery are not well-established. PURPOSE We aimed to identify MRI and circulating biomarkers associated with the need for surgical management in chidlren and adults with ileal CD. METHODS This prospective, multi-center study included pediatric and adult CD cases undergoing ileal resection (n=50), and CD controls receiving medical therapy (n=83). Noncontrast research MRI examinations measured bowel wall three-dimensional magnetization transfer ratio normalized to skeletal muscle (normalized 3D MTR), modified Look-Locker inversion recovery (MOLLI) T1 relaxation, intravoxel incoherent motion (IVIM) diffusion-weighted imaging metrics, and the simplified magnetic resonance index of activity (sMaRIA) (Figure 1). Circulating biomarkers included CD64, ECM1, and GM-CSF autoantibodies (Ab). Clinical variables, including demographics, anthropometrics, and routine clinical laboratory data (e.g., CRP, fecal calprotectin), also were obtained at the research visit. Associations between MRI and circulating biomarkers and need for ileal resection were tested using univariate and multivariable LASSO regression. RESULTS Mean participant age was 23.9±13.1 years. Disease duration and treatment exposures did not vary between the groups. Univariate biomarker associations with ileal resection included log GM-CSF Ab (odds ratio [OR]=2.87; p=0.0009), normalized 3D MTR (OR=1.05; p=0.002), log MOLLI T1 (OR=0.01; p=0.02), log IVIM perfusion fraction (f) (OR=0.38; p=0.04), and IVIM apparent diffusion coefficient (ADC) (OR=0.3; p=0.001). MRI and circulating biomarker Tukey box plots are presented in Figure 2. The multivariable model for surgery based upon AICc criteria included age (OR=1.03; p=0.29), BMI (OR=0.91; p=0.09), log GM-CSF Ab (OR=3.37; p=0.01), normalized 3D MTR (OR=1.07; p=0.007), sMaRIA (OR=1.14; p=0.61), luminal narrowing (OR=10.19; p=0.003), log CRP (normalized) (OR=2.75; p=0.10), and hematocrit (OR=0.90; p=0.13). CONCLUSION After accounting for clinical and MRI measures of severity, normalized 3D MTR and GM-CSF Ab are associated with need for surgery in ileal CD. GM-CSF autoantibodies and MRI biomarker sequences may be useful for guiding management decisions in CD patients. Figure 1 Research MRI images from a surgical Crohn’s disease patient with stricturing behavior involving the terminal ileum. A and B. Coronal and axial fat-saturated T2-weighted single-shot fast spin-echo (SSFSE) images show wall thickening and luminal narrowing of the terminal ileum (arrows) with more proximal bowel dilation measuring greater than 3 cm. C. Axial 3D magnetization transfer images – MT pulse on (bottom image, arrow), MT pulse off (top image, arrow). D. Axial modified Look-Locker inversion recovery (MOLLI) T1 relaxation image (arrow). E. Representative axial intravoxel incoherent motion diffusion-weighted images with increasing b-values (left to right, arrows). Figure 2 Variation in circulating and imaging biomarkers in Crohn’s disease patients with medical and surgical management. Ctrl: non-IBD healthy controls; Med: CD patients with nonsurgical medical management; Surg: CD patients with surgical management.

P227 The learning curve for using intestinal ultrasonography

Abstract Background The use of intestinal ultrasonography (IUS) is recommended for suspected or known inflammatory bowel disease (IBD), but the technique is challenging to learn. This prospective study examined how the accuracy of IUS increases with operator experience (“learning curve”) and if prior abdominal ultrasound experience facilitates the learning process. Methods The study included five gastroenterologists: four trainees and one expert sonographer. Two trainees had limited abdominal ultrasound experience (&amp;lt; 50 exams) and two had extensive experience (&amp;gt; 500 exams); none had IUS experience. The trainees received an eight-hour course on IUS and one week of hands-on training with the expert sonographer on approximately 50 IUS exams. Thereafter, over a four-week period, each trainee performed 99 examinations and reported four IUS findings. The expert sonographer repeated the exam, and concordance (k) between the expert and trainees was assessed in three consecutive testing periods of 33 exams each. Results A progressive improvement in concordance was observed for all IUS findings from Period 1 to Period 3, overall and for both groups of trainees, although those with experience in abdominal ultrasound had faster learning curves. The minimum number of examinations required to achieve concordance with the expert operator (after the initial 50 exams) for detecting increased bowel wall thickness was 34 and detecting bowel dilatation was 29. However, a minimum of 47 examinations was necessary to achieve concordance for detecting intra-abdominal complications, considered an advanced IUS competence. The number of examinations required to achieve concordance was higher for trainees without than with abdominal ultrasound experience. Conclusion Basic competence in IUS can be acquired with relatively few examinations, while advanced competence requires more extensive training, particularly for gastroenterologists without abdominal ultrasound experience. These findings have implications for the development of training programs and the establishment of proficiency levels in IUS.

Closed bowel loop obstruction by a fibrous band mimicking paraduodenal hernia

Abstract Background A closed-loop obstruction occurs when a section of the intestine becomes blocked at two locations along its pathway, increasing the likelihood of volvulus and ischemia. Frequently, a single adhesive band is the primary cause of a closed loop, although internal hernias from congenital defects or iatrogenic intervention in the mesentery or omentum can also become other factors. In closed-loop obstruction, computed tomography (CT) often displays a distinctive pattern where the bowel appears dilated and filled with fluid, forming a ‘C-shaped’ configuration. Case presentation A 43-year-old female patient presented to the emergency department complaining of acute abdominal pain and repeated bilious vomiting with no history of absolute constipation. By examination, there were tenderness, guarding and rigidity. Her medical history includes type 1 diabetes since the age of 9 years and her surgical history included a onetime cesarean section and negative history of laparoscopic interventions. Ultrasound was done as a first-line investigation. It showed a few dilated bowel loops in addition to moderate intraperitoneal free fluid and could not detect the cause of bowel dilatation; therefore, non-contrast CT scan was requested and revealed the following findings: Two bowel loops exhibited distension and mucosal edema, and the configuration of bowel loops resembled a distinctive C-shape. Conclusion Distinguishing between adhesive small bowel obstruction (SBO) and paraduodenal hernia relies on clinical history, imaging features, and risk factors. Adhesive SBO often stems from prior surgery or inflammation and may exhibit ‘beak’ or ‘whorl’ signs on CT scans.

A rare case of Pouch of Douglas hernia- Atypical presentation in a postnatal mother

Background: Internal hernias are quite rare which constitutes right and left paraduodenal, trans-mesenteric hernia and pelvic hernias. Case presentation: 23 year old female postnatal mother delivered 4 months back, IUCD was inserted post delivery now presented with C/O greenish discharge PV and vaginal fullness. Ultrasound showed few dilated small bowel loops.Computed tomography revealed multiple dilated fluid filled small bowel loops suggestive of subacute small bowel obstruction. Herniation of the small bowel loops into the POD is noted.MRI revealed the small bowel loops in POD herniating through fornix into the vagina. Intraoperatively , small bowel loops were seen herniating through a defect in the POD on the right side into the fornix and formed a sac within the vagina. A sealed perforation was seen within the herniated loop and short segment gangrene was identified. Resection and anastomosis of bowel loop along with closure of defect in broad ligament defect was done. Conclusion: Pelvic hernia through the defect in cul-de-sac is very rare and high clinical suspicion is needed to diagnose this rare condition. Radiological knowledge of this rare entity in a patient with small bowel obstruction aids in early diagnosis and intervention avoiding the complications of bowel ischemia.