Dilated Bowel Research Articles

Obstruction in the third portion of the duodenum due to a diospyrobezoar: a case report

BackgroundDuodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors. Obstruction due to bezoars is rare. We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy for early gastric cancer.Case presentationA 73-year-old man who underwent laparoscopic distal gastrectomy for early gastric cancer 15 months before admission experienced abdominal distension and occasional vomiting. The symptoms worsened and ingestion became difficult; therefore, he was admitted to our department. Computed tomography (CT) performed on admission revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach. Esophagogastroduodenoscopy (EGD) revealed a bezoar deep in the third portion of the duodenum. We could neither remove nor crush the bezoar. At midnight on the day of EGD, he experienced sudden abdominal pain. Repeat CT revealed that the bezoar had vanished from the duodenum and was observed in the ileum. Moreover, small bowel dilatation was observed on the oral side of the bezoar. Although CT showed neither free air nor ascites, laboratory data showed the increase of leukocyte (8400/μL) and C-reactive protein (18.1 mg/dL), and abdominal pain was severe. Emergency surgery was performed because conservative treatment was considered ineffective. We tried advancing the bezoar into the colon, but the ileum was too narrow; therefore, we incised the ileum and removed the bezoar. The bezoar was ocher, elastic, and hard, and its cross-section was uniform and orange. The postsurgical interview revealed that the patient loved eating Japanese persimmons (Diospyros kaki); therefore, he was diagnosed with a diospyrobezoar. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings.ConclusionsWe describe a rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer.

Congenital Peritoneal Band Causing Bowel Ischaemia Post Caesarean Section: A Rare Occurrence

Congenital peritoneal band is an extremely rare condition, but may induce small bowel obstruction (SBO) at any age, predominantly in childhood and rarely in adults. We report a case of extensive bowel ischaemia following caesarean section, due to trapping of an intestinal loop between a congenital peritoneal band and the mesentery. A 42-year-old, Gravida 2 Para 1, who has no history of prior abdominal surgery or trauma, presented in spontaneous labour and underwent an uncomplicated emergency lower segment caesarean section, for fetal distress. Postoperatively, she had worsening abdominal distension and pain, followed by vomiting. Computed Tomography Scan of the abdomen showed gross fluid retention with marked small bowel dilatation and fluid filled bowel loops. An emergency exploratory laparotomy was performed which revealed a congenital band, extending between the right fimbrial end and the small bowel mesentery, looping over the small bowel, causing extensive small bowel ischemia. Postoperative course was uneventful. In conclusion, congenital peritoneal band causing small bowel obstruction, although rare, should be considered in the differential, especially for patients with virgin abdomen.

Analysis of the clinical outcomes of fetal bowel dilatation combined with other abnormal ultrasonographic features

Objectives: To explore the significance of fetal bowel dilatation combined with other abnormal ultrasound features in the diagnosis of gastrointestinal malformation.Methods: A retrospective study of fetuses with bowel dilatation was performed, from August 2012 to October 2015. All the cases were identified from the ultrasound database and all observations of the relationship of prenatal abnormal abdominal ultrasound features and intestinal malformation were performed through the infancy stage.Results: We found 52 fetuses with prenatal suspicion of bowel dilatation. Of these, 20 cases were surgically confirmed to have intestinal malformation, 13 cases had no abnormal bowel loops after birth, 8 cases had abnormal intestinal features while no surgical intervention was performed after birth, 10 cases were lost to follow-up and 1 fetus died in utero at 34 weeks of gestation. Forty cases with full data were divided into three groups, including Group A (Small bowel dilatation combined with other features vs. Isolated small bowel dilatation), Group B (Colonic bowel dilatation combined with other features vs. Isolated colonic bowel dilatation) and Group C (Bowel dilatation combined with other features vs. Isolated bowel dilatation). The intestinal malformation occurrence rates were 73.33% vs. 31.25% in Group A, 50% vs. 25% in Group B, and 70% vs. 30% in Group C. These results suggest that malformation occurs at a lesser frequency in simple bowel dilatation versus bowel dilatation in combination with other abnormal ultrasound features (p = .026), similarly in simple small bowel dilatation versus small bowel dilatation in combination with other abnormal ultrasound features (p = .032).Conclusions: Prenatal bowel dilatation in combination with other abnormal ultrasound features, especially small bowel dilatation in combination with other abnormal ultrasound features, detected in the second and third trimesters, tended to indicate intestinal malformation, which contributes to enhance the accuracy of prenatal diagnosis of intestinal malformation.

穿孔性腹膜炎によるAeromonas hydrophila敗血症の1例(A case of Aeromonas hydrophila sepsis with perforation peritonitis)

要旨症例は77歳男性で，胃癌，S状結腸癌，前立腺癌に対する手術歴を認め，腸閉塞を複数回発症した既往があった。嘔気・嘔吐と腹痛を主訴に外来受診となり，画像所見より腸閉塞と診断され入院となった。イレウス管を挿入したが，減圧効果は不十分で状態は改善しなかった。第6病日，急に腹痛と腹膜刺激症状が出現し，CTで腹腔内遊離ガスと腹水を認め，穿孔性腹膜炎と診断した。緊急手術を行い，腹腔内には独特の腐敗臭を伴う緑黄色腹水が多量にあり，Treitzから50cm肛門側の空腸に径5mm程の穿孔部位を認めた。また，回盲部より80cm口側の回腸が癒着により閉塞しており，腹腔内を洗浄後に回腸の閉塞を解除し，穿孔部位で双孔式空腸ストマを造設して手術を終了した。術後は敗血症性ショック，播種性血管内凝固症候群（以下DIC）を発症したが，抗菌薬とリコンビナントトロンボモジュリンの投与，polymyxin–B direct hemoperfusionの使用による集中治療により救命し得た。腹水および血液の培養よりAeromonas hydrophila （以下A. hydrophila）が検出され，A. hydrophila敗血症により重症化したと判断した。A. hydrophila敗血症は急激な経過をたどって重篤化すると報告されている。本邦での穿孔性腹膜炎によるA. hydrophila敗血症は稀であるため，文献的考察を加え報告する。

Segmental absence of intestinal musculature with metachronous bowel perforations in an infant

Abstract Segmental absence of intestinal musculature is a rare condition. A female patient was born at 39 weeks gestational age with birth weight of 2,900 g. The patient was prenatally diagnosed as having segmental bowel distension in the fetal stage. She manifested bilious emesis with abdominal distension at day 1. Although excretion of viscous meconium was observed by gastrografin enema, gastrointestinal perforation developed. Emergency laparotomy and peritoneal drainage was required at that time and further laparotomy was performed on day 15. Multiple perforations were recognized discontinuously from the jejunum to the transverse colon, and jejunostomy was constructed. Additional bowel perforations occurred and re-exploration was required at day 43. We found newly formed small perforations in the proximal jejunum, ileum and the transverse colon and a tube jejunostomy and a colostomy were established. The patient required prolonged TPN management, which induced correlated cholestasis and liver failure, and died at day 143. Pathologic findings showed partial hypoplasia of the intrinsic muscle layer in the small intestine and diagnosed as segmental absence of intestinal musculature. Her disorder was unusual in its presentation, which included prenatal bowel dilatation, metachronous superimposed bowel perforation, and extensive discrete lesions from the jejunum to the transverse colon.

Gastrectomy for Giant Stomach Due to Hypertonic Pylorus in a Patient With Simpson-Golabi-Behmel Syndrome: First Known Case Reported

SImpson-Golabi-Behmel Syndrome (SGBS)is inherited in an X-linked fashion. If there is only one affected individual in a family, which is the case of our patient,he may have inherited the mutation from his mother or may have a de novo mutation. Reviewing all published cases of SGBS indicates that the frequency of de novo mutations is about 20-30%. Clinical findings in the abdominal region of the reported cases include visceromegaly (nephromegaly, splenomegaly and hepatomegaly), which were common conditions. Congenital diaphragmatic hernia (CDH) was described in less than 10% of children. Neonatal liver disease and choledochal cyst were both reported once in distinct cases. A 15 year old male presented at our urgent care department complaining of a 20 days abdominal pain with occasional episodes of vomiting. On clinical exam he presented distended abdomen, and mild abdominal tenderness. He underwent X-Ray investigation, which showed a significant large gastric distention and therefore we placed a nasogastric tube to relieve the gastric distention that did not bring any improvement of the condition. Abdominal computed tomography (CT) photo 1, was performed and detected dilated stomach without bowel dilation. Afterwards an endoscopy, photo 2, was executed to investigate hypertrophic pyloric and found open pyloric without stenosis. We have found in intra op field a dilatated stomach and 20 cm long tear involving antrun and boby without perfuration leeding us to decide to do a partial gastrectomy,photo 3,, no complications were found in the early post operative period. Our case of pyloric ring leading to gastric outlet obstruction in the SGB Syndrome appears not to have been reported previously. Hypertrophy of the pyloric sphincter in the adult is not a common condition, even less common associated with SGBS, so that the knowledge of the surgeon plays a important role in making this condition diagnosable. Awareness of the disease may lead to an more accurate intervention, which is advantageous for both patient and medical staff.Figure: Ct showing a dilatated stomach and pectus excavatum.Figure: A) Endoscpy showing an open non-functional pylorus B) the intraop view - dilatated stomach and the tear.Figure: Hipertrophic pylorus.

Pseudo-Riglerʼs Sign With Intrabiliary Reflux of Gastrografin Due to Severe Constipation

Introduction: Rigler's triad, a manifestation of gallstone ileus, is constituted by the radiographic finings of ectopic gallstone, pneumobilia and small bowel obstruction. We report this very rare case of pneumobilia and reflux of oral Computerized Tomography (CT) contrast-Gastrografin into the biliary tree, in a patient with bowel obstruction/severe ileus due to constipation without an ectopic gallstone (pseudo-Rigler's sign). Patient was treated with colonic enemas, polyethylene glycol, and nasogastric tube decompression with resolution of these radiological findings. Case report: Here in, we present a case of a 58-year-old man with medical history of systolic congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease who presented with hypoxic respiratory failure due to pneumonia. Patient was intubated and put on mechanical ventilation. Patient was found to have worsening abdominal distension. Physical examination revealed diminished bowel sounds. CT scan of abdomen and pelvis showed diffuse dilation of large and small bowel with abundant stool in the sigmoid colon and rectum, Gastrografin contrast in dilated intrahepatic bile ducts and pneumobilia (Figure 1). The patient was managed with high colonic enemas, polyethylene glycol and nasogastric tube decompression. Electrolytes and renal function were monitored and corrected accordingly. The patient subsequently had bowel movements with resolution of ileus and pneumobilia with contrast drainage from bile ducts.Figure: Intrahepatic ducts with gastrografin.Discussion: Constipation commonly occurs in the elderly population. Severe or chronic constipation can very rarely lead to fecal impaction, intestinal obstruction and pneumobilia. Our patient presented with atypical signs of Rigler's triad (barring the ectopic gallstone) in the setting of chronic constipation. Patient was also found to have reflux of oral contrast material from the duodenum via the ampulla into the common bile duct and dilated intrahepatic biliary tree- which is an extremely rare radiological finding. To our knowledge this is the first reported case of biliary reflux of oral in the setting of chronic constipation.

Lupus Enteritis in a Young Female: A Rare Disease Requiring a Rapid Diagnosis

Intro: Though systemic lupus erythematosus (SLE) frequently involves the gastrointestinal tract, lupus enteritis (LE) is a rare manifestation of the autoimmune disease and can have catastrophic effects if missed. We present a case of LE to raise physician awareness of an uncommon disease. Case: A 21-year-old female with newly diagnosed SLE and class V lupus nephritis presented to the ER with a 4 day history of nausea, non-bilious, non-bloody vomiting, abdominal pain and decreased appetite. Symptoms began within 1 week of initiating treatment with mycophenolate mofetil and prednisone 50mg. Physical exam was notable for mild abdominal distention with diffuse tenderness on palpation, and a faint malar rash. Labs were notable for normocytic anemia, paraprotein gap of 5mg/dL, nephrotic range proteinuria, and elevated levels of CRP 1.92mg/dL, ESR 29mm/Hr, double-stranded DNA antibody 39 IU/mL, and anticardiolipin IgM 12.8 MPL. CT abdomen with contrast demonstrated ileitis with marked wall thickening and stranding involving multiple ileal loops from the mid jejunum to terminal ileum, engorgement of mesenteric vessels, and a 0.9 x 1.2 x 1.6 inferior vena cava thrombus between the liver and right atrium. She was to follow up as an outpatient for colonoscopy. For lupus nephritis and enteritis, she was treated with 3 days of pulse dosed steroids with immediate improvement of symptoms. She was discharged on day 5, with complete symptom resolution on a steroid taper. Discussion: The British Isles Lupus Assessment Group define LE as a vasculitis or inflammation of the small bowel with supportive image or biopsy findings. As seen in our patient, LE most often presents with abdominal pain and vomiting. Abdominal CT is the gold standard for diagnosis and images show bowel wall thickening and dilatation, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat. The disease is reversible and steroid responsive. First line treatment in a severe flare involves IV corticosteroids. Cyclophosphamide and mycophenolate can be added in cases of steroid resistance, enteritis recurrence, or as in our case, if additional organs are involved. If unrecognized, LE may result in perforation and bowel necrosis. Knowledge of this rare complication of SLE is paramount to the diagnosis, treatment, and prevention of potentially fatal complications. As depicted in our case, rapid detection and treatment results decreased hospital length of stay, morbidity, and mortality.Figure: CT (axial view). Marked wall thickening and inflammatory stranding involving terminal ileum.Figure: CT (coronal view). Marked thickening and surrounding inflammatory stranding in the small bowel with engorgement of mesenteric vessels.

Refractory Ileal Fecaloma Causing Small Bowel Obstruction

Fecalomas are extremely rare and often occur in the in the rectum and sigmoid colon. In patients with multiple comorbidities limiting clinical decisions, it is important to understand the treatment options available with fecalomas and their outcomes. Here we present a 61-year-old ventilator-dependent male with advanced dementia, status post heart and lung transplant, and status post prior small bowel resection for unclear reasons who presented with abdominal distention and bilious emesis following a recent hospitalization for respiratory failure secondary to pneumonia. Vitals were notable for tachycardia to the 110s and exam was significant for palpable stool along the right side of abdomen. An abdominal radiograph revealed dilated loops of small and large bowel with air-fluid levels (Figure 1). Conservative treatment with a nasogastric tube, crystalloids, and rectal laxatives were unsuccessful. An abdominal CT scan showed a dilated fluid-filled small bowel extending to distal ileum where there was a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with distinct transition point (Figure 2). Multiple attempts at laxatives from patient's gastrostomy tube and rectally were trialed with no significant improvement in patient's abdominal distension and pain. Unfortunately, the patient was a poor candidate for surgery due to his multiple comorbidities. The family ultimately decided to pursue hospice. Fecalomas, or hard intraluminal tumor-like mass of feces, are most commonly found in the rectum and sigmoid colon. It has been more commonly reported in patients with old age, long-term enteral feeding, and neuropsychiatric disease, likely leading to sluggish bowel function. Fecalomas in the small bowel causing obstruction has only been reported in a 10-year-old boy. Fecalomas in the distal colon are often managed by conservative methods such as bowel rest, rectal suppositories, enemas, digital evacuation and rectal decompression. More aggressive treatments include endoscopic disimpaction and surgical intervention for those who are otherwise good surgical candidates. Our case posed a management dilemma in that the fecaloma was located in an aperistaltic segment of the ileum rather than more distally, making colonoscopic decompression difficult, and as patient was not a surgical candidate, surgery was a nonviable option. Since patient has exhausted all conservative managements, comfort care became the best available option.Figure: An abdominal radiograph showing dilated loops of small and large bowel obstruction with air-fluid levels.Figure: An abdominal CT scan showing a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with a distinct transition point.

A Rare Case of Uterine Leiomyosarcoma With Metastasis to the Colon

Laeeq Butt, MD, MBA, Rajiv Mallipudi, MD, Swami Nathan, MD A Rare case of Uterine Leiomyosarcoma with Metastasis to the Colon and Small Bowel Introduction: Uterine leiomyosarcoma is an extremely rare and aggressive malignancy with an overall poor prognosis. It typically metastasizes through hematogenous dissemination to the lungs, bones and brain. However, there have not been many cases of metastasis to the colon. In reported cases the patients presented with acute abdomen secondary to uterine leiomyosarcoma invasion of the small bowel or colon. Here we present an extremely rare case of a leiomyosarcoma of the uterus with metastasis to the colon.Figure: P1: Colonoscopy image of the tumor.Figure: P2: Colon mass pathology shows Spindle Cells (elongated narrow cells) indicative of Sarcoma.Case: 48 year old female with uterine leiomyosarcoma with metastasis presented with acute blood loss anemia, small bowel obstruction and intussusception. Colonoscopy showed a 20mm ascending colon mass with pathology consistent with high grade sarcoma consistent with metastatic leiomyosarcoma (P1,P2). CT scan showed hypodensity in the right quadriceps muscle of 1.2 x 1 cm and intraluminal metastatic lesions causing intermittent intussusception and dilated small bowel loops. Three metastatic lesions in the lung were also identified (P3). Immunohistological staining showed that the colon mass was strongly positive for C-kit, DOG1 and negative for CD34. Karetin stains (MN116, AE1.3 and high molecular weight Keratin) did not stain the tumor. Key sarcoma markers such as Desmin, Actin and smooth muscle were negative. Metastatic tumors on occasion can be dedifferentiated and fail to express expected markers; therefore, pathologist believed that given recent diagnosis this colon tumor must be metastasis from the uterine leiomyosarcoma. Patient was offered palliative chemotherapy and surgical treatment and was lost to follow up post discharge.Figure: P3: Chest X-Ray with metastatic lesions identified.Conclusion: Melenoma is the most comon tumor that metastesizes to the colon. Metastasis to small bowel and colon from uterine leiomyosarcoma is extremely rare and is a sign of advanced disease. The more common sites for metastasis are lung, liver, abdomen, pelvic/aortic lymph nodes. Bone and brain are less common. It is important to differentiate between primary tumors of the colon versus metastatic and immunohistochemistry can be utilized to differentiate between the two. Metastasis to the heart is also possible via direct extension, hematogenous spread, and implantation or via lymphatic route.

Chronic Intestinal Pseudo-obstruction in the Setting of Inactive Systemic Lupus Erythematosus

Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder of intestinal hypomobility, which presents a similar fashion to a bowel obstruction, but without evidence of anatomic obstruction. We present a case of CIPO associated with inactive systemic lupus erythematosus (SLE).A 42 year-old woman with a history of SLE presented with obstipation, with episodic nausea, vomiting, and abdominal pain. No prior history of abdominal surgery. CT abdomen & pelvis did not reveal any anatomic obstruction. Colonoscopy showed no masses. Impaired intestinal motility was confirmed with scintigraphy, consistent with CIPO. Anti-rho antibody was positive. She was treated with laxatives, enemas, and pro-motility agents. Since being diagnosed with SLE patient encountered several complications, including pulmonary hemorrhage, hemolytic anemia, nephritis, and retinitis from hydroxychloroquine. Aside from bowel disturbances, the patient remained asymptomatic between lupus flares. Over several years, the patient developed 6 episodes of acute colonic pseudo-obstruction, treated with intravenous methylprednisolone. Exploratory laparotomy showed a large, dilated colon with fecal impaction, without any anatomic cause of obstruction. A subtotal colectomy and end ileostomy were performed. Pathology showed mucosal ulceration with transmural fibrosis, and pericolic lymph nodes with reactive follicular hyperplasia. She did well initially, but then required several ostomy revisions for pseudoobstruction. Ultimately, her stoma prolapsed, requiring decompression.The etiology of CIPO is unknown, but may involve vasculitis. Several pathologic changes may be observed, including fibrosis. CIPO is often idiopathic, but may occur due to an underlying condition, such as lupus. CIPO usually occurs in the setting of active lupus. No laboratory tests are specific for CIPO; however, 83% of cases have anti-Rho antibodies.To our knowledge, this represents the second reported incidence of intestinal pseudo-obstruction associated with inactive systemic lupus erythematosus. There are less than 35 cases of CIPO associated with SLE published in English. CIPO is a rare and life-threatening complication of lupus. Awareness of the condition may facilitate early recognition and appropriate treatment, which includes intravenous glucocorticoids, immunosuppressants, and promotility agents. When possible, surgery should be avoided, as the condition tends to recur.Figure. X: ray abdomen showing diffusely dilated small bowel loops.Figure: Trichrome stain, showing transmural fibrosis.Figure: Elastic stain to show intimal fibroplasia and luminal stenosis.

A Case of Superior Mesenteric Artery Syndrome in Perianal Crohnʼs Disease

Superior Mesenteric Artery (SMA) syndrome is a rare condition caused by compression of the duodenum between the aorta and SMA due to loss of mesenteric and retroperitoneal fat. Among IBD patients, SMA syndrome occurs more commonly in patients with ulcerative colitis (UC) after ileal pouch anal anastomosis (IPAA). This is the first reported case of SMA syndrome in a patient with perianal Crohn's disease (CD). A 32 year old female with perianal CD and diverting loop sigmoid colostomy on infliximab presented with 1 month of progressive, colicky, postprandial abdominal pain, nausea, sitophobia, diarrhea, and a 7 lb weight loss leading to an episode of orthostatic syncope. Contrast enhanced computed tomography showed distension of the stomach and proximal duodenum, but no obstruction, bowel wall thickening, or intraabdominal abscess. Small bowel follow through showed delayed transit through the duodenum in the region of the SMA as well as small bowel dilation proximal to the region of the SMA consistent with SMA syndrome. Magnetic resonance enterography showed no evidence of active CD. Serum inflammatory markers were within normal limits. Alternative etiologies such as delayed motility from diabetes, hypothyroidism, and other metabolic neuropathies were ruled out, and she was diagnosed with SMA syndrome. Despite modest improvement of her nausea with scheduled metoclopramide, total parenteral nutrition was started for inadequate nutrition prior to hospital discharge. SMA syndrome in IBD patients is most commonly associated with IPAA, which is performed for refractory ulcerative colitis or for resection of IBD-associated colon cancer. One proposed mechanism for this phenomenon is surgery-induced stretching of the SMA, flattening it against the aorta to cause duodenal narrowing. This is the first reported case of SMA syndrome in perianal CD status post diverting loop sigmoid colostomy. Perianal CD is an uncommon variant of CD and phenotypically mimics limited UC. Although our patient's surgery did not involve significant bowel resection as in an IPAA, perhaps this phenotypic similarity and post-surgical anatomic changes predisposed her to increased risk of SMA syndrome. For IBD patients presenting with obstructive symptoms such as nausea, vomiting, sitophobia, and abdominal pain, clinicians must maintain a low threshold for considering SMA syndrome since treatment differs significantly from treatment of IBD exacerbation.Figure: CT abdomen and pelvis axial image showing compression of duodenum between the superior mesenteric artery (SMA) and aorta.Figure: CT abdomen and pelvis sagittal image showing acute angulation of the superior mesenteric artery (SMA) and the aorta.

Lupus Enteritis: A Non-surgical Cause of Acute Abdomen

Introduction: SLE is a multisystem autoimmune disorder. Lupus enteritis is potentially rare complication of SLE presenting as abdominal pain. Case report: A 32 year old woman with the history of SLE came for evaluation of 1 week history of subjective fever, cough, and pleuritic chest pain after failing outpatient treatment for community acquired pneumonia with levofloxacin. She had stable vitals on admission. Laboratory investigations showed leukopenia, anemia, raised C-reactive protein, and positive anti-dsDNA antibodies with higher titers from baseline and low complement levels. Her CXR and echocardiogram showed moderate bilateral pleural effusion and mild pericardial effusion. The patient was started on IV steroid to treat SLE flare. On day four of hospitalization, she complained of nausea, vomiting, and severe abdominal pain. Abdominal CT scan showed dilated and thickened small bowel loops, mild abdominal ascites without any evidence of arterial and venous thrombosis. She was given bowel rest and empirically started on IV antibiotics, and steroids were continued. Stool studies including C diff, bacterial cultures and ova and parasites were negative. She had clinical improvement in 2-3 days and was able to tolerate diet. Antibiotics were discontinued, and she was discharged home on tapering doses of steroid. Discussion: Lupus enteritis is an uncommon condition in SLE patients with the prevalence of about 0.9 %. About 8%-40% of SLE patients have acute abdominal pain during the stage of an active disease. Inflammatory vasculitis secondary to immune complex deposition and thrombosis of the intestinal vessels are the proposed pathogenic mechanisms. It can cause very severe abdominal symptoms and signs and sometimes is diagnosed as the acute surgical abdomen. Early diagnosis is critical to allow prompt treatment to avoid unnecessary surgical intervention. Characteristic CT abdomen findings include dilated bowel, focal or diffuse bowel wall thickening, abnormal bowel wall enhancement which is also called “target sign,” mesenteric edema, stenosis or engorgement of mesenteric vessels which is also called “the comb sign” and ascites. Treatment is symptomatic management and high dose intravenous methylprednisolone. Those who do not have an adequate response to steroids should be considered for immunosuppressive agents like intravenous cyclophosphamide. When a rapid response to immunosuppressive therapy is not achieved, surgical intervention should be considered.Figure: Thickened loops of small bowel on CT abdomen and pelvis.

Using prenatal MRI to define features of meconium peritonitis: an overall outcome

To use prenatal magnetic resonance imaging (MRI) to define features of meconium peritonitis (MP) and analyse the relationship between prenatal MRI findings and postnatal outcomes. Eight cases were enrolled who had been diagnosed with MP through prenatal MRI; the diagnoses were confirmed at surgery and pathology or follow-up. MP was diagnosed by the findings of meconium ascites, meconium pseudocyst, or dilated bowel loops. Prenatal follow-up after diagnosis by MRI was performed by ultrasound. Prenatal MRI findings included massive meconium ascites (five out of eight cases), a small meconium pseudocyst (one out of eight), a large meconium pseudocyst along with a dilated bowel loop (one out of eight), a dilated bowel loop alone (one out of eight), and micro-colorectum (six out of eight). Six fetuses showed abdominal distension, bilious vomiting, and no normal meconium at birth; they underwent exploratory laparotomies and subsequently, survived and prospered. Only one fetus (with a small meconium pseudocyst) received conservative treatment. There was one mortality, and the cause of death was full-bowel necrosis. Prenatal MRI may be helpful for diagnosing MP, in cases where the specific MRI findings are persistent meconium ascites, a dilated bowel loop, micro-colorectum, and meconium pseudocyst. In particular, a micro-colorectum might indirectly reflect ileum atresia, which requires postnatal surgery.

Clinical utility of the patency capsule: a large volume center experience.

In patients with suspected or known obstructive gastrointestinal pathology, the use of patency capsule (PC) aims to minimize the risk of subsequent retention of the endoscopic capsule. However, its clinical utility is not consensual. The aim was to evaluate the indications, results and safety profile of the PC. Retrospective analysis of PCs (agile patency capsule) conducted between 2011 and 2015. Patency evaluation was performed after 30 hours, with radiological confirmation if PC was detected. We included 369 PCs, 54% female. The average age was 42±16 years. Main indications included suspected Crohn disease (CD) (45%), CD staging (32%), neoplastic diseases (9%), radic enteritis (3%), prior surgery (3%), NSAIDs enteropathy (2%) and anemia (2%). Before the exam 5% of patients were taking constipation-induced medications and 5% reported occlusive symptoms; 38% of patients had previous abdominal surgeries, most often ileal resection due to CD (24%); 42% of patients had previous imaging studies, revealing strictures in 20% and bowel dilation in 11%. Patency capsule was negative (patent gastrointestinal tract) in 73% of cases at 30h and 2% of PCs were fully recovered in the following days. Seven patients (2.5%) showed self-limiting occlusive symptoms during the procedure. All patients with negative PC subsequently performed capsule endoscopy with no cases of retention. History of occlusive symptoms (P=0.023) and strictures in imaging studies (P=0.029) were associated with the detection of the PC at 30 hours. PC is a safe and effective exam. Occlusive symptoms and imaging strictures were significantly associated with the retention. The retention rate was 25%, a similar result to that described in other series but higher than expected for the various indications, suggesting the importance of new research studies.

P28.06: Perinatal management in cases of fetal abdominal wall defects (fAWD): retrospective survey on predictors of final outcome

Perinatal management in cases [cs.] of fAWD, in particular timing of delivery, is an issue of debate and strategies changed from scheduled late preterm towards early term delivery. We address the questions: Is intended prolongation until 38 weeks of gestation [wksGA] justified in cases of fAWD and are there predictors to optimise outcome? In a retrospective study all cs. transferred to either of 2 level 1 perinatal centres in Thuringia/Germany (Jena [JE], ∼1500; Erfurt [EF] ∼1800 del./year) with suspected fAWD between 2003-2014 were reviewed. Data on prenatal care, perinatal management and pediatric surgery were collected from patient's records. The initial cohort consisted of 74 cs.; 64 were applicable to analysis (complex syndromes/TOP 4; LOF 3; diagnosis not confirmed 3). Gastroschisis [GSC] was present in 42 (JE 24; EF 18), omphalocele [OMPH] in 22 cs. (JE 14; EF 8). 2 perinatal deaths occurred in association with early PTB [GSC, maternal HELLP, 28+6 wksGA; OMPH, preterm labour [PTL], 23+5 wksGA]; 1 fetus was born at 28+2 wks GA [OMPH]. 21/41 [GSC] and 4/20 [OMPH] of the remaining deliveries (all >33+0 wksGA) were rescheduled or performed as an emergency (GSC: progressive dilation of bowel 5, PTL 7, fetal compromise 8, mat. disease 1; 11/16 >36+0 wksGA; OMPH: PTL 4, none <36+0 wks GA). Perinatal outcome parameters were positively correlated (GA, weight, APGAR, pHart) and negatively to duration of postnatal hospital stay (R2 between -0.35 to -0.41). 5 infants (8%) required surfactant administration. Where available (31 cs.) a longer duration of the primary operation was associated with a higher risk for secondary surgery. In our cohort intended prolongation >36 wksGA did improve perinatal outcome but increased the probability of unscheduled delivery. Premature contractions are a predictor of early labour in cs. of OMPH; fetuses with GSC are more likely to develop IUGR (22%). Surgical outcome was generally favourable but still related to perinatal outcome after delivery >33+0 wksGA.

Small Bowel Dilatation Predicts Prolonged Parenteral Nutrition and Decreased Survival in Pediatric Short Bowel Syndrome.

To analyze risk factors and prognostic significance of small bowel (SB) dilatation in children with short bowel syndrome (SBS). In SBS, the remaining SB may dilate as part of intestinal adaptation. The impact of dilatation on parenteral nutrition (PN) dependence and survival has not been studied systematically. SB diameter of SBS children (n = 61) was measured in contrast SB series (n = 169, median age 0.94, range 0.32-2.7 years) during 2002 to 2015, and expressed as millimeters (SB width) and as ratio to L5 vertebra height (SB diameter ratio). Linear regression was used to examine risk factors for dilatation. PN weaning and survival were analyzed with Cox proportional hazards regression. Maximal SB diameter ratio during follow-up was predicted by PN dependence and SB atresia, while maximal absolute SB width by birth weight, age, PN duration, and remaining bowel length. Weaning off PN was 14-fold more likely in patients with maximal SB diameter ratio <2.00 compared with >3.00 (P = 0.005), and 5.4-fold more likely when maximal SB width was <20 mm compared with >30 mm (P = 0.023). After adjustment for age, remaining SB length, and the presence of ileocecal valve, both estimates of maximal SB dilatation remained significant independent predictors for weaning off PN. When all measurements were included, the cumulative survival was worse if SB diameter ratio exceeded 2.00 (P = 0.002-0.042). SB dilatation predicts prolonged PN duration and decreased survival in SBS children. Measurement of maximal SB diameter standardized to L5 vertebra height may be a valuable objective tool for patient follow-up and assessment of prognosis.

Pneumatosis Intestinalis in Patients Receiving Tube Feeds

Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.

An uncommon case of small bowel obstruction due to phytobezoar in a known case of tubercular abdomen: a decisional dilemma

Study report the case of middle aged male who was presented with abdomen pain and diagnosed of small bowel obstruction caused by bezoar in a case of tubercular abdomen and review the literature. The initial presentation was generalised pain with nausea and vomiting and abdominal distension. Plain abdomen film showed diffuse dilated bowel loop in upper abdomen. Patient had similar recurrent episode 12 months back when he was managed conservatively and diagnosed as tubercular abdomen and he had taken ATT for 3 months. At this time patient managed conservatively, but did not respond. Later a CECT whole abdomen was done and patient diagnosed as cocoon abdomen with mass or a foreign body impacted at distal jejunal region with proximal bowel dilatation. Later patient revealed ingestion of a large mango seed 4 months back. Later patient was explored, adhesionolysis and enterotomy was done and phytobezoar was removed. Early history of recurrent tubercular obstruction with non- specific symptoms. Later recognition of condition by typical imaging and leading questions induced history image play an important role in to come to a diagnosis, with significant delay in diagnosis; and increase the morbidity and mortality.

Small bowel dilation in children with short bowel syndrome is associated with mucosal damage, bowel-derived bloodstream infections, and hepatic injury

Liver disease occurs frequently in short bowel syndrome. Whether small bowel dilation in short bowel syndrome could influence the risk of liver injury through increased bacterial translocation remains unknown. Our aim was to analyze associations between small bowel dilation, mucosal damage, bloodstream infections, and liver injury in short bowel syndrome patients. Among short bowel syndrome children (n = 50), maximal small bowel diameter was measured in contrast series and expressed as the ratio to the height of the fifth lumbar vertebra (small bowel diameter ratio), and correlated retrospectively to fecal calprotectin and plasma citrulline-respective markers of mucosal inflammation and mass-bloodstream infections, liver biochemistry, and liver histology. Patients with pathologic small bowel diameter ratio >2.17 had increased fecal calprotectin and decreased citrulline (P<.04 each). Of 33 bloodstream infections observed during treatment with parenteral nutrition, 16 were caused by intestinal bacteria, cultured 15 times more frequently when small bowel diameter ratio was >2.17 (P<.001). Intestinal bloodstream infections were predicted by small bowel diameter ratio (odds ratio 1.88, P=.017), and their frequency decreased after operative tapering procedures (P=.041). Plasma bilirubin concentration, gamma-glutamyl transferase activity, and histologic grade of cholestasis correlated with small bowel diameter ratio (0.356-0.534, P<.014 each), and were greater in the presence of intestinal bloodstream infections (P<.001 for all). Bloodstream infections associated with portal inflammation, cholestasis, and fibrosis grades (P<.031 for each). In linear regression, histologic cholestasis was predicted by intestinal bloodstream infections, small bowel diameter ratio, and parenteral nutrition (β=0.36-1.29; P<.014 each), while portal inflammation by intestinal bloodstream infections only (β=0.62; P=.033). In children with short bowel syndrome, small bowel dilation correlates with mucosal damage, bloodstream infections of intestinal origin, and cholestatic liver injury. In addition to parenteral nutrition, small bowel dilation and intestinal bloodstream infections contribute to development of short bowel syndrome-associated liver disease.