Cause Of Mechanical Bowel Obstruction Research Articles

FP7.9 - Caecal Volvulus with Ischaemia in Pregnancy Requiring Right Hemicolectomy

Abstract Background Caecal volvulus is a rare but significant pathology, accounting for 1-3% of all bowel obstructions. There are only 3 published case reports in pregnancy, and there is often a significant delay in diagnosis. Presentation A patient in her 30s was 22 weeks pregnant with her first baby conceived through IVF. She presented with a 2 hour history of severe epigastric pain and vomiting. Inflammatory markers were normal with lactate 3.5, which normalised after fluids. This was her third presentation of pain during pregnancy. She was treated as gastritis and kept in for observation. An ultrasound demonstrated free fluid with no cause. The patient remained in severe pain and repeat bloods demonstrated worsening inflammatory markers. By this time, MRI was no longer available so a CT occurred at 9pm which showed caecal volvulus with acute ischaemia. Treatment At emergency laparotomy, the diagnosis of caecal volvulus was confirmed with a non-viable ascending colon but no perforation or enteric contamination. A right hemicolectomy with ileocolic anastomosis was performed. She was admitted to ITU post-operatively, then stepped down to the ward on day 2 where she continued to make a good recovery and was discharged on day 5. Conclusion Caecal volvulus is a recognised cause of mechanical bowel obstruction in pregnancy but can be difficult to diagnose. Optimum outcome of surgical complications in pregnancy relies on optimum treatment of the mother. Pregnant patients with pain out of proportion to their clinical presentation need a low threshold for cross-sectional imaging, which should be discussed promptly with radiology.

An important cause of mechanical bowel obstruction in older patients: gallstone ileus.

An important cause of mechanical bowel obstruction in older patients: gallstone ileus.

Symptoms: Abdominal Pain, Diaphoresis, Fever, Nausea, and Constipation

Symptoms: Abdominal Pain, Diaphoresis, Fever, Nausea, and Constipation

Gallstone ileus in a middle-aged male with an atypical history: a case report

Currently, gallstone ileus is an unusual complication of cholelithiasis (0.3–3.0 %) and a rare cause of mechanical bowel obstruction (0.1–4.0 %). The rarity of the condition makes it impossible to plan the large prospective randomized clinical trials, so the analysis of case reports is significant for decision making in the management of gallstone ileus. We report a case of gallstone ileus in a middle-aged male who had a history of surgery for duodenal ulcer perforation in past. A combination of peptic ulcer disease and cholelithiasis is based on a reduced gastrointestinal hormones secretion. Clinical specialists need to consider information about the greater frequency and asymptomatic clinical course of gallstone disease against a background of duodenal ulcer. Duodenal ulcer scar and bulbar deformity may promote to the cholecystoduodenal fistula formation. In the presence of an acute bowel obstruction symptoms and the absence of gallbladder instrumental examination results, it is possible to recommend the prior gastroduodenoscopy for the pre-operative pneumobilia detection. The optimal surgical approaches for acute gallstone ileus are still controversial.

A216 WHEN CANCER CASTS THE FIRST STONE: A CASE REPORT OF GALLBLADDER CANCER PRESENTING AS GALLSTONE ILEUS

BackgroundGallstone ileus is a rare cause of mechanical bowel obstruction. It occurs when a biliary stone passes through a cholecystoenteric fistula and becomes impacted in the bowel lumen, most commonly at the terminal ileum or ileocecal valve.Gallbladder cancer is rare and often has a poor prognosis. Many patients present with advanced-stage disease and only 10% of patients are candidates for surgical resection. Early research has shown there is an increased incidence of gallbladder cancer among patients with gallstone ileus. To date, this relationship remains poorly understood.AimsTo present a case of an elderly female whose gallbladder cancer presented after causing a cholecystoenteric fistula and gallstone ileus.MethodsA retrospective review of a single patient case.ResultsOur patient was a 78-year-old female with a background history of hypertension, iron-deficiency anemia, osteoporosis, and treated bilateral breast cancer. She initially presented with acute cholecystitis, complicated by a concurrent pulmonary embolism. Given her need for systemic anticoagulation, she was treated non-operatively with antibiotics and an outpatient cholecystectomy was planned.She returned to hospital eight months later reporting two days of nausea and vomiting. A repeat CT scan showed a cholecystoduodenal fistula with a 3.5cm x 2.6cm gallstone impacted 20cm from the ileocecal valve. A laparoscopic-assisted enterolithotomy was performed and her postoperative course was uneventful.One month later, a CT scan was organized by her family physician to follow-up on incidental liver lesions. While the liver lesions were deemed benign, there was new lobulated soft tissue within the gallbladder, measuring 4.8cm x 4.7cm x 6.2cm, suspicious for a primary gallbladder malignancy. A follow-up MRI confirmed an intraluminal mass with direct invasion into hepatic segment III as well as marked segment III intrahepatic biliary dilatation. Endoscopy to the duodenum and cholecystoduodenal fistula was performed with a biopsy confirming gallbladder adenocarcinoma.She underwent an open radical cholecystectomy, left hepatic lobectomy, antrectomy, resection of 1st portion of duodenum, and reconstruction with a Roux-en-Y gastrojejunostomy. Final pathology and staging confirmed a pT3pN0M0 adenocarcinoma of the gallbladder with a fistula tract within the cancer extending to the duodenum. She was then referred to a cancer center to complete a six-month course of adjuvant chemotherapy with capecitabine.ConclusionsGallstone ileus is a cause of mechanical bowel obstruction and rarely, it can be the first presentation of gallbladder cancer. Gallbladder cancer has a poor prognosis with many patients presenting with late-stage disease. As a result, we recommend the consideration of post-enterolithotomy imaging in select patients to evaluate for evidence of malignancy.Funding AgenciesNone

Gallstone ileus: A rare cause of small intestine obstruction.

Gallstone ileus is a very rare cause of mechanical bowel obstruction with often‐delayed presentation and nonspecific symptoms. Aerobilia is found in approximately 50% of patients with gallstone ileus.

A Rocky Situation: Judicious Management of Gallstone Ileus Complicated by Bowel Necrosis and Perforation

Gallstone ileus is an uncommon cause of mechanical bowel obstruction, associated with high rates of mortality. This case report details the management of a case of complicated gallstone ileus in a rural setting. A 64 year old male presented to a rural emergency department with acute lower abdominal pain, and was found to be in septic shock with generalised peritonitis. Past history was significant for rheumatoid arthritis on immunosuppression, chronic obstructive pulmonary disease and obesity. Blood tests revealed an elevated bilirubin (45mmol/L) and lactate (2.8mmol/L), whilst Computer Tomography demonstrated Rigler’s triad. The patient was resuscitated and underwent an emergency laparotomy. Intraoperatively, there were multiple areas of full-thickness necrosis and one area of perforation in the distal ileum. A 4cm diameter gallstone was removed from a one metre segment of resected distal ileum. The patient’s haemodynamic instability requiring inotropic support limited the operation to damage control, leaving the remaining small bowel stapled off. The patient was transferred via air ambulance to a tertiary hospital. An end ileostomy was created with a view of re-anastomosis in future. He had an uneventful recovery. This case raises awareness of the rare phenomenon of enteric full-thickness necrosis and perforation associated with gallstone ileus. In the rural setting with limited intensive level care, the less invasive surgical approach is safer. Early communication with the receiving hospital is vital. Due to the paucity in the literature comparing outcomes, there is no consensus on management but should be individualised to the patient’s condition, co-morbidities and healthcare setting.

Gallstone ileus after hepaticojejunostomy in liver transplant recipient: case report

Presenter: Patricio Vanerio MD | Hospital Central de las Fuerzas Armadas Background: Gallstone ileus is an infrequent cause of mechanical bowel obstruction. It is caused by transition of a gallstone in the gastrointestinal tract usually through a biliary-enteric fistula, occurring in 1 to 3% of all cases of mechanical bowel obstruction. In patients with a hepaticojejunostomy gallstones can be formed at the proximal side of it and then pass through the lumen. In this cases hepatolithiasis is associated with recurrent anastomotic stricture and cholangitis. Even though abdomen computed tomography (CT) is very informative for diagnosis of gallstone ileus, it is oftenly found during laparotomy performed for unexplained small bowel obstruction. We present the case of a patient who was admitted with a gallstone ileus, in whom the gallstone stone was formed at the hepaticojejunostomy (liver transplant recipient) and entrapped at afferent loop of the Roux-en-Y jejunojejunostomy. Methods: We present the case of a 22yo female. Heretopic reduced liver recipient 20 years ago because of biliary atresia. Admitted 2 years ago with a mild cholangitis, MRCP demonstrated stenosis of hepaticojejunostomy associated with hepatolithiasis. Treatment consisted in percutaneous dilation of bilioenteric anastomosis and progression of litiasis to jejunum. No complications or symptoms were registered during follow up in the next 2 years. Begun with sudden intermittent colicky abdominal pain, nausea, and vomiting. Computed tomography (CT) evidenced small intestine dilation associated with 2 hyperdense structures of about 30 and 40mm as cause of obstruction (figure). Mild intraabdominal fluid, no large intestine dilation, no other pathological findings. Exploratory laparotomy was performed, extensive adhesiolysis, dilation of roux en Y afferent loop, a gallstone of 40mm was the cause of obstruction. A second gallstone was found distally. Enterotomy with gallstone removal was performed. Postoperative occurred without incidents. Patient was discharged at day 3. Results: Intestinal obstruction has many causes, gallstone ileus is infrequent and usually secondary to cholecystoduodenal fistula which is corresponds to an abnormal communication between the gallbladder and the duodenum that occurs as a rare complication of an untreated gallstones. Other cause of gallstone ileus is hepatolihtiasis formed over a pathologic hepaticojejunostomy with anastomotic stricture and recurrent cholangitis. In this cases, the usual complication is a cholangitis secondary to the obstruction and infection of the bile duct. Percutaneous approach consists in stricture dilation and extraction and/or progression of lithiasis, surgery is a more aggressive and morbid approach which consists in hepaticojejunostomy re do. In our patient gallstone ileus was caused by gallstones advanced during percutaneous treatment 2 years before. Clinical and radiological manifestations of small bowel obstruction do not differ. Neither does surgical treatment, in which laparotomy is the most common approach and enterotomy with gallstone extraction is indicated. Conclusion: We present an extremely rare case of gallstone ileus due to hepatolithiasis caused by stricture of hepaticojejunostomy in a liver transplant recipient. Percutaneous treatment was performed to treat bilioenteric stricture, however this procedure progressed lithiasis distally into jejunal loop causing a small bowel obstruction 2 years later.

Gallstone Illeus, a difficult diagnosis


 Gallstone ileus is a rare cause of mechanical bowel obstruction seen in patients with a history of cholelithiasis or cholecystitis. Its diagnosis is difficult since it presents vague and nonspecific symptoms. This is the case of a 69-year-old woman with a history of arterial hypertension and type 2 diabetes mellitus, without a surgical history, who is admitted to the emergency room due to abdominal pain. Her diagnosis is based on contrast X-ray images, computed tomography (CT) and upper gastrointestinal endoscopy. Surgery remains being the gold standard treatment.

S2813 Mimicking Superior Mesenteric Artery Syndrome: A Case of Duodenal Malrotation

INTRODUCTION: Intestinal malrotation is a rare cause of mechanical bowel obstruction in adults. We describe a case of duodenal malrotation mimicking superior mesenteric artery syndrome. CASE DESCRIPTION/METHODS: A 22-year-old male with history of schizophrenia presented with abdominal pain and distension. He fasted for the past two months with 40 lbs weight loss, limiting himself to water in order “challenge himself.” The day prior to arrival, he ended his fast with a “large meal.” He immediately had abdominal pain and distension. Vital signs were normal. Labs were only remarkable for hypokalemia 3.4 mmol/g and trace levels of urinary ketones. CT revealed gastric distension filled with large air-fluid levels. An NG tube was placed for decompression with significant improvement. EGD revealed LA grade A esophagitis, mild diffuse gastric erythema, and a single 8 mm gastric ulcer with clean base. The endoscopist reported difficulty traversing from the second to third portion of duodenum and was concerned about extrinsic compression. MRE and upper GI series showed no obstruction. Both studies revealed that the duodenum did not cross midline and loops of jejunum in the right upper quadrant, indicative of malrotation. The patient improved gradually over several days and resumed a full diet. He was discharged to inpatient psychiatry with follow-up to assess for further surgical intervention. DISCUSSION: Bowel obstruction results from a mechanical or functional impedance of the intestines. Duodenal malrotation is a rare cause of mechanical obstruction. In adults, it occurs between 2%–5% of patients and most remain asymptomatic throughout life. Symptomatic patients typically present postprandially such as in ours, with also emesis, pain, failure to thrive, weight loss, and malabsorption. In our patient, the weight loss may likely have been due to poor intake due to the malrotation rather than the patient wishing to “challenge himself.” In a rare subset of malrotation patients, they present with a potentially life-threatening condition called acute midgut volvulus. Abdominal CT is the first line of screening and oral contrast studies are needed to confirm diagnosis. Treatment includes enteric tube for decompression, bowel rest, and possible surgical intervention. Patients presenting as adults with intestinal malrotation may be misdiagnosed, which can delay management. However, duodenal malrotation should be in the differential for patients presenting with obstruction without significant surgical history.Image 1.: The duodenum does not cross midline to the left with loops of jejunum seen in the right upper quadrant, indicative of malrotation.Image 2.: EGD image revealing narrowed second and third portion of the duodenum concerning for external compression.Image 3.: Descending duodenum is normal, however the 2nd portion of the duodenum does not cross the midline, but rather extends to the right. There is no distention of the duodenum to suggest SMA syndrome.

SCLEROSING ENCAPSULATING PERITONITIS (SEP) DUE TO MYCOBACTERIUM BOVIS

Sclerosing Encapsulating Peritonitis (SEP), a visceral encapsulation syndrome of inflammatory origin either primary or secondary based on causation, is an infrequent cause of mechanical bowel obstruction that may commonly be seen in young patients. Preoperative diagnosis is quite challenging and usually missed due to the non-specific nature of the clinical picture. In most of the cases, a definitive diagnosis is reached intra and postoperatively with histopathological and culture findings. Herein, we report a young male patient that presented to our emergency department with signs and symptoms suggestive of intestinal obstruction. Intraoperatively, a thin membrane encasing the small bowels with transmesenteric herniation noted with a clinical diagnosis of SEP as the primary cause of obstruction. Postoperatively, a definitive cause was identified by histopathological findings and specimen culture. The report of this case, as one of the few male patients with this entity in the published literature, highlights the notion that surgeons should be vigilant to keep in mind this extremely rare cause while managing a patient with intestinal obstruction.

A case of successful conservative management of gallstone ileus

Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, only a handful of cases having been reported. Management is mainly surgical, but conservative treatment is occasionally appropriate. We report the case of an 86-year-old female who presented with a clinical picture of bowel obstruction, proven to be related to gallstone ileus which resolved spontaneously. We discuss the role of conservative management for this condition.

Endometrial tumour as a cause of mechanical bowel obstruction – a case report

Endometriosis is a disease that involves the presence of physiologically active uterine tissue beyond the uterus. It is classified as a non-malignant disease that typically develops within the reproductive system: in the ovaries, fallopian tubes, or uterine ligaments. These changes tend to occur also beyond the reproductive structures, usually within the digestive system, where the most common sites are the peritoneum, postsurgical scars or umbilicus. Moreover, the disease can occur in the intestine, usually in the large bowel, and particularly in the caecum. The literature reports that endometriosis may affect even 10% of women of child-bearing age. The authors present a case of a patient admitted to the surgical ward due to mechanical bowel obstruction. Intraoperatively, an endophytic tumour, completely occluding the ileum, was found. Due to its location, i.e. approximately 15 cm from the Bauhin’s valve, it was resected together with the ascending colon and the right half of the transverse colon. Based on the morphology of the lesion and a positive family history, cancer was thought to be the most probable cause of the patient’s symptoms. The result of the histopathological examination did not confirm this, however. The specimen showed endometriosis. On the day of surgery, the patient was administered antibiotics, total parenteral nutrition and essential fluid supplementation. The wound healed normally, and abdominal pain did not return as diet was being extended. The patient was discharged on the 6th day after the operation with recommended follow-up in a surgical clinic.

A rare cause of mechanical bowel obstruction: ingested vinyl glove. Unexpected diagnosis at laparoscopy.

Key Clinical MessageThe report suggests that, when the patient's history, clinical examination, and findings do not lead to a clear diagnosis in case of an acute abdomen, a laparoscopic approach, that has both, diagnostic and therapeutic value, is advised.

Minilaparotomy for biliary ileus: A different approach

Introduction: Biliary ileus is a rare cause of mechanical bowel obstruction and results from the passage of gallstones into the small bowel. Case presentation: 62-year old woman with episode of biliary ileus was underwent to minilaparotomy (5 cm) to extract gallstone from small bowel. In this particularly patient we used this approach, because we had highly suspicious diagnostic. The patient was discharged on postoperative day 5 without any complication. Conclusion: Minilaparotomy approach is a feasible option in centers without laparoscopy surgery, with excellent results when one-stage procedure is not considered.

Gallstone Ileus Presenting With Cholelith Emesis and an Incidental Benign Ovarian Fibroma: A Case Report

Gallstone ileus (GI) is a rare but important cause of mechanical bowel obstruction associated with high levels of mortality. The classic radiological triad ( Rigler’s triad) of pneumobilia, bowel obstruction and an aberrant gallstone is present in 40-50% of cases. The vomiting of gallstones, “cholelith emesis” , is a rare presentation of cholecystoduodenal fistula with bowel obstruction occurrence of which should prompt investigation for GI. Surgical management with enterolithotomy is the most common treatment option with fewer post-operative complications compared to one-stage procedures. We describe a case of GI in an elderly female patient presenting with cholelith emesis secondary to mid-ileal gallstone impaction and small bowel obstruction with an incidental large pelvic mass requiring emergency enterolithotomy. J Curr Surg. 2015;5(1):137-139 doi: http://dx.doi.org/10.14740/jcs258w

Incidentally diagnosed intussusception spontaneously resolved in an adult patient after blunt trauma: A rare case report

Although intussusception is a rare cause of mechanical bowel obstruction in adults, traumatic intussusception is exceedingly rare. In adults, intussusception contributes less than 1–5% of bowel obstructions. The first report of the diagnosis of intussusceptions was over three centuries ago (1674) by Barbette in Amsterdam. However, the first surgical treatment for this condition in literature was not until almost 100 years later in 1871 by Sir Jonathan Hutchinson, who operated on a child with intussusceptions. Risk factors include age, sex, abnormal peristalsis and pre-existing abdominal pathology. A case of jejunojejunal intussusception in an otherwise healthy 48-year-old female following blunt trauma is presented. The patient was treated conservatively with complete spontaneous resolution of her symptoms. Intussusceptions following blunt trauma is a very rare condition, which may be difficult to diagnose, and usually present as incidental findings. Laparotomy may be necessary in unstable trauma patients and in those individuals whose symptoms of mechanical bowel obstruction fail to resolve in a timely manner or who develop acute peritonitis. In conclusion, intussusception associated with blunt trauma may occur more frequently than previously suspected. Surgical intervention is not always necessary. Conservative management of patients that present with post-traumatic intussusception without other symptomatology may be safely undertaken, unless changes in clinical exam warrant operative intervention. Trauma surgeons should be aware of the possibility of intussusception in any patient that presents with obstructive symptoms after blunt trauma. Early diagnosis is the key to avoiding bowel ischemia and resection.

Colonic gallstone ileus treated with radiologically guided extracorporeal shock wave lithotripsy followed by endoscopic extraction

Gallstone ileus is a rare cause of mechanical bowel obstruction due to the passage of a solitary large gallstone into the gastrointestinal tract through a cholecystoenteric fistula [1]. Early surgical intervention is the treatment of choice; however, the surgical mortality rate is high as most patients are elderly and many suffer from concomitant diseases [2]. Ultrasound-guided extracorporeal shock wave lithotripsy (ESWL) has been suggested as an effective, noninvasive therapeutic alternative to surgery. Cases of jejunal and gastric gallstone ileus treated with ESWL have already been described [3] [4] [5]. However, the use of ultrasound-guided ESWL is limited in the colon because the stones are often not radiopaque or only partially calcified, and are frequently covered by intestinal gas, which prevents clear localization of the gallstone. We describe a case of gallstone ileus of the colon that was successfully treated with radiologically guided ESWL that visualized the obstruction by focusing on a metallic clip that had been inserted during a previous rectosigmoidoscopy.

Mechanical Bowel Obstruction and Related Risk Factors on Morbidity and Mortality

Background: Mechanical bowel obstruction is a common emergency problem resulting in high morbidity and mortality. In this study, we aimed to investigate the clinical presentation and outcome of the patients who underwent surgery due to mechanical bowel obstruction, as well as the effective risk factors on morbidity and mortality. Methods: Between January 2005 and December 2010, 148 patients who underwent surgery with a diagnosis of MBO were evaluated retrospectively. Results: The common cause of mechanical bowel obstruction was benign diseases (79.1%), such as adhesions (48.6%) and sigmoid torsion (15.5%), while 20% of causes were malignancies, like colorectal (16.2%) and small bowel tumors (3.4%). The 56.8% of the patients underwent surgery in the first 24 hours. Intra-operatively, severe ischemic features in the bowel were determined in 48% of the patients, while perforation in 2.7% and necrosis in 7.4%. Resection procedures were performed in 60.1%, while 37.8% of the patients underwent adhesiolysis. Morbidity rate was 41.9%, and 12.8% of the patients had died. While age, comorbidity, etiology, admission time and respiratory complications were the risk factors for mortality, age, comorbidities, admission time, and surgical procedures were effective on morbidity. Independent risk factors were comorbidity and admission time for morbidity and mortality, while age for only mortality. Conclusion: Morbidity and mortality rates may be decreased with considering the etiological causes and the related risk factors of the patients, and increasing the awareness of the public about mechanical bowel obstruction. doi:10.4021/jcs19w

A rare cause of mechanical bowel obstruction: mesh migration

The use of mesh has become the gold standard in hernia operations recently due to advantages such as lower recurrence rates, lower post-surgical pain and earlier return to work. Plug mesh application, first described by Robins and Rutkow [Robbins AW, Rutkow IM (1993) The mesh-plug hernioplasty. Surg Clin North Am 73:501-512], is a popular method of hernia repair. Although rare, there may be complications of surgery using plug mesh. This report presents a case of mechanic bowel obstruction due to mesh migration, 3years after a left inguinal hernia repair with plug mesh method.