Cause Of Mechanical Obstruction Research Articles

Intestinal intussusception in adult as an uncommon cause of mechanical obstruction.

A 61-year-old woman admitted for epigastric abdominal pain, three months of evolution, worsens after ingestion, associating abdominal distension and constipation. Physical examination: abdominal pain and distension in the mesogastric zone. Blood tests: slight increase in C-reactive protein; abdominal X-ray: the small bowel dilatation; computed tomography scan: small bowel obstruction due to intussusception. An exploratory laparotomy was performed, confirming a mechanical intestinal occlusion secondary to 5 centimeters jejunal intussusception (image 3); It was execute an intestinal resection with adequate margins and an anisoperistaltic mechanical side-to-side anastomosis. Correct postoperative evolution; hospital discharge on the sixth day. Pathology report: polypoid intussusception, 4.3x3.3 centimeters, superficial ulceration, edema, chronic inflammation; resection margins without alterations.

The Technique of Mobilization of the Colon for Pull-Through Procedure in Hirschsprung's Disease.

BackgroundIn patients with Hirschsprung's disease (HD), persistent obstructive symptoms may develop after surgery. The causes of mechanical obstruction may be a retraction of the pulled-through bowel due to insufficient mobilization of the mesentery or impaired blood supply in the area of the coloanal anastomosis in the case of excessive ligation of the supplying vessels. Leakage and stenosis are formidable complications and require repeated surgical intervention.ObjectiveThe purpose of this study is to describe our experience and short-term results of the developed method: mobilization of the descending colon for its pull-through during the surgical treatment of the children with HD, which allows ensuring good mobility to the descending colon and maintaining blood supply at the same time.MethodsThe medical records of 20 patients with rectosigmoid HD, who underwent parietal mobilization of the descending colon with preservation of the marginal artery, sigmoid arteries, and ligation of the left colon artery, were reviewed. This method is aimed at increasing the mobility of the brought-down bowel and maintaining the blood supply to the distal part of the brought-down bowel not only from the superior mesenteric artery but also from the lower one.The SPSS Statistics 26.0 package was used for statistical analysis. To describe the analyzed data with a normal distribution, the mean values and the error of the mean were used. To determine the differences, Student’s t-test was used, and the differences were considered significant at a significance level of p < 0.05.ResultsIn all patients, the postoperative period was uneventful, without complications. The patients were discharged for outpatient treatment on average on the seventh day after the surgery. In all cases, there were no signs of anastomotic leakage or stricture on follow-up after 6–12 months.ConclusionThe method of mobilization of the colon in the rectosigmoid form of HD, parietal mobilization of the descending part of the colon preserving the marginal artery, sigmoid arteries, and ligating the left colon artery, can reduce the risk of complications by eliminating the tension of the descending colon.

Double ureteric obstruction mimicking bowel obstruction managed by minimal invasive surgery

This case highlights bowel obstruction like symptoms post-laparoscopic pyeloplasty for pelvi-ureteric junction obstruction (PUJO), caused by concomitant vesico-ureteric-junction obstruction (VUJO). The endoscopic management is presented along with a review of the literature. A 16-month-old-girl was diagnosed antenatally with a left hydronephrosis. The post-natal scan confirmed severe left pelvi-calyceal dilatation with cortical thinning, no ureteric dilatation, and a 32 mm anterior-posterior (AP) renal pelvis. The mercaptoacetyltriglycine (MAG-3) renogram demonstrated thinned cortex with steady accumulation of contrast and poor drainage along with split renal function of 26% on left side. The patient underwent a laparoscopic pyeloplasty for PUJO, with some difficulty in passing the JJ stent distally. Postoperatively, the patient developed symptoms of ileus, that were progressively unsettled with bilious vomiting and abdominal distension. An ultrasound examination revealed the distal end of stent still positioned in the distal ureter with stable upper tract dilatation. Serial radiographs showed progressive distended bowel loops with the stent coiled in ureter. On the fourth day; as symptoms did not improve, emergency laparoscopy was performed that confirmed no mechanical cause of obstruction and no bowel injury. Cystourethroscopy in the same session revealed ipsilateral VUJO. The left ureteral orifice was cannulated with difficulty using a 0.0014 inch guide wire, following which the vesico-ureteric junction was dilated with 4Fr ureteric catheter and a 3.7Fr JJ stent was placed. The newly inserted JJ stent displaced the existing stent into the renal pelvis. Post-operative course showed dramatic improvement in obstructive symptoms. Both JJ stents were subsequently removed after 3 months using a cystoscope and rigid uretero-renoscope. Pre-operative diagnosis of coexistent VUJO and to PUJO is clinically challenging and requires high level of suspicion especially when postoperative recovery is not smooth. With the availability of endo-ureterotomy procedures PUJO and VUJO could be managed together without the risk of endangering ureteric vascularity.

A rare cause of mechanical obstruction: case report of cryptoorchidsm in adult

Small bowel obstruction is common complication following abdominal surgery and other causes. However, cryptorchidism leading to intestinal obstruction with no previous abdominal surgery is extremely rare. We report a case of 22 year old man presented with small bowel intestinal obstruction due to cryptorchidism. Mechanical obstruction due to cryptorchidism were either from direct adhesion to gut loops or internal herniation or as complication of malignant transformation (torsion, mass effect, rupture or haemorrhage). It is important to keep in mind that undescended intra-abdominal testes may lead to acute life-threatening complication which should be considered in patient presented with acute abdomen and an empty scrotum. It is important to keep in mind that undescended intra-abdominal testes may lead to acute life-threatening complication which should be considered in patient presented with acute abdomen and an empty scrotum.

Íleo biliar como causa poco frecuente de abdomen agudo obstructivo, presentación de caso clínico

Introducción: El íleo biliar es una complicación infrecuente de la colelitiasis y además es causa de obstrucción mecánica del intestino delgado o grueso, la cual es producida por la migración de un lito a través de una fístula bilioentérica misma que es más frecuentemente colecisto duodenal (65-77%) y, que, a pesar de poder alojarse en cualquier parte del trayecto, este muy comúnmente se aloja en el íleon terminal debido a su estrechez anatómica.&#x0D; Objetivo: Realizar una revisión bibliográfica sobre la sospecha clínica del íleo biliar, así como su manejo quirúrgico y ejemplificarlo mediante la presentación de un caso clínico.&#x0D; Material y métodos: Estudio descriptivo, retrospectivo, presentación de caso clínico en el “Hospital Básico IESS Latacunga”, caso que fue tratado en el servicio de Cirugía General del hospital.&#x0D; Resultados: Paciente que 24 horas antes de acudir a consulta presentó sin causa aparente dolor abdominal tipo cólico de moderada intensidad, localizado en epigastrio con irradiación difusa a flancos, este dolor fue acompañado por náusea que llega al vómito en más de 20 ocasiones siendo al inicio de contenido alimenticio, pero posteriormente tornándose bilioso, también se realizó tacto rectal donde se encontró esfínter tónico, ampolla rectal vacía, sin masas y dedo de guante limpio, se realiza exámenes complementarios de imagen donde se identifica la Triada de Rigler, compatible con un íleo biliar. Se decide intervención quirúrgica de emergencia.&#x0D; Conclusiones: El íleo biliar es una causa importante e infrecuente de obstrucción mecánica y su conocimiento por parte del cirujano es indispensable para un diagnóstico lo más precoz posible.

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.

The Challenges of Esaphagogastric Junction Outflow Obstruction, Is It Really a Diagnosis? Creating a Systematic Clinical Approach for EGJOO.

Esophagogastric junction outflow obstruction (EGJOO) is currently diagnosed according to the Chicago Classification V3 by an elevated median integrated relaxation pressure on high resolution manometry. However, EGJOO may not be an accurate diagnosis, as it may be based on abnormal IRP from an artifact, affected by narcotics, an achalasia variant, or a mechanical cause of obstruction. This heterogenous diagnosis can often lead to unnecessary testing and treatment. The purpose of this study is to develop a stepwise clinical management protocol on how to evaluate EGJOO. Motility studies were reviewed for the last 2years and 39 patients were diagnosed with EGJOO. Clinical information was reviewed, and patients were classified into six stepwise categories to explain an elevated IRP resulting in EGJOO diagnosis: (1) underlying catheter artifact (2) opioid use (3) achalasia variant (4) jackhammer esophagus with obstruction (5) missed esophageal lesion (ex. Schatzki ring, EOE) and (6) extrinsic compression. 40% (n = 14) of patients with elevated IRP were due to an underlying catheter artifact. 8.6% (n = 3) were due to opioid use. 8.6% (n = 3) were due to achalasia variant. 31.4% (n = 11) were due to jackhammer esophagus with obstruction. 5.7% (n = 2) were due to missed esophageal lesion. 5.7% (n = 2) were due to external compression by cardiomegaly and aortic aneurism. EGJOO is not a diagnostic end point, but a heterogenous category with multiple underlying etiologies. We believe the use of a stepwise approach to these patients can help avoid further unnecessary testing.

2771 Acute Gastric Dilatation: A Cause for Concern

INTRODUCTION: Gastroparesis in diabetics can be worsened by hyperglycemia. Acute elevations in blood glucose suppress the frequency and contraction amplitude of antral pressure waves while stimulating phasic pyloric pressure waves, which can result in Acute Gastric Dilatation (AGD). Though an unusual occurrence, it requires a high degree of suspicion to avoid its rare but life-threatening complications. We present our experience of two patients with AGD. CASE DESCRIPTION/METHODS: Case 1: A 30-year-old male presented to the ER with nausea, vomiting and abdominal pain. His comorbidities included type 1 diabetes and end-stage renal disease. On examination, his abdomen was notably distended and bowel sounds were sluggish. No guarding or rigidity was appreciated. He was hypotensive (76/49 mmHg) and hypoxic. Lab values were significant for blood glucose of 1155 mg/dL and a pH of 6.97. He was emergently intubated and started on IV insulin and Epinephrine. An abdominal plain film x-ray showed acute gaseous distention of the stomach. An NG tube was passed which drained 500cc of brownish gastric content. A repeat x-ray 4 hrs later revealed resolution of gastric dilatation which was confirmed by CT-abdomen. Patient's abdominal symptoms improved thereafter and he made a full recovery in time. Case 2: 59-year-old male was brought to the ER with an altered mental status. As per EMS, he had “very high” blood sugar levels. His comorbidities included diabetes mellitus and chronic hepatitis C. His abdomen was distended with decreased bowels sounds. His vital signs were stable. Lab values were significant for hyperglycemia (649 mg/dL), and a blood pH of 7.29. He underwent an abdominal x-ray which showed marked distention of the stomach. A follow-up CT abdomen confirmed the finding, with no mechanical cause of obstruction identified. He was started on IV Insulin, IV antibiotics and was planned for endoscopic workup, however, his conditioned rapidly deteriorated and he required pressors with mechanical ventilation. The patient eventually suffered a cardiac arrest and was unable to be revived. DISCUSSION: AGD presents with nausea, vomiting, succussion splash, and abdominal distension. Acute hyperglycemia in uncontrolled diabetics is the precipitating factor. If intragastric pressures exceed 20 cmH20 (lower limit of gastric venous pressure), it can cause mucosal ischemia and necrosis. This may be followed by perforation, which has a high mortality rate. Emergency decompression with NG tube seems to be the treatment of choice.

Small bowel obstruction secondary to Ascaris lumbricoides in the setting of prior exploratory laparotomy

Ascaris lumbricoides is a parasitic roundworm that is transmitted via the fecal-oral route and is endemic in many areas around the world. At the end of its life cycle it resides in the small bowel, and while it can be asymptomatic, large masses of worms can result in intestinal obstruction, volvulus and perforation. While it is a common cause of mechanical obstruction in endemic areas, it is far less so in the developed world, where adhesions and other postoperative mechanical etiologies are more common. We present the case of a young man with a prior history of exploratory laparotomy for trauma, who had recently immigrated from the Philippines, where ascariasis is endemic, to the Central Valley of California in the United States. He presented with a small bowel obstruction, and at laparotomy was noted to have both a proximal Ascaris bezoar as well as a distal anastomotic stricture.

Small bowel volvulus post gastric bypass

Small Bowel Volvulus (SBV) is an uncommon cause of Small Bowel Obstruction (SBO), which can be difficult to diagnose. However, it is very important to recognise and intervene in a timely manner due to the high risk of bowel ischemia. Unfortunately, SBV does not always have clinical features that differentiate it from other causes of mechanical obstruction. The most reliable investigation appears to be Computed Topography (CT) scan with around 50% of patients displaying the classic ‘whirl’ sign on CT. However, many remain undifferentiated SBO patients. Any of these patients who have any clinical or radiological suspicion of bowel ischemia, should be considered for surgery, as delays in diagnosis of bowel ischemia are associated with an increased risk of morbidity and mortality. In this case reported, author detailed a 55year female who presented with SBV had a CT scan which showed the classic ‘whirl’ sign and thus had timely surgical intervention and an uncomplicated recovery. Her history was significant for a subtotal colectomy, and a Rouxeny gastric bypass. This case highlights the importance of early recognition of SBV and also carries a reminder to consider rare causes of abdominal pain in patients who have had previous bariatric surgery. They have altered anatomy and thus are at increased risk of internal hernia and volvulus including SBV.

RELATONSHIP BETWEEN SERUM LIPOPROTEIN-ASSOCIATED PHOSPHOLIPSAE A2 AND CAROTD INTMAMEDIA THICKNESS WITH CEREBRAL INFARCTON

Background and Purpose: Cerebral atherosclerosis is the leading cause of mechanical obstruction of blood flow that final event is cerebral infarction. Lipoprotein-associated phospholipase A2 (Lp-PLA2) is an inflammatory biomarkers specific for blood vessels, is an important factor predicted extent of atherosclerosis. The study aimed to assess the association between serum Lp-PLA2 concentration with carotid intimamedia thickness (IMT). Materials andMethod: The cross – sectional study, in 37 patients who presented to Department of Cardiology - Hue University Hospital and Hue Central Hospital. Vulnerability asessment of the external carotid artery into the skull through ultrasound by measuring carotid intima-media thickness. Testing serum Lp-PLA2 concentration, lipid profile, blood glucose. Results: Group of patients with thickness of carotid IMT levels of serum Lp-PLA2 was 27.73 IU/ml higher than the group with thickness normal carotid IMT was 14.35 IU/ml; p &lt; 0.05. Total cholesterol, LDL cholestrol, triglycerid and Lp-PLA2 are the factors capable of predict the changes in size IMT; (p &lt;0.05). There is moderate correlation between Lp-PLA2 levels and carotid intima-media thickness (r = 0.47; p &lt; 0.05). Conclusion: Higher Lp-PLA2 levels is significantly associated with carotid intimamedia thickness in patients who have cerebral infarction. Key words: Stroke, atherosclerosis, inflammation, biomarker.

Small Bowel Obstruction

S mall bowel obstruction remains an important cause of morbidity, accounting for up to 15% of surgical admissions for acute nontraumatic abdominal pain. Clinical evidence of complete small-bowel obstruction or complications such as strangulation necessitates emergent surgical management. Traditional medical teaching advocated early operative management of small-bowel obstruction (“Never let the sun rise or set on an obstructed abdomen.”) because clinical features were often unreliable in determining whether complications were present. Radiologic imaging has assumed a paramount role in directing the management of small bowel obstruction, promoted by the widespread availability of MDCT. The key question for a clinician managing a case of suspected small bowel obstruction is how to optimally treat the patient. MDCT accurately answers this question by determining if small bowel obstruction is present, identifying the site and cause of mechanical obstruction, and detecting complications. The sensitivity and specificity of MDCT in this clinical setting is more than 95%, with high accuracy reported in distinguishing small bowel obstruction from adynamic ileus in postoperative patients. Imaging is therefore pivotal in determining whether the patient can be managed conservatively and in guiding the operative approach if surgical management is required.

Chronic intestinal pseudo-obstruction in adult patients: multidetector row helical CT features

Chronic intestinal pseudo-obstruction (CIPO) is a rare condition due to severe gastrointestinal motility disorder. Adult patients with CIPO experience symptoms of mechanical obstruction, but reliable clinical signs that may help distinguish between actual mechanical obstruction and CIPO are lacking. Additionally, abdominal plain films that commonly show bowel dilatation with air-fluid levels do not reach acceptable degrees of specificity to exclude actual obstruction. Therefore, most adult patients with CIPO usually undergo multiple and often fruitless surgery, often leading to repeated bowel resections before diagnosis is made. In these patients who present with abdominal signs mimicking symptoms that would warrant surgical exploration, multidetector-row helical CT (MDCT) is helpful to resolve this diagnostic dilemma. MDCT shows a diffusely distended bowel and helps to rule out a mechanical cause of obstruction, thus suggesting CIPO and obviating the need for unnecessary laparotomy. In adult patients with CIPO, MDCT may show pneumatosis intestinalis, pneumoperitoneum or intussusception. However, these conditions generally do not require surgery in patients with CIPO. This pictorial essay presents the more and less common MDCT features of CIPO in adult patients, to make the reader more familiar with this disease.

Emergency ultrasound and gallstone ileus

Gallstone ileus is an uncommon cause of mechanical obstruction due to a biliary stone that wedges the intestinal lumen. It is a surgical emergency representing a clinical and diagnostic challenge: the clinical manifestations are rarely specific, often causing diagnostic delay that can adversely affect the prognosis. Emergency ultrasound could be useful in assessing the level and identifying the cause of bowel obstruction. We report a case of a 74-year-old patient with a 6-day history of constipation and crampy abdominal pain without previous history of abdominal diseases. Emergency ultrasound led to an early diagnosis showing dilated small bowel loops with a shadowing mass inside consistent with an ileal stone, in the absence of aberrant located stone on plain abdominal film.

The enigma of underdrainage in shunting of hydrocephalus

Materials and Methods In a series of 202 patients of different etiologies treated with the hydrostatic Dual-switch-valve (DSV), 22 cases were suspected of suffering from underdrainage. Using a new algorithm to differentiate between different causes of mechanical obstruction on the one hand and functional underdrainage, we saw an indication to exchange the DSV to one with a lower opening pressure in 15 cases.

Ogilvie's syndrome after cervical discectomy

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is characterized by abdominal distention and massive colonic dilatation without any mechanical cause of obstruction. Lumbar spine operations can be an etiologic factor. We had a case with Ogilvie's syndrome after cervical discectomy. We also treated successfully this case by parasympathetic agent, neostigmine.

Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound.

Gallstone ileus is an uncommon cause of mechanical obstruction. Its high mortality rate can be reduced with earlier diagnosis and treatment. We wanted to determine whether ultrasound (US) performed after plain film increases the sensitivity for the preoperative diagnosis. We performed a 5-year retrospective analysis of radiologic and sonographic results of 23 patients who had surgery because of gallstone ileus. Rigler's triad was identified by plain abdominal film in two patients (9%) and by US in 16 patients (69%). Plain abdominal film contributed to a definitive diagnosis in four cases and to a probable diagnosis in six cases (sensitivities of 17% for definitive diagnoses and 43% for definitive and probable diagnoses). US confirmed the diagnosis in six cases of probable gallstone ileus and provided the diagnosis in seven of 13 patients without suspected gallstone ileus based on plain abdominal film. The best results were obtained by combining plain film and US findings, with sensitivities of 74% for definitive diagnoses and 96% for definitive plus probable diagnoses. The preoperative diagnosis of gallstone ileus significantly increases by combining plain film and US findings.

Physiology & pathophysiology of gastrointestinal fluids

Intestinal obstruction is a rare but serious complication of pregnancy with significant maternal and fetal mortality. The reported incidence of intestinal obstruction complicating pregnancy varies widely, from 1 in 66,431 to 1 in 1,500 deliveries. A retrospective review of 66 cases of intestinal obstruction complicating pregnancy and the puerperium, including 2 cases from our institution, revealed that the most common causes of mechanical obstruction were adhesions (58%), volvulus (24%), and intussusception (5%). Seventy-seven percent of the patients with obstruction due to adhesions had undergone previous abdominal or pelvic surgery.Presenting symptoms and signs were similar to those of the nonpregnant patient; abdominal pain was present in 98% of patients, vomiting in 82%, and tenderness to palpation in 71%. In 82% of patients, obstruction was evident on radiographic evaluation. Prompt management of obstruction is essential; the median length of time from admission to laparotomy in the 66 patients was 48 hours. Bowel strangulation requiring resection was present in 23% of patients. Thirty-eight percent of patients completed term pregnancies after operative resolution of obstruction; total maternal mortality was 6%, and total fetal mortality 26%. Thus, both mother and fetus are at risk when intestinal obstruction complicates pregnancy. Clinical suspicion of the presence of obstruction and aggressive intervention are required to decrease the morbidity and mortality of this rare complication of pregnancy.

LATERAL FEMORAL HERNIA AND STRANGULATED MECKEL'S DIVERTICULUM

THE MOST frequent cause of mechanical obstruction of the small intestine is incarceration or strangulation in an external hernia. The occurrence of incarceration or strangulation of Meckel's diverticulum within an external hernia, with or without intestinal obstruction, is a rare finding and still more rare within a femoral hernia. The infrequency of this surgical emergency is illustrated in Table 1. Twenty-eight cases have been reported to date. 1 A review of the literature failed to reveal a case of Meckel's diverticulum strangulated in a femoral hernia of the lateral type, i. e., a herniation lateral to the neurovascular bundle. In itself, this type of femoral hernia is very infrequent. According to Watson, 2 the firm attachment of the iliac and transversalis fasciae to the outer half of the inguinal ligament and the resistance offered by the psoas and iliacus muscles and the iliac fascia account for the rarity of this