Bowel Edema Research Articles

First Reported Incidence of Delayed Secondary Abdominal Compartment Syndrome in a Trauma Patient with Scleroderma: A Case Report and Review of the Literature

Background: Scleroderma is a complex immune-mediated rheumatic disease that is characterized by fibrosis of the skin, internal organs, and vasculopathy. Extensive fibrosis, especially in the limited compartment, has been reported to induce acute compartment syndrome frequently reported involving the upper and lower extremities. Case Presentation: We present a rare case of a 54-year-old Caucasian female who underwent surgery for abdominal compartment syndrome in the setting of scleroderma. Upon arrival, at the hospital, the patient’s health status showed signs of improvement with no indicators of abdominal compartment syndrome until the tenth hospital day. A CT scan showed a new intra-abdominal fluid collection with total lower abdominal anasarca and a stable retroperitoneal hematoma. Following emergency surgery, significant bowel edema without other intra-abdominal injuries was noted. Conclusion: Secondary abdominal compartment syndrome may occur in patients with scleroderma without evidence of intra-abdominal trauma or emergent abdominal surgery. Further research is warranted to investigate the relationship between scleroderma and secondary abdominal compartment syndrome.

Staged Liver Transplantation with Delayed Biliary Reconstruction in the Face of Serious Biliary Disparity and Severe Bowel Edema – A Safe Reality

Two stage liver transplants have been described for ‘toxic liver syndrome’ and for shattering liver trauma. We herein report a cadaveric liver transplant where the grafting was completed in two stages – graft reperfusion in the first stage with a tube hepaticostomy, and a delayed biliary reconstruction. Case study: A 48 years diabetic male (BMI 32) with cryptogenic cirrhosis, refractory ascites, hepatorenal syndrome and a prior surgery, was taken up for cadaveric liver transplantation. The donor liver was healthy except for an unexplainable 15mm common bile duct. The recipient had 18 litres of ascites at surgery and a 3mm fibrotic bile duct, with grossly edematous stomach, duodenum and small bowel. After a piggy-back engraftment, the liver produced copious bile. A duct-to-duct biliary reconstruction was not feasible because of the size disparity and unhealthy native bile duct. Severe bowel edema precluded a safe bilio-enteric anastomosis. A 14 Fr T-tube was inserted into the graft CBD and the procedure completed as a tube hepaticostomy. Postoperatively he maintained his immunosuppression level well on bile refeeding. His ascites resolved in 80 days. On the 86th day post-engraftment, he underwent a Roux-en-Y hepaticojejunostomy, with uneventful recovery and discharge after two weeks. 90 months post-HJ, the patient remains healthy with a normal graft function. Delayed biliary reconstruction in such situation is novel, and the excellent longterm outcome prompts this report.

Long segment “Hanging-snout” end ileosotmy a safe “Surgical disaster mitigating” technique for an “Un-brookeable” end ileum: a study of 23 cases over 12 years

Background: In 1952, Professor Bryan Brooke described his technique for everting an ileostomy in order to minimise skin excoriation1. Pouting, mucosa-everting Brooke’s ileostomy have been accepted as the best technique for stoma formation in almost all cases, save a few difficult situations – such as edematous friable bowel with bulky short mesentry! In such cases formation of standard Brooke’s ‘Pouting’ ileostomy is not only difficult, but an impossible and a dangerous surgical exercise! In these situations where the bowel is “Un-Brookeable” due to aforementioned causes. Over a period of 12 years we could device a formula – “Ray’s Criteria” to decide at operation, if a given ileum in a particular patient, is safely “Brookeable” (i.e. evertable into a neat Brooke, spouting ileostomy) or is “Un-Brookeable”.Methods: 23 patients were included in this study over 12 years, who due to the peculiarity of their body morphology (obesity or thick abdominal fat), edematous friable bowel with bulky mesentry, the ileum could not be drawn outside the abdomen and everted as Brooke’s ileostomy. The “Brookeability” of the exteriorized ileum was decided based on satisfying two issues of Ray’s criteria.Results: By using “Ray’s criteria”, we could seggregate patients safely as “Brookeable” and “Un-Brookeable”. Those deemed “Un-Brookable” underwent “Long segment Hanging snout” end ileostomy, which is the theme of our study.Conclusions: We are emphatic in stating that by using “Ray’s criteria” we could accurately segregate cases into “Brookeable” and “Un-Brookeable” ileum.

Submucosal Lipoma at the lead point of Small bowel Intussusception in an Adult

Abstract Introduction/Objective Morbidity and mortality among adult patients presenting with acute abdominal pain are high, and these patients often require hospitalization with prompt surgical consultation Important differentials include small bowel obstruction from previous surgeries and hernias, acute mesenteric ischemia, and ruptured abdominal aortic aneurysm. Intussusception in adults is rare accounting for about 1% - 5% of small bowel obstructions and thus requiring a high index of suspicion for early detection. In most cases, the lead point is a benign mass, commonly a lipoma, but histopathologic examination of the resected segment is required to rule out malignancy. Methods/Case Report We present a case of a 50-year old male with a medical history of psoriasis and hypertension who was admitted on account of a 1-day history of sudden onset persistent abdominal pain with associated nausea non-bilious emesis. Physical examination reveals no fever and soft non-distended abdomen with diffuse tenderness. CT scan demonstrated long segment small bowel-small bowel intussusception with markedly edematous and dilated bowel, compatible with obstruction. The lead-point was suspected to be a 3.9cm lipoma. Segmental resection and primary re-anastomosis were performed. Gross examination revealed a 13cm segment of bowel telescoping into a distal segment with a lead-point demonstrating mucosal congestion and submucosal thickening corresponding to a well-circumscribed 3.5cm tan yellow soft lobulated mass with yellow cut surface. Histopathology was consistent with lipoma. The patient made an uneventful postoperative recovery. Results (if a Case Study enter NA) N/A Conclusion Intussusception should be kept in the differential diagnosis of adults presenting with sudden onset abdominal pain and pathologic examination of the resected segment is necessary to rule out malignancy.

Intrauterine Intussusception Presenting as Fetal Ascites and Meconium Peritonitis

Intussusception is a well-known cause of intestinal obstruction in children. Its occurrence in fetus as an intrauterine incidence is extremely rare and poses a diagnostic difficulty. Intrauterine intussusception may result in intestinal atresia once the gangrenous segment resorbed. However, a very late occurrence of intussusception just prior to delivery may present as meconium peritonitis. We are reporting a case of premature baby who was born at 35 weeks gestation via emergency caesarean for breech in labour. Routine scan 4 days prior to the delivery showed evidence of fetal ascites. She was born with good Apgar Score and weighed 2.5kg. Subsequently she developed respiratory distress syndrome requiring mechanical ventilation. She passed minimal meconium once after birth then developed progressive abdominal distension and vomiting. Abdominal radiograph on day 4 of life revealed gross pneumoperitoneum and bedside percutaneous drain was inserted to ease the ventilation. Upon exploratory laparotomy, a single ileal perforation was seen 20cm from ileocecal junction with an intussusceptum was seen in the distal bowel. Gross meconium contamination and bowel edema did not favour the option of primary anastomosis, thus stoma was created. Reversal of stoma was performed a month later and she recovered well. Fetus with a complicated intrauterine intussusception may present with fetal ascites and their postnatal clinical and radiological findings need to be carefully assessed for evidence of meconium peritonitis; in which a timely surgical intervention is required to prevent the sequelae of prolonged intraabdominal sepsis in this premature baby.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S18

Small bowel obstruction caused by intrauterine device infection.

A 39-year-old previously healthy woman was referred to our emergency department by a primary care doctor on suspected to be acute enteritis, complaining of fever, anorexia, lower abdominal pain, and frequent diarrhea. The day after admission, although frequent diarrhea stopped, the abdominal distension worsened. An abdominal radiograph revealed several dilated loops of the small bowel, suggested that small bowel obstruction (SBO) had developed. White blood cell count and c-reactive protein were markedly increased, and abdominal contrast-enhanced computed tomography scan showed localized severely edematous bowel mucosa, increased adipose tissue concentration in the pelvis, and a beaded low absorption area in the uterus. Gynecological examination revealed the presence of a pus-filled plastic intrauterine device (IUD) in the uterus. The patient confided that she had sex with her husband 2 days before the onset of symptoms. A diagnosis of SBO due to pelvic peritonitis caused by IUD infection during sexual activity was made. The SBO was cleared in 12days with fasting, peripheral parenteral nutrition, antibiotic treatment, and insertion of an ileus tube. This case reminds us that it needs to consider disorders associated with the uterine appendages, in women of reproductive age with lower abdominal pain.

Anasarca in an Infant – An Unusual Cause

ObjectivesPrimary intestinal lymphangiectasia is a rare cause of protein losing enteropathy. It is usually seen in children less than 3 years of age. The disease is characterised by dilatation and engorgement of lymphatics in the small bowel due to congenital malformation of lymphatic channel or hypoplasia of lymphatics. MethodsA 10 month old female child was admitted with a h/o persistent diarrhoea and generalised swelling of the body for 15 days. She was exclusively breastfed till 6 months, complementary feeding started thereafter. On examination, both eyelids were edematous with b/l pedal edema and abdominal distension. Investigations showed hypoalbuminemia, hypoproteinemia and thrombocytosis. Urine, stool examination and spot urine protein creatinine ratio were normal. USG abdomen showed mild ascites and edematous bowel loops. UGI endoscopy and biopsy showed multiple fragments of duodenal mucosa with subepithelium showing multiple dilated lymphatic spaces. The child was started on high protein, low fat diet with MCT, vitamin D, zinc and FFP transfusion. Child improved clinically with reduced edema and loose stools, hence discharged. I/v/o persistent thrombocytosis, we considered possibility of a rare syndrome, CHAPLE (Complement hyperactivation, Angiopathic Thrombosis and Protein losing enteropathy). However, CD55 level was normal and hence we also considered further evaluation for non -CHAPLE PIL but genetic work up could not be done. ResultsPIL should be considered as one of the differential diagnosis in a child presenting with anasarca. The main modality of treatment in our case was high protein, low fat diet and MCT supplements. Child was on regular follow up with pediatric gastroenterologist for about 3 months. Mother reported the baby had persistent loose stools and was treated at home and died before reaching a hospital. We have heard in literature about good outcomes in PIL as well as frequent relapses with chronicity. This acute life threatening event in PIL needs to be discussed regarding possibility of any thrombosis secondary to dehydration and thrombocytosis. ConclusionsPIL is a rare condition seen in children less than 3 years. Early diagnosis with endoscopic visualization of the gut and biopsy of the small bowel may play a great role. Mainstay of treatment is high-protein, low fat diet with MCT supplement. Funding SourcesNone.

P193 Assessement of cumulative bowel damage using Lemann index and MaRIA score in surgically naive patients with Crohn’s disease

Abstract Background The Lémann index (LI) is a unique tool that measures cumulative bowel damage in Crohn’s disease (CD) using data on surgical procedures and severity and extent of bowel lesions. Magnetic resonance index of activity (MaRIA) is composed of features independently associated with endoscopic disease activity. Primary aim was to investigate differences in factors associated with elevated LI in total population and surgically naive patients. Secondary aim was to compare diagnostic accuracy of gMARIA and LI in determing active disease in surgically naive patients. Methods In this cross-sectional study on 251 CD patients LI was calculated evaluating 20 small bowel, 7 large bowel and 3 upper GI segments. For each segment bowel resections, inflammatory, stricturing or penetrating lesions were taken into account. Global MaRIA (gMaRIA) index was calculated using following parameters on 6 bowel segments: bowel wall thickness, ulcers, edema and relative contrast enhancement. Longstanding disease was defined as ≥10 year disease duration. Disease activity was defined as combination of clinical and biochemical disease activity (CRP>5 or HBI≥5). Results This study included 251 CD patients [age 35 (25–47), 55.3% males, disease duration 7 (2–15) years]. There were 103 (40%) surgically naïve and 112 (44.6%) patients with longstanding disease. In total population, higher LI values were observed in patients with longstanding disease (10.47 vs 5.41, p<0.001), patients treated with biological therapy (9.6 vs. 6.3, p=0.005) and with prior surgery (11.92 vs. 1.57, p<0.005). There was no difference in LI according to activity (7.53 vs. 7.66, p=0.911) and smoking status (6.9 vs. 7.3, p=0.336). In multivariate analysis adjusted for age, gender and BMI, independent predictors of elevated LI in total population was prior surgery (β=9.26, p<0.001) and disease duration (β=0.20, p<0.003). Independent predictors in surgically naive patients were current or ex smoking status (β=1.69, p<0.001) and gMARIA (β=0.10, p<0.001). Biological therapy, disease duration and clinical and biochemical disease activity were not significant predictors (p>0.05). Diagnostic accuracy of LI in surgically naive patients in defining active disease was lower [AUC 0.75 (95%CI 0.65–0.84)] compared to gMaRIA [AUC 0.82 (95%CI 0.73–0.89)]. Conclusion Since surgical procedures contribute significantly to the LI, it is important to determine predictors of cumulative bowel damage in surgically naive patients. CD patients should be strongly advised to stop smoking and to regularly monitor disease activity using radiological methods. gMaRIA is superior to LI in detecting active disease in surgically naive patients.

P212 Assessment of Crohn’s disease activity using global MaRIA score in patients with ileal and ileocolonic disease

Abstract Background Magnetic resonance index of activity (MaRIA) is composed of features independently associated with endoscopic disease activity and is surrogate marker of disease activity. The aim of this study was to evaluate correlation of global MaRIA (gMaRIA) with clinical and biochemical disease activity indices and diagnostic accuracy for active disease in patients with terminal ileum disease and ileocolonic disease. Methods This is a cross-sectional study which included 251 patients with diagnosed CD. Global MaRIA (gMaRIA) index was calculated on 6 bowel segments (the distal ileum, ascending, transverse, descending, sigmoid colon and rectum) using following parameters: bowel wall thickness, ulcers, edema and relative contrast enhancement. Disease activity was defined as combination of clinical and biochemical disease activity (CRP>5 or HBI≥5). Disease extension was classified using Montreal classification (L1 ileum, L2 colon, L3 ileum and colon). Results This study included 251 CD patients [age 35 (25–47), 55.3% males, BMI 21.8 (18–25) kg/m2, median disease duration 7 (2–15) years]. Ileal disease (L1) was present in 84 (33.5%) and ileocolonic disease (L3) in 151 (60.1%) patients. Correlation of gMARIA with biochemical indices of disease activity (CRP) was r=0.48, p<0.001 and with HBI r=0.33, p<0.001. Diagnostic accuracy of gMARIA in defining active disease in patients with L1 disease was considerably high [AUC 0.83 (95%CI 0.72–0.91)]. On the other hand, diagnostic accuracy in defining active disease in patients with L3 disease was good [AUC 0.71 (95%CI 0.62–0.79)], which is lower compared to L1 disease. In surgically naïve patients diagnostic accuracy of L1 disease was [AUC 0.88 (95%CI 0.72–0.96)], and for L3 disease [AUC 0.78 (95%CI 0.64–0.89)]. Conclusion Global MaRIA index showed higher diagnostic accuracy in detecting clinically and biochemically active disease in terminal ileum compared to ileocolic disease. These results emphasize the important role of magnetic resonance enterography in monitoring disease activity in patients with isolated ileal disease. Global MaRIA score correlates better with biochemical disease activity compared to clinical disease activity, which points out to the significance of biochemical remission.

782 A Rare Complication in A Post-Operative Bariatric Patient: COVID-19 Induced Mesenteric Venous Thrombosis

IntroductionThe emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has provided enormous challenges in the delivery of surgical care. In addition to respiratory tract infections, coronavirus disease 2019 (COVID-19) is associated with both arterial and venous thrombotic complications.Case Details:We present a case of acute superior mesenteric venous (SMV) thrombosis in a 36-year-old female patient who underwent Roux-en-Y gastric bypass three years previously. Her presentation with acute abdominal pain occurred 6 days after a positive nasopharyngeal swab. An admission CT scan demonstrated an abrupt cut off in the proximal SMV with resultant small bowel oedema. Subsequent thrombophilia screening and mutation testing for myeloproliferative neoplasms were all negative. She had also previously carried three pregnancies to term without any thrombotic complications. Hence, the high suspicion of acute COVID-19 induced mesenteric thrombosis.ConclusionsIn patients who have previously undergone Rouy-en-Y gastric bypass and lost significant weight, acute abdominal pain normally raises a high suspicion of internal hernia. However, as the pandemic progresses surgeons need to be mindful of COVID-19 induced mesenteric thrombosis as a differential diagnosis during the workup of acute abdominal pain. This was well demonstrated on a CT scan with intravenous contrast.

Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis?

AIM: To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS: We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS: The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION: NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer’s instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.

How to make “Unresectable” resectable? “Low” locally advanced pancreatic cancer with the involvement of smv and all its tributaries

Background: Pancreatic ductal adenocarcinoma(PDAC) involving superior mesenteric vein (SMV) and all its tributaries consider unresectable because of impossibility of venous reconstruction. Aim: To show technical possibility of R0-resection in abovementioned situation Patients and methods: Database retrospective analysis of 202 vein resections during 594 pancreatic surgeries. Five patients were found who underwent R0-resections for locally advanced PDAC involving SMV and all its tributaries. Age: 52-71y.; Neoadjuvant chemotherapy FOLFIRINOX 4-12 courses. Results: Excision of SMV and all its suppliers associated with Whipple procedure without reconstruction in 3 cases and total duodenopancreatectomy with replantation of inferior mesenteric (IMV) in the stump of splenic (SV) vein, once with resection and reconstruction of SMA were performed (2012 -2020). True vein involvement was found in 100% of cases. Temporary (2-14 days) postoperative bowel edema was the constant symptom, lymphorrhea of more than 500 ml longer than 3 days was revealed in 3 cases. All the patients alive, functional and four disease-free 21, 18, 13,12 and 11 months after treatment. The mandatory condition for selection for this surgery is the functioning venous Riolan arch, which can be delineated by CT preoperatively and confirmed at surgery together with adequate portal blood flow, which should not be less than 10 cm/sec. Conclusion: Neoadjuvant therapy, definite controllable anatomical, physiological and technical conditions make systemic performance of R0-resections for locally advanced PDAC involving SMV and all its tributaries feasible, which can reduce number of unresectable cases for PDAC.

A Case of Superior Mesenteric Venous Thrombosis Managed by Thrombectomy without Bowel Resection

We present a case of superior mesenteric venous thrombosis (SMVT) treated successfully with thrombectomy without bowel resection. A 73-year-old female was referred to our hospital with complaints of stomach ache. The patient was diagnosed with SMVT with impending bowel necrosis and underwent an emergency operation, after computed tomography (CT) revealed a thrombus in the superior mesenteric vein (SMV) extending to the splenic vein, ascites, and extremely edematous intestines. The intestines were not necrotic though highly congested. To avoid massive bowel resection, aggressive thrombectomy was performed. Postoperative CT confirmed resolved SMV and improved bowel edema. Prompt thrombectomy should be considered in such cases.

Superior Mesenteric Arteriovenous Fistula

Arteriovenous fistulae between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) are extremely rare; most are associated with abdominal trauma. A 47 year old woman who was diagnosed with extensive metastatic ovarian carcinoma presented with right sided low abdominal pain. She denied any history of abdominal surgery. Plain computed tomography (CT) showed bowel oedema. Intestinal vasculopathy was suspected. Contrast enhanced CT angiography revealed not only a hyperaemic bowel (white arrow), but also a fistula between the SMA (red arrow) and SMV (blue arrow; A and B). Endovascular fistula exclusion was recommended, but the patient declined further treatment.Image 1

Diffuse Hemorrhagic Enterocolitis in the Setting of 2019 Coronavirus

A 47-year-old woman with diabetes diagnosed with COVID-19 was transferred to our institution for extracorporeal membrane oxygenation therapy. Gastroenterology was consulted because of worsening diarrhea, which started before transfer, and new hematochezia after extracorporeal membrane oxygenation was discontinued. Contrast-enhanced computed tomography demonstrated diffuse small and large bowel wall thickening and edema (Figure A, arrows), resulting in ribbon-like bowel. Upper endoscopy and colonoscopy were pursued. Atrophic and friable gastric and duodenal mucosa was found. Diffuse congested, friable, and hemorrhagic mucosa (Figure B) was seen throughout the colon and terminal ileum. Biopsies from the ileum and colon (Figure C) showed complete loss of glandular epithelium without associated increase in lamina propria inflammation despite the degree of epithelial damage. Supportive management was pursued. Extracorporeal membrane oxygenation is associated with immune system activation, leading to a systemic inflammatory response and a procoagulant state that can ultimately cause organ injury, such as ischemic colitis. COVID-19 has demonstrated a wide range of gastrointestinal manifestations. We present a case of diffuse hemorrhagic enterocolitis with endoscopic biopsies showing diffuse mucosal damage with relative lack of inflammatory response. This histologic pattern of injury resembles immunosuppressed states and apoptosis-mediated processes. Based on timeline and findings, the gastrointestinal tract injury is likely related to severe COVID-19.

It Is Complex: Predicting Gastroschisis Outcomes Using Prenatal Imaging

BackgroundGastroschisis occurs in one of 2000 births with survival rates partially contingent on intestinal complications and time to establishing feeding. Enhancements in prenatal imaging have given better insight into postnatal outcomes. The goal of this study was to examine the gastroschisis patient population at a single children's hospital in the modern era and to use prenatal ultrasound (US) to develop new prenatal prognostic indicators. MethodsWe performed a retrospective review of gastroschisis patients at a quaternary-care referral children's hospital from 2010 through 2018. We recorded demographics, prenatal data and imaging, early postnatal data, operative data, and patient outcomes. We compared patients within our cohort born with complex gastroschisis (bowel atresia/perforation) to uncomplicated gastroschisis patients. Second trimester and third trimester prenatal US were evaluated for changes in amniotic fluid level, amount of external bowel, bowel dilatation, and bowel wall edema to identify prognostic indicators of the status of the bowel at birth. For categorical variables, chi-square tests were used to assess for significance. Univariate and multivariable analyses were used to assess significance between categorical and continuous variables using medians and interquartile ranges or means. ResultsA total of 134 patients were included in the study: complex (n = 24), uncomplicated (n = 110). Compared with uncomplicated gastroschisis, complex patients required longer median days to feeding initiation (44 versus 10; P < 0.001), full feeding (80 versus 23; P < 0.001), length of stay (83 versus 33; P < 0.001), and total parenteral nutrition at discharge (P = 0.004). Full US data were available on 81% of patients, and partial data were identified on 19%. Prenatal US analysis showed significantly more complex patients had polyhydramnios on third trimester US (23.5%-4.3%; P = 0.018). US analysis showed these additional factors to be most associated with complex gastroschisis: large amount of external bowel on third trimester US, increase in bowel edema on third trimester US, and increase in external bowel dilation on third trimester US. Multivariable logistic regression analyses revealed amniotic fluid on third trimester US to be the most significant predictor of complex gastroschisis (P = 0.01). Polyhydramnios in combination with two-thirds of the other US factors had both sensitivity and positive predictive value for predicting complex gastroschisis of 75%. Patients with two or less of these positive US factors had high specificity (96.8%) and negative predictive value (87.5%), suggesting uncomplicated disease. There were no differences in perioperative or long-term complications in the complex group when compared with the group with uncomplicated gastroschisis. ConclusionsPolyhydramnios on third trimester prenatal US on babies with gastroschisis can predict complex gastroschisis at birth, whereas the absence of markers on prenatal US can suggest uncomplicated disease. Complex gastroschisis is associated with increased time to feeds and length of stay.

S2797 First Case of Isolated Angioedema of the Bowel Caused by Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

INTRODUCTION: Visceral angioedema (VA) has been widely reported as a side-effect of angiotensin-converting enzyme inhibitors (ACEI). We report the first case of VA from NSAIDs. CASE DESCRIPTION/METHODS: An 80 y/o F with history of multiple abdominal surgeries, hypertension on lisinopril, and lumbago on aspirin 325 mg twice daily presented with acute epigastric pain, nausea, and vomiting. A CT scan showed moderate thickening and dilation of the distal small bowel (SB), without transition point. Symptoms resolved within days with supportive measures. One month later, while asymptomatic, a non-contrast MRI for pancreatic cyst surveillance showed normal SB. Two weeks after the MRI, her abdominal symptoms recurred. CT scan revealed multiple dilated, edematous fluid-filled stretches of SB, without transition point. Symptoms resolved spontaneously within days. Two months later, symptoms returned, with CT showing similar edema in the colon wall (Figure 1). Due to sharp angulations from edematous bowel, only a gastroscope could traverse the colon, with normal appearance of mucosa from the anus to the hepatic flexure. No SB evaluation was attempted due to SB edema. She improved after conservative management. She discontinued her lisinopril. One month later, symptoms recurred, with CT scan showing worsened bowel wall edema from prior CT (Figure 2). Labs were unremarkable for serum complement C4, C1 esterase inhibitor functional assay, extended stool pathogen panel, complete blood count, monoclonal gammopathy screen, and serum cytomegalovirus DNA. Aspirin was stopped. Symptoms abated within 24 hours. Five weeks later, while asymptomatic, her CT showed normalization of bowel wall (Figure 3). In no episode did the patient experience constitutional symptoms, dermatologic changes, dyspnea/wheezing, diarrhea, melena, or hematochezia. She had no new exposure to medications, travel, or dietary changes. In all cases where intravenous contrast was used, splanchnic vessels were patent. DISCUSSION: Episodic bowel obstructive symptoms associated with bowel thickening—and interval clinical improvement paralleling radiologic improvement of bowel thickening—illustrate the cadence of VA. As the VA occurred one month after stopping her ACEI, and symptoms resolved after stopping NSAIDs, it was likely triggered by her NSAID use. The shared pathogenesis and presentation of angioedema and enteropathy caused by NSAIDs provide a rationale for NSAID-induced VA. In patients without resolution of VA after stopping ACEI, NSAID cessation is the next step.Figure 1.: Computed tomography scan of the abdomen with intravenous contrast showed diffuse wall thickening of the descending and rectosigmoid colon. No transition point observed. Wall thickening, edema, and increased mucosal enhancement of multiple loops of the ileum and distal jejunum were observed, as well.Figure 2.: Computed tomography scan of the abdomen with intravenous contrast showed worsened evaluation compared to the previous scan. Diffuse wall thickening of the descending and rectosigmoid colon can be seen. No transition point can be seen. Wall thickening, edema, and increased mucosal enhancement of multiple loops of the ileum and distal jejunum were observed as well.Figure 3.: Five weeks after discontinuing her twice-daily aspirin, the patient underwent computed tomography scan with oral contrast (no intravenous contrast used), which showed interval resolution of the small bowel and colon wall thickening.

A RARE SITE OF PRESENTATION OF KLEBSIELLA PNEUMONIAE INTRA-ABDOMINAL ABSCESS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Klebsiella pneumoniae, a gram-negative bacterium found in human gut flora commonly causes pneumonia, empyema, pyogenic liver abscess, catheter-related bacteremia, genito-urinary infection, nosocomial meningitis, etc. Intra-abdominal abscess caused by K. pneumonia commonly include sites such as liver and spleen. CASE PRESENTATION: 34-year-old female with PMH of diabetes mellitus presented with fever & left-sided lower abdominal pain. WBC was 16K/μL. Physical exam showed left lower quadrant abdominal tenderness. Bimanual pelvic exam revealed bulging anterior vaginal wall & cervix abutting a tense and tender mass. CT abdomen revealed ascites, 7 cm left-sided adnexal complex mass. Pelvic ultrasound described adnexal mass suspicious for abscess. She was admitted to Medical ICU and treated for sepsis secondary to intra-abdominal infection following the sepsis protocol which failed to show clinical improvement leading to septic shock. Exploratory laparotomy revealed cloudy light brown peritoneal fluid, diffuse dilated & edematous bowel, edematous bladder, diffuse fibrinous exudative coating of the serosal surfaces, edematous fallopian tubes & ovaries bilaterally, normal-appearing appendix. Vesico-uterine space was tense and obliterated, consistent with imaging for the abscess location sandwiched between the anterior wall of the uterus & posterior wall of the bladder which on surgical digital exploration drained approximately 200 mL of thick yellow purulent fluid. Culture obtained from the intra-abdominal abscess & blood culture obtained at the time of the admission was consistent with K. pneumoniae. The patient showed clinical improvement after the surgery. DISCUSSION: Intra-abdominal abscesses typically develop after perforation of a hollow viscus or colonic cancer, extension of an infection (E.g. pyogenic liver abscess) from appendicitis, diverticulitis, Crohn's disease, pancreatitis, pelvic inflammatory disease (E.g. Neisseria gonorrhoeae and Chlamydia trachomatis) &/or gynecological and surgical procedures. Causative organisms typically reflect normal bowel flora, complex mixture of aerobic gram-negative bacteria & anaerobic bacteria. K. pneumoniae is known to cause pyogenic liver abscess reported as a complication in diabetic patients. If presenting as a complication of Crohn's disease or diverticulitis in females, the recto-uterine space is the most common site due to the proximity of the bowel to the bladder. However, an abscess in the vesico-uterine space has not been commonly reported. Although this patient's presentation was concerning for tubo-ovarian abscess from imaging, surgical exploration ruled it out and found the abscess in vesico-uterine space. CONCLUSIONS: This case describes a rare presentation of spontaneous intra-abdominal abscess in a female diabetic patient found in the vesico-uterine space (not the liver and spleen) caused by Klebsiella pneumoniae. Reference #1: Di Carlo P, Pantuso G, Cusimano A, et al. Two cases of monomicrobial intraabdominal abscesses due to KPC--3 Klebsiella pneumoniae ST258 clone. BMC Gastroenterol. 2011;11:103. Published 2011 Sep 30. https://doi.org/10.1186/1471-230X-11-103 Reference #2: Jen-Hsien Wang, Yung-Ching Liu, Susan Shin-Jung Lee, Muh-Yong Yen, Yao-Shen Chen, Jao-Hsien Wang, Shue-Ren Wann, Hsi-Hsun Lin, Primary Liver Abscess Due to Klebsiella pneumoniae in Taiwan, Clinical Infectious Diseases, Volume 26, Issue 6, June 1998, Pages 1434–1438, https://doi.org/10.1086/516369 Reference #3: Itzhak Brook, Edith H. Frazier, Aerobic and Anaerobic Microbiology of Retroperitoneal Abscesses, Clinical Infectious Diseases, Volume 26, Issue 4, April 1998, Pages 938–941, https://doi.org/10.1086/513947 DISCLOSURES: No relevant relationships by Jagadish Akella, source=Web Response No relevant relationships by Fatima Anjum, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response No relevant relationships by Robin Sharma, source=Web Response

S3551 Factors Related to Patient Outcomes Following Intestinal Transplant Surgery for Gunshot-Related Short Bowel Syndrome

INTRODUCTION: We discuss factors that may have contributed to variations in patient outcome after intestinal transplant surgery secondary to short bowel syndrome (SBS). Trends in this research are relevant for gastroenterologists considering intestinal transplant surgery for applicable patients. CASE DESCRIPTION/METHODS: A retrospective chart review was conducted for two intestinal transplant patients at a large urban medical center. Both patients underwent intestinal transplants secondary to SBS after small bowel resections for gunshot related injury (GSW). A 22-year old male underwent a small bowel and colon resection after injury from GSW, leading to the development of SBS. Eleven months later, he underwent an intestinal transplant surgery with a terminal ileostomy created. No co-morbidities were noted before transplant surgery; after transplant surgery, the patient developed acute kidney injury (AKI) and anemia. He was treated with Cidofovir and thymoglobulin for acute cellular and humoral transplant rejection via adenovirus enteritis at five years and again at eight years post-transplant. Complications secondary to acute transplant rejection led to enterectomy nine years post-transplant. A 37-year old male underwent a small bowel and right hemicolectomy after injury from GSW, leading to the development of SBS. Eight years later, he underwent an intestinal transplant surgery from a high-risk donor with a proximal jejunojejunostomy, distal ileo-colostomy, and ileostomy created. Surgical complications included congestion of graft and bowel edema. Co-morbidities before transplant surgery included history of DVT, cholecystectomy, and smoking history; after transplant surgery, the patient developed AKI, anemia, and inferior vena cava/superior mesenteric vein stenosis. The patient was treated with Cidofovir, plasmapheresis, and intravenous immunoglobin (IVIG) for acute cellular and humoral transplant rejection via adenovirus enteritis a month post-transplant. The patient passed away from complications secondary to acute transplant rejection eleven months post-transplant. DISCUSSION: Variations in patient outcome post-intestinal transplant are due to multi-factorial causes such as pre-transplant comorbidities, alterations in transplant surgical procedure, and severity of surgical complications. Further research is needed to examine the contribution of immunosuppression regimens, viral, social, and age-related factors on outcomes in intestinal transplantation.

S1759 Early Post-Endoscopic Transverse Colo-Colonic Intussusception

INTRODUCTION: Intussusception is a form of bowel obstruction defined as the telescoping of proximal segment of bowel into a distal segment. Intussusception in adults accounts for 5% of all cases and is usually secondary to a lead point such as a tumor or polyp. Intussusception in adults presents with vomiting, abdominal pain, hematochezia, or constipation. Cases where organic lesions act as the lead point present as a bowel obstruction. CT scan is diagnostic, which can identify location and presence of a lead point. Those with lead points can cause obstruction and ischemia- surgery is the treatment. Intussusception developing after an endoscopic procedure is extremely rare. In several cases there was a polypectomy performed and the subsequent intussusception was attributed to bowel edema acting as a lead point. All cases were treated with surgical intervention. CASE DESCRIPTION/METHODS: A 54-year-old female patient with a history of diabetes presented to the ED with worsening colicky abdominal pain starting four hours after a colonoscopy with polpectomy in the transvsere colon was performed. She also experienced red mucus in her stools. Her vital signs were within normal limits. On exam, she had a non-distended abdomen, with mild tenderness over the RUQ without any palpable masses. Her blood work was significant for a white count of 13 with a normal metabolic profile and lactate. The patient had an abdominal X- ray and CT of the abdomen which showed a transverse colo-colonic intussusception with partial obstruction. The patient was seen by the surgical team who opted for a conservative management with IV fluids and nil per os. Her symptoms rapidly improved the next day. She was started on a liquid diet which was advanced without complications. She was discharged on the third day after a normal bowel movement. An MRI two months after discharge was unremarkable. DISCUSSION: Intussusception with colonoscopy as an etiology is very uncommon. In our patient, polypectomy in the setting of colitis likely contributed to her development of an intussusception and partial bowel obstruction. There are no standard guidelines for management. In all colonoscopy-related cases cited, surgical interventions were pursued. Conservative management was pursued for our patient who had complete resolution of her symptoms. This report demonstrates that in non-malignant intussusception cases a conservative approach at first, with surgery reserved for patients with worsening symptoms, is practical.Figure 1.: Intussusception shown on abdominal CT (orange arrow).Figure 2.: Followup MRI showing resolution of intussusception (orange arrow).