Bowel Perforation Research Articles

Diuresis-led volume replacement strategy in extremely low birth weight infants.

In extremely low birth weight infants, fluid overload has been associated with bronchopulmonary dysplasia and death. Excessive weight loss may increase the risk of meconium obstruction and intestinal perforation. As these infants display oliguria followed by polyuria, we embarked on a diuresis-led volume replacement strategy as of January 2020. This single-centre analysis presents data of infants <1000 g birth weight surviving for more than 3 days admitted 2017-2019 (n = 217, daily volume increase) versus 2020-2022 (n = 2022, diuresis-led volume replacement). The second cohort had lower gestational age (median [interquartile range]: 253/7 [243/7-264/7] vs. 263/7 [251/7-282/7] weeks), less antenatal steroids (58% vs. 69%), more indomethacin (66% vs. 47%) and higher initial diuresis (5.6 [4.9-6.8] vs. 4.8 [4.2-5.5] mL/kg/h) but did not differ by relative weight loss at Day 7 of life. Employing binary logistic regression with gestational age, antenatal steroids and indomethacin as covariates, the cohorts did not differ by rates of patent ductus arteriosus, abdominal surgery or severe retinopathy of prematurity, while there were significant declines in sepsis (from 32% to 19%), bronchopulmonary dysplasia (from 26% to 23%) and mortality (from 13% to 7%). Diuresis-led volume replacement appears to be safe and maybe beneficial.

Case of colon perforation due to segmental absence of intestinal musculature accompanied by cancer treated with colonic resection and anastomosis

BackgroundSegmental absence of intestinal musculature (SAIM) is a partial defect of intestinal muscularis propria without diverticulum. Many reports indicate that the increase in intestinal pressure caused by enemas or endoscopic examinations leads to bowel perforation, but there are few reports involving malignant tumors. Moreover, few reports have had good outcomes after performing one-stage intestinal anastomosis.Case presentationA 60-year-old male came to the office with right-side abdominal pain, and was diagnosed with acute generalized peritonitis caused by ascending colon perforation. Emergency laparotomy was performed, and oval and smooth perforation at the ascending colon was observed, which caused ascites with feces. In addition, there was a tumor on the distal side. The terminal ileum was not dilated, so the cause of the perforation was more likely the SAIM-related thin intestinal wall rather than increased internal intestinal pressure due to obstruction of the tumor. Therefore, a right hemicolectomy with functional end-to-end anastomosis (FEEA) between the ascending colon and ileum was performed, rather than creating a stoma. On pathological examination, the resected bowel segments had a partial defect of intestinal muscularis propria around the perforation, leading to the diagnosis of SAIM. The patient had a favorable postoperative course without anastomotic issues and was discharged safely.ConclusionsThis case implies that initial intestinal anastomosis can be performed without creating a stoma when SAIM is suspected from the shape of the perforation and proximal intestine. This case report suggests surgeons should keep SAIM in mind during operations for colon perforations.

Safety and Tolerability of Nintedanib in Patients with Fibrosing Interstitial Lung Diseases: Post-marketing Data.

Nintedanib is approved for the treatment of idiopathic pulmonary fibrosis (IPF), other forms of progressive pulmonary fibrosis (PPF), and systemic sclerosis-associated interstitial lung disease (ILD). We present global post-marketing safety data for nintedanib in these fibrosing ILDs. Data on adverse events in patients with fibrosing ILDs who were treated with nintedanib were collected via spontaneous reporting and solicited reporting in various studies (excluding clinical trials).Data were collected from 15 October 2014 (first regulatory approval) to 15 October 2023. Adverse events were coded using the Medical Dictionary for Regulatory Activities. Cumulative exposure to nintedanib was estimated using sales data. Cumulative exposure to nintedanib was 380,557 patient-years. Diarrhoea was reported at a rate of 227.5 per 1000 patient-years. Only 2.6% of diarrhoea events were reported as serious. Of 39,788 (33.6%) diarrhoea events with a known time to onset, almost 60% occurred within the first 3months of treatment. The rate of serious liver enzyme and bilirubin elevations (including drug-induced liver injury) was 4.0 per 1000 patient-years. Bleeding was reported at a rate of 24.2 per 1000 patient-years. Most (81.3%) bleeding events were non-serious. The rates of myocardial infarction, ischaemic stroke, and venous thromboembolism were 3.3, 3.3, and 2.0 per 1000 patient-years, respectively. Gastrointestinal perforation was reported at a rate of 0.9 per 1000 patient-years. Post-marketing safety data on established and potential adverse events associated with nintedanib in patients with fibrosing ILDs, collected over 9years, demonstrated a safety profile that was similar to that established in clinical trials and provided in the product labels. Education of patients about the adverse events that may be associated with nintedanib, and the effective management of adverse events when they occur, is important to minimise the impact of adverse events and help patients remain on treatment.

Metabolomic analysis to predict the onset and severity of necrotizing enterocolitis

BackgroundNecrotizing enterocolitis (NEC) is the most devastating gastrointestinal (GI) emergency in preterm neonates. Untargeted metabolomics may allow the identification of biomarkers involved in NEC pathophysiology.MethodsWe conducted a prospective study including preterm infants born at < 34 gestational weeks (GWs) whose urine was longitudinally collected at birth (< 48 h, T0) and at 14 (T1) and 28 days (T2). Neonates were followed for their development of NEC, spontaneous intestinal perforation (SIP), or other GI conditions and compared to those of matched healthy controls. Urine samples were investigated by untargeted metabolomic analysis based on mass-spectrometry.ResultsThirty-five patients with NEC, 5 patients with SIP, 14 patients with other GI diseases and 113 controls were enrolled and selected for metabolomic analysis on the basis of their clinical characteristics and available samples. Considering urine samples at T0, the one-class classification approach was able to correctly classify 16/20 subjects (80%) who developed NEC, 3/3 (100%) who developed SIP and 5/7 subjects (71.4%) with other GI pathologies as not belonging to the control group. Neonates with surgical NEC had higher N-acetylaspartic acid, butyrylcarnitine and propionylcarnitine levels than did those with medical NEC. Considering the time evolution of the urinary metabolome, the NEC and control groups showed differences independently of the time point.ConclusionsThe urinary metabolome is closely associated with the underlying GI disease from birth. Urinary metabolic features characterize NEC patients from healthy controls until 28 days of life. The early urinary metabolome has the potential to predict surgical NEC. Future studies are needed to validate our results.

Prognostic impact of postoperative management by an intensive care unit intensivist after colonic perforation.

Postoperative management for colonic perforation is an important prognostic factor, but whether intensivists perform postoperative management varies between institutions. We investigated 291 patients with colonic perforation between 2018 and 2022. Patients were divided into those managed by an intensivists (ICU group; n = 40) and those not managed by an intensivists (non-ICU group; n = 251). We examined how management by intensivists affected prognosis using inverse probability weighting, and clarified which patients should consult an intensivists. The ICU group showed a significantly higher shock index (1.15 vs. 0.75, p < 0.01), higher APACHE II score (16.0 vs. 10.0, p < 0.001), and more severe comorbidities (Charlson Comorbidity Index 5.0 vs. 1.0, p < 0.001) and general peritonitis (85% vs. 38%, p < 0.001). Adjusted risk differences were - 24% (-34% to -13%) for 6-month mortality rate. Six-month mortality was improved by ICU intensivist management in patients with general peritonitis (risk difference - 22.8; 95% confidence interval - 34 to -11); APACHE II score ≥20 (-0.79; -1.06 to -0.52); lactate ≥1.6 (-0.38; -0.57 to -0.29); shock index ≥1.0 (-40.01; -54.87 to -25.16); and catecholamine index ≥10 (-41.16; -58.13 to -24.19). Intensivists were involved in treating patients in poor general condition, but prognosis was extremely good. Appropriate case consultation with intensivists is important.

Colonic Perforation Caused by a Monopterus albus.

Colonic Perforation Caused by a Monopterus albus.

Necrotizing enterocolitis following spontaneous intestinal perforation in very low birth weight neonates.

Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are severe gastrointestinal complications of prematurity. The clinical presentation and treatment of NEC and SIP (peritoneal drain vs laparotomy) can overlap; however, the pathogenesis is distinct. Therefore, a patient initially treated for SIP can subsequently develop NEC. This phenomenon has only been described in case reports, and no risk factor evaluation exists. We evaluate clinical characteristics, risk factors, and outcomes of patients treated for a distinct episode of NEC after SIP. We performed a retrospective review of very low birth weight (<1500 g) neonates who presented with pneumoperitoneum between 07/2004 and 09/2022. Data was obtained from two separate neonatal intensive care units that were part of the same institution. Patients with an initial preoperative, intraoperative, or pathological diagnosis of NEC were excluded. Patients with an intraoperative diagnosis of SIP or preoperative diagnosis of SIP successfully treated with a peritoneal drain (PD) were evaluated. Patients subsequently treated (medically or surgically) for NEC after SIP were then compared to SIP-alone patients. Clinical characteristics included demographics, gestational age (GA), birth weight (BW), perinatal risk factors (chorioamnionitis, steroids, indomethacin), postoperative feeding regimen, and length of stay (LOS) were compared. Of the 278 patients included, 31 (11.2%) patients had NEC after SIP. There was no difference in GA (25 weeks vs 25 weeks, p = 0.933) or BW (760 g vs 735 g, p = 0.370) between NEC after SIP vs SIP alone cohorts, respectively. Twenty (64%) of NEC after-SIP patients were previously treated with LP. NEC after SIP occurred with a median onset of 56 days. Pneumatosis was the most frequent (81%) presenting symptom and 12 (39%) patients had hematochezia. Four (12.9%) patients required LP for NEC and all had NEC intraoperatively and on pathology. A majority (77.4%) of patients were on breast milk (BM) at time of NEC diagnosis. NEC after SIP patients had lower maternal age at delivery (29.0 vs 25.0, p = 0.055) and the incidence of NEC after LP (primary or failed drain) was higher than PD alone (16.7% vs 6.2%, p = 0.007). NEC after SIP patients had longer LOS (135 vs 81, p < 0.001). We report an 11.2% incidence of NEC at a median of 56 days following successful treatment of SIP, resulting in increased LOS. SIP patients are a high-risk cohort and protocols to prevent this phenomenon should be investigated.

Characterization of novel sequence type 12531 and O8:H7 serotype carbapenem-resistant Escherichia coli with strong swimming and intestinal epithelial cell barrier migration abilities.

Carbapenem-resistant Enterobacteriaceae have become widely prevalent globally because of antibiotic misuse and the spread of drug-resistant plasmids, where carbapenem-resistant Escherichia coli (CREC) is one of the most common and prevalent pathogens. Furthermore, E. coli has been identified as a member of normal gut flora and does not cause disease under normal circumstances. However, certain strains of E. coli, due to the expression of virulence genes, can cause severe intestinal and extra-intestinal infections. Therefore, clinically, drug resistance and pathogenic E. coli strains are significantly challenging to treat. In this study, a novel CREC strain DC8855 was isolated from the ascites of a patient with intestinal perforation, identified as a novel sequence type 12531 (ST12531) and an unreported serotype O8:H7. It was revealed that the resistance of ST12531 CREC was predominantly conferred by an IncFII(K) plasmid carrying blaNDM-4. Furthermore, phylogenetic analysis indicated that this is the first discovery of such plasmids in China and the first identification in E. coli. Moreover, regarding virulence, the swimming assays, qRT-PCR, and in vitro intestinal barrier model indicated that DC8855 had significantly higher motility, flagella gene expression, and intestinal epithelial cell barrier migration ability than the other sequence types CREC strains (ST167 and ST410). In conclusion, this study identified novel CREC which was multidrug resistant as well as enteropathogenic and therefore requires continuous monitoring.

Gossypiboma with enterocutaneous fistula after cesarean section: a case report and review of the literature

IntroductionAlthough precautions taken for surgical procedures are strict and effective in most operative theaters, the incidence of retained foreign bodies following surgery has a reported rate of 0.01–0.001%, of which gossypibomas make up 80% of cases.Case presentationA 42-year-old woman who was Oromo in ethnicity came to the hospital with symptoms of infection, including pus drainage from her lower abdominal incision, fever, chills, and weight loss. Tests indicated an intraabdominal mass consistent with a foreign body from a previous surgery. An exploratory laparotomy revealed a surgical pack causing intestinal perforations. The foreign body was removed, and the patient recovered well postoperatively.ConclusionRetained surgical items are serious problems of surgical operations that can result in morbidity and mortality. Therefore, it should be among the differential diagnoses of any abdominal pain in patients having a history of prior surgery.

Scoring model for the diagnosis of colorectal perforation and its differentiation from gastroduodenal perforation.

Distinguishing colorectal from gastroduodenal perforations is clinically important and challenging. We aimed to establish a scoring model based on objective findings (excluding computed tomography findings) for the diagnosis of colorectal perforation and its differentiation from gastroduodenal perforation. Patients diagnosed with colorectal or gastroduodenal perforations between January 2014 and December 2021 were retrospectively studied. Univariate and multivariate analyses were performed to identify independent variables, and a scoring model was developed based on these variables. Among 131 eligible patients, 64 (48.9%) were in the colorectal group and 67 (51.1%) were in the gastroduodenal group. White blood cell count, C-reactive protein, and quick Sequential Organ Failure Assessment score were identified as independent clinical variables associated with the diagnosis of colorectal perforation, which differentiated colorectal perforation from gastroduodenal perforation, and were used to develop a new scoring model. The scores ranged from 0 to 5, with an area under the receiver operating characteristic curve of 0.846. The probabilities of colorectal perforation with scores of 0, 1.5, 2, 3, 3.5, and 5 were 3.2, 20, 55.6, 81.8, 73.9, and 82.4%, respectively. The new scoring model may help in treatment selection and perioperative management of patients with gastrointestinal perforation.

Simulation of intestinal perforation in experiment

The current problem of neonatal and pediatric surgery remains the tactics of surgical treatment and postoperative management of patients with perforated peritonitis. Mortality with perforation of the stomach and intestines in children in the newborn period reaches about 40-80 %. The combination of the syndrome of increased intra-abdominal pressure and multiple organ failure causes the extremely serious condition of patients. In this connection, new approaches to the surgical treatment of such patients are currently being actively developed. For this, new medical devices are tested in experimental practice, but the problem of such studies, first of all, lies in the lack of an adequate model of the pathological process. The aim of the work is to analyze the methods of experimental modeling of intestinal perforations described in the public domain. For this, a study was conducted of the most significant scientific publications of such databases as Google Scholar, PubMed, Scopus, eLIBRARY. The present work provides a detailed description of existing options for modeling perforations of various parts of the gastrointestinal tract (stomach, small intestine and colon), depending on the goals of the experiment. Several rather rare techniques based on the introduction of microorganisms are also presented. In addition, the article describes the method proposed by the authors for modeling perforation using laparoscopic access.

Olokizumab plus methotrexate: safety and efficacy over 106 weeks of treatment

ObjectiveTo report long-term safety and tolerability of olokizumab (OKZ) in combination with methotrexate (MTX) in subjects with active rheumatoid arthritis (RA), using pooled data from three randomised clinical trials (RCT)...

A Rare Presentation of Abdominal Mucormycosis with Gastric Perforation and Splenic Infarction: A Case Report and Review of Literature

A Rare Presentation of Abdominal Mucormycosis with Gastric Perforation and Splenic Infarction: A Case Report and Review of Literature

Gastrointestinal effects of caffeine in preterm infants: a systematic review and Bayesian meta-analysis

ObjectiveCaffeine is widely used in preterm infants to prevent or treat apnoea of prematurity. Adverse gastrointestinal effects of caffeine have not been thoroughly researched in preterm infants. With this systematic...

Leukocytosis and thrombocytosis after splenectomy: expected finding, infection, or something else: a case report

BackgroundLeukocytosis and thrombocytosis often follow splenectomy in blunt trauma patients, complicating the postoperative identification of infection. While the platelet count to white blood cell ratio provides diagnostic assistance to discern between expected laboratory alterations and infection, diagnoses such as leukemia are often overlooked.Case presentationA 53-year-old Hispanic male presented with abdominal pain, nausea, tachycardia, and focal peritonitis 4 days after being assaulted and struck multiple times in the abdomen. Initial white blood cell count was 38.4 × 109/L, platelet count was 691 × 109/L, and lipase was 55 U/L. Computed tomography abdomen/pelvis demonstrated a hematoma encasing the distal pancreas and abutting the stomach and colon. Emergent laparotomy revealed a nearly transected pancreas and devascularized colon, necessitating a distal pancreatectomy, splenectomy, and colonic resection with primary anastomosis. Postoperatively, he had a persistently elevated leukocytosis, thrombocytosis, segmented neutrophils, eosinophilia, and basophilia (peak at 70, 2293, 64, 1.1, and 1.2 × 109/L, respectively). Despite sepsis workup, including repeat computed tomography, no source was identified. Hematology/oncology was consulted for concern for hematologic etiology, with genetic testing and bone marrow biopsy performed. The diagnosis of breakpoint cluster–Abelson gene-positive chronic myeloid leukemia was made based on genetic tests, including polymerase chain reaction and fluorescence in situ hybridization analysis, which confirmed the presence of the Philadelphia chromosome. Bone marrow biopsy suggested a chronic phase. The patient was treated with hydroxyurea and transitioned to imatinib.ConclusionsThrombocytosis following splenectomy is a common complication and a plate count to white blood cell count ratio < 20 indicates infectious etiology. A significantly elevated white blood cell count (> 50 × 109/L) and thrombocytosis (> 2000 × 109/L) may suggest something more ominous, including chronic myeloid leukemia , particularly when elevated granulocyte counts are present. Chronic myeloid leukemia workup includes peripheral smear, bone marrow aspiration, and determination of Philadelphia chromosome. Post-splenectomy vaccines are still indicated within 14 days; however, the timing of immunization with cancer treatment must be considered. Tyrosine kinase inhibitors are the first-line therapy and benefits of pretreatment with hydroxyurea for cytoreduction remain under investigation. Additionally, tyrosine kinase inhibitors have been associated with gastrointestinal perforation and impaired wound healing, necessitating heightened attention in patients with a new bowel anastomosis.

Immune effector cell-associated enterocolitis following chimeric antigen receptor T-cell therapy in multiple myeloma

We report 14 cases of immune effector cell (IEC)-associated enterocolitis following chimeric antigen receptor T-cell (CAR-T) therapy in multiple myeloma, with a 1.2% incidence overall (0.2% for idecabtagene vicleucel and 2.2% for ciltacabtagene autoleucel). Patients developed acute-onset symptoms (typically non-bloody Grade 3+ diarrhea) with negative infectious workup beginning a median of 92.5 days (range: 22–210 days) after CAR-T therapy and a median of 85 days after cytokine release syndrome resolution. Gut biopsies uniformly demonstrated inflammation, including intra-epithelial lymphocytosis and villous blunting. In one case where CAR-specific immunofluorescence stains were available, CAR T-cell presence was confirmed within the lamina propria. Systemic corticosteroids were initiated in 10 patients (71%) a median of 25.5 days following symptom onset, with symptom improvement in 40%. Subsequent infliximab or vedolizumab led to improvement in 50% and 33% of corticosteroid-refractory patients, respectively. Five patients (36%) have died from bowel perforation or treatment-emergent sepsis. In conclusion, IEC-associated enterocolitis is a distinct but rare complication of CAR-T therapy typically beginning 1–3 months after infusion. Thorough diagnostic workup is essential, including evaluation for potential T-cell malignancies. The early use of infliximab or vedolizumab may potentially hasten symptom resolution and lower reliance on high-dose corticosteroids during the post-CAR-T period.

Appendiceal Mucosal Schwann Cell Proliferation Associated with Incidentally Detected Goblet Cell Adenocarcinoma of Appendix in a Case of Invasive Adenocarcinoma of Sigmoid Colon- A Case Report

Abstract Introduction/Objective Appendiceal mucosal Schwann cell proliferation has been suggested to be a putative histologic marker of appendiceal diverticular disease. Appendiceal Goblet cell adenocarcinoma, (GCA) is amongst the most rare appendiceal tumors with a reported incidence of 0.05 cases per 100,000 population per year in United States. They have features of both neuroendocrine tumors and adenocarcinomas, but behave more similarly to adenocarcinomas. Methods/Case Report Herein, we report a case of appendiceal mucosal schwann cell proliferation associated with incidentally detected Goblet cell adenocarcinoma of appendix in a known case of invasive adenocarcinoma of sigmoid colon. A 75-year-old female presented with sigmoid colon obstruction. Intraoperatively, she was found to have gangrenous and perforated colon, as well as a large obstructing sigmoid mass, and underwent total abdominal colectomy with end-ileostomy. On gross examination, a tan bosselated tumor (up to 3.5 cm) was seen in proximal sigmoid colon. Microscopic examination showed Invasive adenocarcinoma, moderately-differentiated. Appendix was unremarkable on gross examination. Incidentally, the appendix microscopically demonstrated “Goblet cell adenocarcinoma”, histologic grade 1 out of 3 (pathologic stage pTis pN0), present in multiple foci within lamina propria of the distal third of appendix over an area measuring 1.5 cm. Additionally, there were foci of SOX10-positive bland- looking spindle cell proliferation in lamina propria of the appendix. This proliferation is rendered as “Schwann cell proliferation”. Results (if a Case Study enter NA) NA Conclusion One study found that “Schwann cell proliferation” is seen in 42% of appendiceal diverticula cases. It has never been reported in association with “Appendiceal GCA” before. Here we report an intriguing case of Schwann cell proliferation associated with this rare entity of GCA for the first time in literature. Therefore, awareness of such coexistence of these pathologic entities in the same appendix is essential to alert the pathologist to look for GCA, whenever Schwann cell proliferation is encountered in random section of an appendix. This case also emphasizes the importance of being vigilant of the possible presence of other tumors in a specimen with a known tumor.

Safety study on adverse events of zanubrutinib based on WHO-VigiAccess and FAERS databases.

The study endeavors to elucidate AE signals associated with zanubrutinib data from the WHO-VigiAccess and FAERS databases. The aim is to furnish robust scientific evidence to inform clinical practice and regulatory decisions. We meticulously extracted all AE breports tied to zanubrutinib from the both databases, encompassing the period from the drug's market introduction until 30 April 2024. Retrospective quantitative analysis employing ROR, PRR, and BCPNN methodologies were utilized to analysis. The investigation unveiled 1,304 reports from WHO-VigiAccess and 1,141 reports from FAERS related to zanubrutinib. Among the top 30 reported PTs in both databases, those not recorded in the drug label included pyrexia, dizziness, and death. In the FAERS database, signals for zanubrutinib were detected across 19 SOCs. Systems not covered in the drug label included reproductive system and breast disorders, metabolism and nutrition disorders, ear and labyrinth disorders, among others. Unmentioned signals included intestinal perforation, onychoclasis, night sweats, etc. This study confirms common AEs of zanubrutinib and identifies new ones, highlighting the need for careful monitoring and personalized treatment. It also emphasizes the importance of ongoing drug safety surveillance and patient management to maximize therapeutic benefits and minimize risks.

Oral Gastrografin: A Safe Alternative in Meconium Obstruction of Prematurity

Meconium obstruction of prematurity is primarily seen among very low birthweight or extremely low birthweight premature babies, causing low intestinal obstruction. It may delay the establishment of early full enteral feeding and compromise nutrition or cause obstruction requiring surgery or intestinal perforation. Currently, the management is mainly based on expert opinion and low-quality evidence. Conventional hyperosmolar contrast enema and gastrografin enema may not reach the site of obstruction because of the proximal nature of the meconium obstruction. Oral gastrografin is an effective and safe alternative for relieving meconium obstruction in a 28-week preterm baby. This avoids the need for surgery. This article highlights the use of oral route of gastrografin as a good nonsurgical alternative in extreme preterm babies in resource-limited circumstances.

Double Trouble: The Perilous Intersection of Amoebic Colitis and Candida Infection Leading to Colonic Perforation

Double Trouble: The Perilous Intersection of Amoebic Colitis and Candida Infection Leading to Colonic Perforation