Dilated Small Bowel Loops Research Articles

A Case of Lower GI Bleeding Caused by Localized Amyloid Light-Chain Amyloidosis in the Small Intestine

Introduction: Amyloidosis is a disorder characterized by the abnormal deposition of extracellular amyloid fibrils that leads to disruption of tissue structure. Systemic amyloidosis can involve the gastrointestinal tract. The small intestine is the most commonly involved gastrointestinal site. However, cases of localized amyloid light-chain amyloidosis in the small intestine are rarely reported. Here we report a case of primary amyloidosis only in the small intestine without any other organ involvement. Case: A 73-year-old male with history of alcoholic pancreatitis, hypertension was transferred to our hospital with complaints of hematochezia before 2 days ago. Laboratory tests revealed that serum hemoglobin level decreased from 11.6 to 7.7 g/dL. There was no bleeding focus on gastroduodenoscopic and colonoscopic examination. Contrast enhanced CT enterography for evaluation of small bowel bleeding showed that two sites of aneurysmal dilatation of small bowel loops with concentric wall thickening (Figure 1a, 1b). Balloon enteroscopy to examine the lesions in the small bowel detected cystic mucosal lesion with hemorrhagic surface change with easily touch bleeding below the 2nd portion of duodenum (Figure 2a). For control of bleeding, he underwent surgery of small bowel resection. There were 2 segmental lesions (5cm in the jejunum, 8cm in the ileum) of small bowel wall dilatation. Also small bowel between the lesions showed distended and edematous in the operation finding (Figure 2b). Histologic examination of the specimen revealed amyloid deposition (Figure 3a) and positive Congo red staining in the small intestine (Figure 3b). According to the results of immunohistochemistry, deposits of amyloid were positive for amyloid kappa (Figure 3c), lambda (Figure 3d), but negative for amyloid A. Therefore the results were indicative of amyloid light-chain (AL) amyloidosis. Bone marrow biopsy for evaluation of systemic amyloidosis founded that no definite evidence of plasma cell disorder. Serum and urine electrophoresis revealed no monoclonal gammopathy. There was no evidence of other organ involvement. In conclusion, he was diagnosed with localized AL amyloidosis in the small intestine. He was followed-up as an outpatient without history of re-bleeding and complaining of other symptom.Figure 1Figure 2Figure 3Conclusion: Localized amyloidosis in the small intestine can manifest the symptom of lower GI bleeding. Because our patient underwent resection of involved small intestine without any other treatment, it needs to follow-up about progression to systemic disease, re-bleeding and any other complications.

Unusual Cause of Small Bowel Obstruction Caused by a Prune Pit.

An 86-year-old woman came to our emergency department with a history of nausea and diffuse abdominal pain during the last 24 hours. Since then, she had absence of flatus and stool. At the age of 47, she underwent an appendectomy. Clinical examination revealed a distended and hypertympanic abdomen without bowel peristalsis. Laboratory examination showed slightly increased inflammatory parameters. An upright plain film of the abdomen (Fig. A) revealed multiple air-fluid levels and distended bowel loops. There was no pneumoperitoneum. An aspecific opacity was seen in the pelvis. There is a well-defined translucent supradiaphragmatic area compatible with a sliding hiatus hernia. Ultrasound was performed and revealed dilated small bowel loops. The gallbladder was hydroptic but there was no wall thickening. A CT was performed with IV and retrograde contrast agent opacification, the axial and coronal reformatted images (Figs. B and C) of the abdomen showed a well-defined dense double-layered intraluminal structure in the preterminal ileum and multiple distended bowel loops. A small bowel obstruction caused by a corpus alienum was diagnosed on the basis of radiograph, ultrasound and CT findings. The patient underwent a laparotomy which revealed a prune pit and multiple adhesions at the site of obstruction. The adhesions were possibly due to the appendectomy at the age of 47.

English

Mucocele of appendix (MA) is a rare entity and is defined as mucin filled dilated appendicular lumen which may be due to distal obstruction. It is usually asymptomatic and may present as appendicitis. We present a rare case of an elderly female who presented with features of acute intestinal obstruction secondary to mucinous cystadenoma of appendix for which she had to INTRODUCTION: MA refers to dilated mucin filled appendicular lumen which may be secondary to distal obstruction. It is a rare condition with estimated incidence of only 0.2-0.3% in appendicectomy specimens.(1) It can be asymptomatic, but acute or chronic pain in the right iliac fossa is the most frequent symptom.(2) Intestinal obstruction complicating an appendiceal mucocele has rarely been reported.(3) We describe the case of an old woman who came to emergency with signs and symptoms of intestinal obstruction due to appendiceal mucocele. CASE REPORT: We report the case of a 60years old, previously healthy woman, who presented to our emergency room with a 3day history of acute and diffusely abdominal pain, nausea, vomiting and disruption of bowel movements. Her abdomen was distended and tympanic with diffuse tenderness, especially in the periumbilical areas with exaggerated bowel sounds. She had a history of ant tubercular treatment for pulmonary koch's 5years back. She also had a history of an episode of subacute intestinal obstruction 6months back which was managed conservatively outside. The leukocyte count was 22,000 with 95% neutrophils. An erect film of the abdomen revealed multiple air fluid levels suggestive of small bowel obstruction. CECT abdomen was done which showed small bowel dilatation with abrupt tapering near IC junction with mesentric lymphadenopathy. So, a diagnosis of acute intestinal obstruction secondary to ileocaecal koch's was made. After resuscitation, patient was undertaken for exploratory laporotomy. On inspection, dilated small bowel loops with collapsed large bowel mesentry were found and a 4*3cm in size firm mass was found at the anatomical site of appendix. The mass was preileal in position and was compressing over terminal ileum. About 10ml mucinous collection was found in right iliac fossa and pelvis. So, right sided hemicolectomy was performed. The postop period was uneventful and patient was discharged on day 11 in satisfactory condition. The final histopathology showed mucinous cystadenoma of appendix collection and reactive lymphoid hyperplasia with no epithelial cells in mucin.

Iatrogenic pseudocyst and bowel obstruction from a ventriculo-peritoneal shunt

Ventriculoperitoneal shunts are commonly placed to treat hydrocephalus in infants and children. Expected complications can include infection, malfunction, and obstruction. Abdominal complications are rare, especially bowel obstruction. A 20-year-old nonverbal male with profound mental retardation from shaken baby syndrome as an infant presented with abdominal distension and lethargy. Past medical history was significant for a ventriculoperitoneal shunt that had been placed more than 15 yr prior for hydrocephalus, a feeding gastrostomy tube,, and trans-abdominal spinal surgery for scoliosis. The patient had been vomiting his tube feeds for two days. On physical examaination, the patient was diaphoretic, hypotensive, and tachycardic with a heart rate of 143. The abdomen was quite distended with high-pitched, tinkling bowel sounds. He was afebrile, but had a white blood cell count of 7.1 with a differential showing 50% bands and 41% neutrophils. Computed tomography scan showed a large cyst in the right upper quadrant with the ventriculoperitoneal shuntwithin the cyst. The cyst had an enhancing rim and multiple dilated loops of small bowel could be seen (Fig. 1). Exploratory laparotomy revealed that the ascending colon was tightly wrapped around the lateral and superior walls of the cyst and compressed against the abdominal side wall causing a bowel obstruction. The colon and several loops of small intestine were tenaciously adherent to

An Unusual Cause of Intestinal Obstruction in a Young Female

Question: A 30-year-old woman presented with abdominal pain and distension for 1 month. There were several episodes of vomiting over the last 2 weeks. There was history of open cholecystectomy for gallstone disease 3 years back. There was no other significant past medical or family history. On examination, there was no pallor or icterus. Abdominal examination revealed abdominal distension with mild tenderness in the epigastrium. The rest of the systemic examination was unremarkable. Routine biochemical and hematologic investigations were unremarkable. A diagnosis of subacute intestinal obstruction was considered. Abdominal radiograph in erect position showed dilatation of small bowel with multiple air–fluid levels (Figure A, arrows). Ultrasonography confirmed the dilatation of small bowel loops. There was no ascites. Noncontrast axial CT of the abdomen revealed dilatation of small bowel with air–fluid levels (Figure B, short arrow) and a hyperdense intraluminal lesion showed mottled air (Figure B, arrow). Contrast-enhanced coronal reformatted image localised the intraluminal abnormality within the ileum (Figure C, arrow). The involved segment of bowel showed mild mural thickening and adjacent mesenteric fat stranding. The proximal small bowel was dilated (Figure C, short arrow). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Gossypiboma denotes a mass of cotton sponge that is accidentally retained in the body after an operation. There are 2 usual pathological responses to retained sponge: exudative inflammatory reaction leading to abscess and aseptic/fibrotic reaction leading to a mass.1Dhillon J.S. Park A. Transmural migration of a retained laparotomy sponge.Am Surg. 2002; 68: 603-605PubMed Google Scholar Transmural migration is extremely rare. Such a migration has been reported into the intestinal lumen, urinary bladder, or thorax.1Dhillon J.S. Park A. Transmural migration of a retained laparotomy sponge.Am Surg. 2002; 68: 603-605PubMed Google Scholar Intestinal transmural migration occurs in various intraabdominal locations. It results from inflammation in the intestinal wall progressing to necrosis. After complete migration of sponge, the intestinal loop closes spontaneously. Intestinal peristaltic activity may advance the mop distally with obstruction occurring at various levels, most commonly the terminal ileum. Cases of transmural migration of surgical sponge several months to years after cholecystectomy have been reported.2Patil K.K. Patil S.K. Gorad K.P. et al.Intraluminal migration of surgical sponge: gossypiboma.Saudi J Gastroenterol. 2010; 16: 221-222Crossref PubMed Scopus (21) Google Scholar In a systematic review of transmural migration of gossypiboma, 64 cases were reported. Intestine was the most common site of impaction (75%) followed by bladder (n = 7) and stomach (n = 2). Spontaneous expulsion was reported in 4 cases only.3Zantvoord Y. Weiden R.M. van Hooff M.H. Transmural migration of retained surgical sponges: a systemic review.Obstet Gynecol Surv. 2008; 63: 465-471Crossref PubMed Scopus (47) Google Scholar Diagnosis of gossypiboma should always be considered in a patients presenting with vague abdominal complaints after surgery. Imaging, particularly computed tomography (CT), plays an important role in diagnosis. Besides confirming a diagnosis of intestinal obstruction, CT allows a rather confident diagnosis of intraluminal sponge. The CT findings of a sponge include a rounded mass with whorl-like appearance with trapped air bubbles.2Patil K.K. Patil S.K. Gorad K.P. et al.Intraluminal migration of surgical sponge: gossypiboma.Saudi J Gastroenterol. 2010; 16: 221-222Crossref PubMed Scopus (21) Google Scholar A hyperdense capsule and spotted calcification may also be seen. On ultrasonography, the sponge appears as an echogenic mass with dense shadowing. The patient underwent laparotomy and removal of surgical sponge (Figure D, arrow) from the ileum (Figure D, short arrow).

Jejunal diverticulosis found in a patient with long-standing pneumoperitoneum and pseudo-obstruction on imaging: a case report.

Small bowel diverticulosis is a rare finding within the general population and jejunal diverticulosis, specifically, is even rarer. Clinical manifestations can range from post-prandial pain, constipation and malabsorption to serious complications, such as gastro-intestinal hemorrhage, perforation and acute intestinal obstruction. Here we describe the case of an 81-year-old gentleman who presented with a three-year history of abdominal pain and weight loss. Despite unremarkable physical examination and laboratory tests, persistent pneumoperitoneum and dilated loops of small bowel were found on imaging. Having been given a diagnosis of small bowel bacterial overgrowth, the patient underwent capsule endoscopy study for further evaluation of his small bowel. The capsule did not reach the colon and the patient never noted passing the capsule in his stool so, six months post-procedure, a computed tomography (CT) scan seemed to reveal the retained capsule. Subsequent exploratory laparotomy revealed 200 cm of atonic, dilated jejunum with impressive diverticula along the anti-mesenteric border. This case report is an example of an unusual set of presenting signs and symptoms of jejunal diverticulosis, including persistent pneumoperitoneum, pseudo-obstruction and small bowel bacterial overgrowth. A literature review has revealed that these signs have been present in other cases of jejunal diverticulosis, although the etiology and pathophysiology is not clearly understood.

Small bowel obstruction due to phytobezoar and adhesions following laparoscopic cholecystectomy

We report a case of 51 –year-old female with history of laparoscopic cholecystectomy presented with abdominal pain and diagnosed as small bowel obstruction caused by adhesions. The initial presentation was periumbilical pain with nausea and vomiting. Plain abdominal radiograph showed dilated small bowel loops and multiple air fluid levels. Due to failure of conservative treatment, laparotomy was performed. An open metallic clip was adhering the bowel to the gallbladder fossa causing sharp angulation. A phytobezoar proximal to this angulation was exteriorized through enterotomy. The patient was recovered smoothly and discharged from our hospital.

Perforated obturator Littré hernia in an elderly woman

Obturator hernia is an uncommon condition. It carries the highest mortality amongst abdominal wall hernias, usually presenting in elderly, multiparous and thin ladies. Meckel diverticulum is a rare cause of intestinal obstruction and its existence in an obturator hernia is extremely rare; our literature search revealed only two reported cases. We report the case of a 70-year-old woman who presented with signs and symptoms of intestinal obstruction and peritonitis. An exploratory laparotomy led to diagnosis of a strangulated obturator hernia. The sac contents included a Meckel diverticulum with a perforation at its base and a loop of the ileum. The ischemic ileal segment including the Meckel diverticulum was resected and a loop ileostomy was created.

Transmesenteric hernia causing small bowel obstruction following lumbar microdiscectomy

Summary A 54-year-old male patient underwent an L3–4 and L4–5 microdiscectomy. Two days after this operation, he suffered from acute abdominal pain accompanied by nausea and vomiting. A plain upright abdominal radiograph demonstrated multiple dilated small bowel loops with air-fluid levels. Abdominal computed tomography demonstrated diffuse dilatation of the small bowel loops with collapsed colon lumen. Laparoscopic laparotomy was performed after 4 days of conservative therapy without improvement. A 2–3 cm transmesenteric hernia, an uncommon type of internal hernia, and a short segment of entrapped jejunum were observed 40 cm from the ileocecal junction. The entrapped jejunum was viable and removed from the mesenteric defect without resection, and the defect was repaired; the patient recovered after laparoscopic repair. Small bowel obstruction caused by a congenital defect in the intestinal mesentery following microscopic discectomy has never been reported.

Small Bowel Obstruction Due to MALT Lymphoma

Extranodal marginal zone lymphomas comprise approximately 5% of all non-Hodgkin lymphomas. These tumors may arise in any epithelial tissue, including the bowel lining. A report is presented of a patient who presented to the emergency department with epigastric abdominal pain and vomiting. An abdominal sonogram showed a 3.1 cm dilated loop of small bowel near midline just above the umbilicus as well as an abrupt transition zone to normal bowel suggestive of small bowel obstruction, confirmed by subsequent computed tomography. Small bowel resection found an intraluminal tumor, and biopsy showed extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma).

TRANSOMENTAL HERNIATION CAUSING ACUTE INTESTINAL OBSTRUCTION

Internal Herniation is an unusual cause of intestinal obstruction 1 first described by Steinke 2 in 1932 The incidence of Internal Hernia amongst Acute Intestinal Obstruction in the adult population has been reported as around 0.6-5.8% 3 and amongst these, transomental hernias account for about 1- 8.9%. 4,5 They can be congenital or acquired (Trauma, inflammation, age related atrophy.2,6) There are multiple sites where herniation can occur. There are no specific investigations to rule out internal hernias and should be considered a possibility in cases of acute intestinal obstruction. This patient was operated on early after presentation of acute symptoms and so recovered without any immediate or late post-operative complications. CASE REPORT : A 55 years old male was received in the casualty with the complaints of abdominal pain, distension with nausea and vomiting since 2 days. He had not passed stools since 2 days and flatus since the previous evening. He is a known Hypertensive on irregular treatment. Physical Examination revealed mild abdominal distension, palpable small bowel loops and a collapsed rectum with faecal matter. Bowel sounds were hyperactive with Borborygmi sounds. Patient was afebrile, Pulse rate - 64/ min B.P - 170/100 mm hg. Serum creatinine levels were raised. The first plain abdominal X-ray revealed only intestinal gas with distended bowel loops in upper left quadrant. A Ryles tube was inserted which drained around 500 ml of bilious fluid after which abdominal girth deceased from 73 to 67 cm. Plain CT abdomen revealed pneumomediastinum, an over distended stomach with the tip of the Ryles tube in the Left Iliac fossa, multiple dilated small bowel loops with a segmental collapse in the Ileum. There was a thin rim of air under the Left dome of the diaphragm but there were no clinical signs of hollow viscous perforation, only subacute intestinal obstruction. The patient was kept under observation and was conservatively managed for 2 days in which period, the vitals were stable, there was maintenance of saturation, there was no abdominal guarding or rigidity and no increase in abdominal girth. After 2 days, repeat X-ray and CT abdomen still showed dilated small bowel loops with multiple air fluid levels and signs of impending small bowel gangrene and was thus shifted for an Emergency Open Explorative Laparotomy. There was an internal herniation of distal end of stomach, gastrocolic omentum, gastroduodenum and Rt. 2/3 rds of the transverse colon which appeared to be abnormally pulled subhepatically, but could not be reduced. The C-loop of the duodenum with the head of pancreas was in fact an S-loop, with pancreas occupying one convexity. The DJ flexure was in the normal position. The caecum was in the Rt. Iliac fossa ruling out malrotation. About 10 cm of the jejunum, the entire ileum was occupying the Rt. Side of the abdominal cavity and irreducible. Part of the ileal segment was congested. There were no signs of gangrene. The duodenum was kocherised and reduced through the lesser omentum where

Trichobezoar: presenting as primary Intestinal obstruction

ABSTRACTRapunzel syndrome is a rare type of trichobezoar with an extension of the hair into the small bowel. Clinical presentation is deceptive and vague ranging from abdominal mass to gastrointestinal symptoms.Bezoars are usually confined to the stomach which is seen in individuals with psychiatric illness, like trichotillomania, trichophagia and gastric dysmotility. Long standing bezoars may extend into the small intestine leading to a condition known as Rapunzel syndrome. Trichobezoars presenting primarily as intestinal obstruction is very rare. Diagnosis can be established by endoscopy, ultrasonography and computed tomography scan. Treatment includes improvement of general condition and removal of bezoar by laparoscopic approach or laparotomy. Psychiatric consultation is necessary to treat and prevent relapse. We present the case of a 6 years old girl, where the trichobezoar was not suspected at all, especially with negative history of trichophagia and trichotillomania. This girl presented with history of intermittent pain abdomen since 3 months and recent onset severe pain abdomen with abdominal distension and vomiting. Skiagram of abdomen revealed dilated small bowel loops with multiple air fluid levels suggestive of intestinal obstruction. Even ultrasonogram of abdomen was also inconclusive for cause of obstruction. At laparotomy, dilated small bowel loops with multiple interbowel adhesions were seen. A hard mass measuring 5 × 6 cm was seen at distal jejunum causing distal obstruction with pressure necrosis over bowel wall. Enterotomy was done which revealed trichobezoar which was removeden masse. Resection and anastomosis of necrosed jejunum was done. Patient recovered completely after the procedure.How to cite this articleMadhushankar KC, Manjunath K, Saiprasad B, Saishayam M. Trichobezoar: Presenting as Primary Intestinal Obstruction. J Med Sci 2015;1(1):4-6.

PhytobezoarInduced Small Bowel Obstruction in a Young Male with Virgin Abdomen.

Phytobezoars are a rare cause of small bowel obstruction. Such cases are most commonly associated with previous abdominal surgery or poor dentition or psychiatric conditions. A 40 year old man with a virgin abdomen and excellent dentition and no underlying psychiatric condition presented with an acute abdomen. CT scan revealed a transition point between dilated proximal loops of small bowel and collapsed distal loops. Exploratory laparotomy revealed a phytobezoar unable to be milked into the cecum and an enterectomy with primary anastamosis was performed without complication. A detailed history revealing several less common predisposing factors for phytobezoars should increase clinical suspicion of a phytobezoarinduced small bowel obstruction in the setting of an acute abdomen. Vigilance in presentations of an acute abdomen improves the usefulness of medical imaging, such as a CT, to detect phytobezoars. Understanding mechanisms of phytobezoar formation helps guide management and may prevent surgery.

A rare case of intestinal obstruction mimicking ileocecal tuberculosis: Eosinophilic enteritis

A 52-year-old male presented with complaints of pain abdomen, vomiting, and distention of abdomen since 3 months. He had similar complaints 1 year back and was treated conservatively. He was a known case of pulmonary tuberculosis and completed Category I treatment 3 years back. Abdomen was distended with stepladder pattern of visible peristalsis. Erect X-ray of the abdomen was suggestive of intestinal obstruction. Utrasonography (USG) and computed tomography (CT) scan suggested distal ileocecal thickening-probably ileocecal tuberculosis. A provisional diagnosis of ileocecal tuberculosis causing intestinal obstruction was made and patient was taken up for laparotomy. Laparotomy revealed dilated small bowel loops with distended cecum. Right hemicolectomy was performed. Histopathological Examination (HPE) sent showed features of eosinophilic enteritis a rare cause of intestinal obstruction.

Abdominal Pain and Ileocolitis in a 51-Year-Old Woman

Question: A 51-year-old woman was evaluated over 2 months for abdominal pain. She had a history of appendectomy several years prior for appendicitis, abdominal hysterectomy, and multiple exploratory laparoscopies with lysis of adhesions in the remote past. At presentation, she complained of right-sided, crampy abdominal pain. An abdominal CT showed symmetrical thickening of the distal ileum and serosal inflammation around the cecum, and postoperative changes of appendectomy. Colonoscopy revealed a markedly deformed cecum and inaccessible terminal ileum. A cecal biopsy demonstrated mild chronic inflammation and edema of the lamina propria. She was treated with corticosteroids for presumed Crohn’s ileocolitis. Follow-up MRI enterography showed inflammatory changes of a long segment of distal ileum extending to the ileocecal junction evidenced by mural thickening with mucosal hyperenhancement (Figure A, arrow). Owing to persistence of symptoms and these imaging findings, medical therapy was intensified with initiation of adalimumab. There was no improvement and she developed obstructive symptoms necessitating hospitalization. Upright plain radiograph of the abdomen showed multiple dilated loops of small bowel (Figure B). She underwent a laparoscopic-assisted ileocecectomy with primary stapled anastomosis owing to the refractory nature of her symptoms and to obtain a tissue diagnosis. Histopathology is shown in Figure C. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Figure C shows a poorly differentiated adenocarcinoma ex goblet cell carcinoid (GCC), which is a subtype of the rare GCC tumor that occurs almost exclusively in the appendix.1Roy P. Chetty R. Goblet cell carcinoid tumors of the appendix: An overview.World J Gastrointest Oncol. 2010; 2: 251-258Crossref PubMed Google Scholar Histologic evaluation showed malignant glands infiltrating the muscle layer (Figure C, panel 1; original magnification, ×200), residual focal areas of GCC (Figure C, panel 2; original magnification, ×400), and tumor cells positive for chromogranin (Figure C, panel 3) and cdx2 (Figure C, panel 4). Three subtypes of GCC exist and are classified as typical GCC (group A), adenocarcinoma ex GCC signet ring cell type (group B), and poorly differentiated adenocarcinoma ex GCC (group C).2Tang L.H. Shia J. Soslow R.A. et al.Pathologic classification and clinical behavior of the spectrum of goblet cell carcinoid tumors of the appendix.Am J Surg Pathol. 2008; 32: 1429-1443Crossref PubMed Scopus (221) Google Scholar Histologic examination in this case revealed a group C tumor, which is the least common, and has the highest risk of recurrence and mortality.2Tang L.H. Shia J. Soslow R.A. et al.Pathologic classification and clinical behavior of the spectrum of goblet cell carcinoid tumors of the appendix.Am J Surg Pathol. 2008; 32: 1429-1443Crossref PubMed Scopus (221) Google Scholar GCC most commonly presents as acute appendicitis, but can have a various presentations including nonspecific abdominal pain as seen in our patient.2Tang L.H. Shia J. Soslow R.A. et al.Pathologic classification and clinical behavior of the spectrum of goblet cell carcinoid tumors of the appendix.Am J Surg Pathol. 2008; 32: 1429-1443Crossref PubMed Scopus (221) Google Scholar Cross-sectional imaging findings are usually those of acute appendicitis or a prominent appendix, but are not reported to include abnormalities of long segments of bowel.3Lee K.S. Tang L.H. Shia J. et al.Goblet cell carcinoid neoplasm of the appendix: clinical and CT features.Eur J Radiol. 2013; 82: 85-89Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar There is scant literature describing GCC in general, with group C lesions representing only 7 cases in a large series of 63 patients by Tang et al2Tang L.H. Shia J. Soslow R.A. et al.Pathologic classification and clinical behavior of the spectrum of goblet cell carcinoid tumors of the appendix.Am J Surg Pathol. 2008; 32: 1429-1443Crossref PubMed Scopus (221) Google Scholar in 2008. This case of ex GCC likely arose from the appendiceal stump and to our knowledge has never been described. GCC tumors are rare, malignant lesions primarily of the appendix and may infiltrate the cecum and ileum mimicking Crohn’s ileocolitis. This case underscores the importance of considering the differential diagnosis of inflammatory thickening of the ileum and cecal regions particularly when there are atypical histologic features and lack of response to medical therapy.

Intestinal occlusion due to cryptogenic, multifocal, ulcerous, stenosing enteritis treated by laparoscopy

Background: Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is characterized by stenotic zones and multiple mucosal ulcerations in the small bowel. The diagnosis is clinical and histopathological based on the history of periodic attacks of intestinal obstruction, vomiting and abdominal pain. According to our knowledge, this is the only report of treatment of CMUSE via laparoscopy. Case Presentation: A 47-year-old man arrived to the emergency room with intense colicky pain initiated 24 hours before arrival, accompanied by nausea, gastrobiliary vomiting, constipation and inability to pass flatus. Physical examination revealed abdominal distension, generalized abdominal tenderness to palpation, peristalsis with metallic tone, no signs of peritoneal irritation, and extremities with mild edema. Laboratory exams showed hyperglycemia, hyponatremia and hypoalbuminemia. Plain abdominal X rays reveled dilated loops of small bowel and fluid levels mainly on the left hemiabdomen, suggesting mechanical ileus. No evidence of free air in the abdomen was found. Intravenous fluids and electrolyte replacement was initiated and a nasogastric tube was inserted for decompression. Medical management failed to improve the symptoms after 24 hours, so an exploratory laparotomy was performed. The affected segment was resected laparoscopically. Pathology reported multiple sites of ulceration concerning the mucosae and submucosae, myenteric plexus hypertrophy and pseudo pyloric gland metaplasia. Multiple eosinophils and neutrophils were detected. Patient was discharged from the hospital on the fifth postoperative day and started with prednisolone 30mg/day for 3 months. Three years after he has not had any other episode of intestinal obstruction. Conclusion: Diagnosis of CMUSE must be considered in cases of repeated attacks of small bowel obstruction and when stenotic areas and superficial ulcers are found. Laparoscopic surgery should be considered in patients with repeated attacks of intestinal obstruction and in whom CMUSE is suspected because it permits a diagnosis and resection of the affected segments with the advantages on the minimal invasive surgery.

Solitary intestinal myofibroma – an unusual cause of neonatal intestinal obstruction

Congenital solitary myofibroma is an exceptional tumor of newborn period and presents as solitary or multiple lesions usually confined to soft tissues. It induces intestinal obstruction or perforation, which most frequently involves the jejunum and ileum. However, jejunoileal atresia is the most frequently encountered cause of small bowel obstruction in the neonatal period. We report a new case of solitary myofibroma located in the wall of the ileum, measuring 2×3 cm2 in size, about 25 cm from the ileocecal junction, in a 17-day-old baby girl who presented with abdominal distention and bilious vomiting. Laparotomy was performed on the patient and the tumor was removed; the patient did well after surgery. Despite all the common causes of intestinal obstruction—intestinal atresia, Hirschsprung disease, anorectal anomaly, malrotation, and meconium passage problem in the neonatal period—myofibroma of the small bowel has to be considered because treatment is fairly easy and prognosis is excellent.

Incidental Discovery of Hidden Carcinoid in a Meckel’s Diverticulum

Introduction: Meckel’s diverticulum is a common congenital anomaly of the small intestine that occurs in approximately 2% of the population and is often discovered incidentally at the time of abdominal exploration using laparotomy or laparoscopy. A 75-year-old male underwent gastrectomy 4 weeks ago for newly diagnosed stage IIIB gastrointestinal stromal tumor, currently on gleevac, presented to the hospital with abdominal pain and multiple episodes of nausea and vomiting. On presentation, his vital signs were: blood pressure 208/82 mm Hg, respiratory rate 22/min, pulse 96/min, temperature 99.3° F, and pulse ox 93% on room air. Physical examination was remarkable for hypoactive and tinkling bowel sounds, and diffuse tenderness in all 4 quadrants. Initial lab work revealed a blood glucose of 238 mg/dL; complete blood count was unremarkable except for leukocytosis with a WBC count of 10.6 U/L. Abdominal x ray and small bowel follow-through was performed, which confirmed multiple dilated loops of small bowel. High-grade mid small bowel obstruction was confirmed by a computed tomography. Initial conservative management was performed with placement of a nasogastric tube, but the patient’s condition continued to worsen, so an emergent open exploratory laparotomy was performed for adhesion lysis causing the obstruction. Incidentally, Meckel’s diverticulum was found in the distal small bowel and was also excised. Pathologic analysis revealed 2 mm of carcinoid tumor in the distal part of diverticulum (Figure 1). The patient had an uneventful recovery post-operatively and had complete resolution of symptoms on the day of discharge. The majority of patients with Meckel’s diverticulum remain asymptomatic throughout their lives. The most common complications include bleeding, perforation, ileus, intussusception, and diverticulitis. The removal of asymptomatic Meckel’s diverticulum in adults is controversial, but resection is recommended in children. Incidental discovery of carcinoid tumors in a Meckel’s diverticulum have rarely been reported in the literature.Figure 1: Carcinoid tumor cells with finely granular chromatin.

English

Duplication of gut presenting as perforation, peritonitis in an adult is a very rare clinical presentation. Here we report a case of an adult female patient in generalized peritonitis was caused by perforation of tubular communicating, duplicated, Ileal loop which rotated at its attachment with main ileum. This condition was managed by performing laparotomy, excision of the duplicated gut segment followed by end to end ileoileal anastomosis. CASE REPORT: A 32 yrs. old female presented in surgical OPD with the history of generalized abdominal pain, gradual distension and vomiting off and on for the last 3-4 days. She had been suffering from episodes of these symptoms for past couple of months, suggestive of sub-acute intestinal obstruction. However for last few days, these symptoms were aggravated. Patient had been empirically put on ATT by clinicians whom she had been consulting before coming to our hospital. Patient had undergone laparotomy about 8 years ago for perforated appendix. Patient appeared quite ill, dehydrated with tachycardia tachypnea and mild fever. Physical examination, revealed distended abdomen with tenderness and guarding all over. Rebound tenderness was also present. No hepatosplenomegaly was detected. P/V and P/R examination were within normal limits. A right paramedian scar from previous surgery was present. Hematological profile revealed normal study. X-ray abdomen erect view showed multiple Air fluid levels. USG study of abdomen showed mesenteric thickening with mild fluid and dilated bowel loops. She was taken up for Exploratory Laparotomy after correcting her dehydration. Abdomen was opened through mid-line incision which revealed dilated small bowel loops with free fluid. Exploration revealed about one feet long tubular, dilated and duplicated gut which had rotated upon its own axis where it was joining with the main gut, communicating at both proximal and distal ends, causing obstruction and perforation. (Fig. 1, Fig. 2). The segment had no independent mesentery. It derived it's vascularity from the main ileal wall segment with which it was communicating (as shown by a hand inserted in the intervening empty space between the two segments in the Fig. 2). This segment was about 2.5 ft. away proximal to ileocecal junction. This duplicated gut segment was resected and an end to end ileoileal anastomosis was done. No evidence of abdominal Koch's was detected. Her post-operative period remained uneventful and she was discharged fifteen days after surgery.

A spontaneous strangulated transomental hernia: Prospective and retrospective multi-detector computed tomography findings

Transomental hernias are among the rarest type of all internal hernias which overall account for less than 6% of small bowel obstructions. Most transomental hernias occurring in adults are either iatrogenic or post-traumatic. More rarely, a spontaneous herniation of small bowel loops may result from senile atrophy of the omentum. We report a case of an 86-year-old male who presented with signs and symptoms of small bowel obstruction but had no past surgical or traumatic abdominal history. At contrast-enhanced multi-detector row computed tomography (CT), a cluster of fluid-filled dilated small bowel loops could be appreciated in the left flank, with associated signs of bowel wall ischemia. Swirling of the mesenteric vessels could also be appreciated and CT findings were prospectively considered consistent with a strangulated small bowel volvulus. At laparotomy, no derotation had to be performed but up to 100 cm of gangrenous small bowel loops had to be resected because of a transomental hernia through a small defect in the left part of the greater omentum. Retrospective reading of CT images was performed and findings suggestive of transomental herniation could then be appreciated.