Dilated Small Bowel Loops Research Articles

Type 1a Duodenojejunal Tubular Duplication Cyst with Complex Rotational Anomaly Masquerading as Chronic Anemia

ABSTRACT Enteric duplication cysts and reversed intestinal rotation (RIR) are rare congenital anomalies, with their coexistence being exceptionally uncommon. We report a 4-year-old girl who presented with chronic anemia and intermittent abdominal symptoms since infancy. Detailed workup for medical causes of anemia was inconclusive. Computed tomography of the abdomen revealed intestinal malrotation with a grossly dilated small bowel loop. Intraoperative findings revealed a long duodenojejunal tubular duplication with a separate mesentery (Type 1a) and RIR. The patient underwent a Ladd’s procedure, resection of the duplication cyst, and end-to-end anastomosis. This case underscores the anatomical rarity, varied clinical presentation, and challenges in making an accurate and timely diagnosis in such a case.

A Case Report of Left Paraduodenal Hernia in a young boy

Internal hernia is a relatively uncommon condition and is a rare type of intestinal obstruction. Paraduodenal hernia (PDH) is the most frequent type of congenital hernia, especially on the left side. Although acute intestinal obstruction due to internal hernias is rare, it can be fatal if it is not identified and treated right away. The clinical diagnosis of paraduodenal hernia is difficult due to its rarity and variable symptoms. Here, we present the case of a 14-year-old boy who had been experiencing intermittent abdominal pain for a week duration. The pain had been worse during the previous two days, and the boy also experienced nausea and repeated vomiting episodes. He was otherwise healthy and had no history of previous abdominal operations. A left paraduodenal hernia was diagnosed based on the findings of a computed tomography scan, which showed a dilated small bowel loop occupying the left hypochondrial region anterior to the pararenal region. Due to the complicated nature of the disease, the patient had an exploratory laparotomy, during which herniated jejunal loops were reduced and hernial sac wide opened to prevent a recurrence. The patient tolerated the procedure, and recovery was uneventful. This case sheds light on the importance of considering the diagnosis of left paraduodenal hernia in patients with abdominal pain, particularly among those who have not undergone abdominal surgery previously. Early detection and treatment can prevent life-threatening complications such as intestinal perforation and peritonitis.

A130 RETROGRADE ENDOSCOPIC ULTRASOUND-GUIDED ENTERO-ENTEROSTOMY USING A LUMEN-APPOSING METAL STENT FOR THE MANAGEMENT OF A HIGH-OUTPUT ENTEROCUTANEOUS FISTULA AND ILEAL STRICTURE IN A COMPLEX SURGICAL ABDOMEN

Abstract Background A 26-year-old male sustained significant traumatic thoracoabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, an extended left hemicolectomy with end-colostomy formation, and a flap to close the abdomen. He subsequently developed a high-output enterocutaneous fistula (ECF) and loss of colostomy output. CT imaging confirmed an ECF from the ileum to the anterior abdominal wall and a severe ileal stricture distal to the fistula. Aims In the context of his complex surgical abdomen and proximity of the ECF to the abdominal flap, surgical re-intervention was deemed high-risk. He was placed on total parenteral nutrition and referred for endoscopic management. Methods Under fluoroscopic guidance, we injected methylene blue & contrast dye from the skin side of the ECF. A dilated segment of small bowel was filled, with no downstream passage of contrast (Fig 1A). Retrograde ileoscopy was performed with an Olympus pediatric colonoscope via the patient’s colostomy. 90 cm from the ileocecal valve (ICV), we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis (Fig 1B), extending to the previously filled loop of small bowel. Given the length and characterof the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible. Results We proceeded to retrograde endoscopic ultrasound (EUS)-guided entero-enterostomy creation. With the aid of a guidewire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ICV. 50 cm from the ICV, we identified an adjacent dilated loop of small bowel (Fig. 1C). Water was instilled through the ECF, with the endosonographic view demonstrating filling, thus indicating this location to be upstream from the ECF. A 19-gauge needle was punctured through, with subsequent aspiration of methylene blue (Fig. 1D). We then created an EUS-guided entero-enterostomy using a 15mm lumen-apposing metal stent (Hot-AXIOS; Boston Scientific, Massachusetts, USA; Fig. 1E). Passage of methylene blue & contrast through the stent confirmed accurate deployment (Fig. 1F&G). With both the ECF & stricture bypassed, the patient’s colostomy output returned and ECF output diminished. Conclusions Electrocautery-enhanced lumen apposition with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Herein, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output ECF and deep enteric stenosis. Figure 1: Retrograde EUS-guided entero-enterostomy Funding Agencies None

193 A rare cause of small bowel obstruction- Obturator Hernia

Abstract Obturator hernias are clinically challenging to diagnose, and the incidence reported in the medical literature is between 0.05% to 2.2%. This is commonly seen in thin, elderly female patients. Computed tomography is the gold standard for diagnosis. The mortality has been reported as 12-70%. Here, we present a 90-year-old female with complaints of abdomen pain, distention, vomiting and bowels not opening for a few days. She had a background of severe frailty, poor mobility and comorbidities such as hyperlipidaemia and mild cognitive disorder. On clinical examination, her abdomen was distended on examination with diffuse tenderness. Her blood investigations were normal, apart from CRP 26mg/L. Her abdominal X-Ray showed dilated loops of small bowel in the central abdomen. Computed tomography of the abdomen and pelvis showed high-grade mechanical distal small bowel obstruction with a transition point to probably in the right iliac fossa. She had an emergency laparotomy and was found to have an obturator hernia with bruised but viable small bowel. Hernial contents reduced. Postoperatively she developed hospital-acquired pneumonia, for which she was treated with antibiotics and later discharged. It is a rare case with a high chance of getting missed on clinical examination. In case of diagnostic uncertainty, CT should be promptly performed. Knowledge about this rare acute surgical condition is required for clinical suspicion, appropriate investigation and diagnosis, as the mortality is high.

E020 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

Abstract Background/Aims Pneumatosis intestinalis (PI) is a rare complication of systemic sclerosis (SSc), characterised by submucosal and/or subserosal collections of free gas, forming cystic lesions within the gastrointestinal (GI) tract. Methods A 67-year-old man with SSc-myositis overlap syndrome presented acutely unwell with worsening abdominal pain, bloating, bloody diarrhoea and vomiting for three weeks. He was afebrile and haemodynamically stable. His abdomen was distended with generalised tenderness but soft and regular bowel sounds were audible. There were no palpable organomegaly or signs of peritonism. He had raised CRP, serum amylase, serum lactate and pre-renal acute kidney injury. He tested positive for ANA Hep2 (speckled) and anti-Mi-2b. His contrast-enhanced CT abdomen and pelvis displayed extensive pneumatosis changes, moderately dilated small bowel loops and pneumoperitoneum without portal venous gas or acute thrombotic occlusion in the main-stem superior or inferior mesenteric arteries. He was managed conservatively with bowel rest, elemental diet, cycling antibiotics for small intestinal bacterial overgrowth (SIBO) and commenced on end-of-life care as surgical exploration was deemed too risky considering that he has exceedingly poor cardiac reserve. He made a surprisingly excellent recovery and his repeat CT scans at approximately 11 weeks showed a complete resolution of pneumatosis intestinalis and pneumoperitoneum. Results PI in SSc generally runs a benign course and is usually managed conservatively. The development of PI is multifactorial, involving a complex interplay between mechanical, biochemical, bacterial and drug factors. PI is usually asymptomatic but patients can present with GI and constitutional symptoms or peritonism. CT scan is the most preferred diagnostic modality for PI. Conservative management is preferable to surgical intervention after careful exclusion of acute surgical causes. The underlying cause of PI should be appropriately addressed and managed in all cases. The management of PI is based on the severity of symptoms and it includes bowel rest, elemental diet or parenteral nutrition, antibiotics, high concentration oxygen, hyperbaric oxygen therapy and/or octreotide. Our patient was managed conservatively as he did not exhibit clinical signs of peritonism or bowel ischaemia and surgical interventions were deemed too risky. He was treated with and has responded well to cycling oral antibiotics for SIBO which was thought to be contributory to his PI. Conclusion This case illustrates that PI with or without pneumoperitoneum could be a rare complication of SSc, and contrary to common belief, it is usually benign and managed conservatively with favourable outcome. An accurate interpretation of its clinical significance is crucial as acute presentations and ambiguous imaging findings can simulate acute surgical emergency leading to diagnostic dilemma and unnecessary or risky surgical interventions. However, emergency laparotomy should be considered in patients who exhibit signs of peritonism or bowel ischaemia and therefore timely involvement of surgeons and multidisciplinary team is essential. Disclosure K. Lim: None. S. Knights: None. J. Pauling: None. J. Gotto: None.

Diagnosis and surgical management strategy for pediatric small bowel obstruction: Experience from a single medical center.

Identifying Bowel strangulation and the approach and timing of surgical intervention for pediatric SBO are still uncertain. In this study, 75 consecutive pediatric patients with surgically confirmed SBO were retrospectively reviewed. The patients were divided into group 1 (n = 48) and group 2 (n = 27) according to the presence of reversible or irreversible bowel ischemia, which was analyzed based on the degree of ischemia at the time of operation. The results demonstrated that the proportion of patients with no prior abdominopelvic surgery was higher, the serum albumin level was lower, and the proportion of patients in which ascites were detected by ultrasonography was higher in group 2 than that in group 1. The serum albumin level was negatively correlated with ultrasonographic findings of the fluid sonolucent area in group 2. There were significant differences in the choice of surgical approach between group 1 and group 2. A symptom duration of >48 h was associated with an increased bowel resection rate. The mean length of hospital stay was shorter in group 1 than that in group 2. In conclusion, immediate surgical intervention should be considered in patients with a symptom duration of >48 h or the presence of free ascites between dilated small bowel loops on ultrasonography. Laparoscopic exploration is recommended as first-line treatment in patients with stable status.

Uterine Prolapse as a Rare Cause of Intestinal Obstruction: A Case Report and Literature Review

Background: The etiology of pelvic organ prolapse is multifactorial. Age and parity are especially the two most important risk factors for this condition. Small bowel obstruction is one of the most common clinical presentations to the emergency department that can result in significant morbidity and mortality. Case presentation: A 79-year-old woman with a previous history of uterine prolapse and no previous history of intraabdominal surgery or malignancies presented with nausea and vomiting, abdominal pain, and constipation from 2 days ago. Upright and supine x-rays showed dilated small bowel loops and confirmed bowel obstruction. Due to primary obstruction, the patient was a candidate for surgery. During the surgery, we observed that 100 cm of the terminal ileum and the uterus protruded in the vaginal canal and the ileal loops were strangulated. We decided to perform a right hemicolectomy surgery. Conclusion: In patients with uterine prolapse, we suggest a careful examination and consideration of the entrapment of small bowel loops in the prolapse site as a rare cause of small bowel obstruction.

A rare case of primary gastrointestinal stromal tumour of the stomach presenting as perforation peritonitis

Presentation of gastrointestinal stromal tumours (GISTs) as perforation peritonitis is a rare entity with only few cases reported in literature. Here we present a case of a 50-year-old male with acute abdomen and signs of peritonitis. Abdominal radiography revealed dilated small bowel loops in the absence of any free intraperitoneal air. Exploratory laparotomy revealed a growth arising from the stomach wall at the distal part of the body along the greater curvature. Wide excision of the lesion was done with rent closure. Histopathological examination further confirmed the diagnosis of a GIST of the stomach. Post operatively patient received Imatinib therapy and is doing well on follow up. Although rare, GISTs should be considered in the differential diagnosis of perforated GI lesions.

An extreme case of vanishing gastroschisis with in utero midgut strangulation

Gastroschisis is a congenital ventral abdominal wall defect with subsequent evisceration of intra-abdominal contents. Vanishing gastroschisis is a rare but dreaded complication where closure of the abdominal wall causes strangulation of herniated bowel, with varying degrees of infarction, ischemia or intestinal atresia. An 1856g neonate was delivered at 34 weeks of gestation to a mother with no antenatal care. He was initially referred as an omphalocele. Examination revealed a congested poorly characterized mass (to the right of the umbilical cord) with a narrow base. Xray showed 2 dilated loops of small bowel with no distal pneumatization. Laparotomy confirmed the presumed diagnosis of vanishing gastroschisis. Unfortunately, there was only 13cm of proximal small bowel, with an atretic blind end. Distally, a patent microcolon was seen re-entering the abdomen from the abdominal wall defect. No salvageable bowel was identified within the extra-abdominal mass. Excision of strangulated mid gut, primary anastomosis and closure of abdominal wall was done. Unfortunately, infant succumbed to line related sepsis several weeks post op. Mortality rate for vanishing gastroschisis is high, and survivors usually face short bowel syndrome with long term parenteral nutrition dependence. Several bowel lengthening strategies exist, such as Bianchi, STEP and LILT procedures, if only as temporizing measures until the child is a candidate for transplant. Severe cases are sometimes managed palliatively.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

Abdominal Cocoon Syndrome (ACS) or Idiopathic Sclerosing Peritonitis: An Extremely Rare Cause of Intestinal Obstruction

Introduction: Abdominal cocoon syndrome is an extremely rare cause of intestinal obstruction in which loops of small bowel are encapsulated by a fibro-collagenous membrane. This condition is also known in the literature as sclerosing peritonitis, and in the majority of cases, it has no known cause. The majority of patients exhibit long-standing signs and symptoms of partial intestinal obstruction. Presentation of case: A 15-year-old female patient presented with complete intestinal obstruction with no known co-morbidity and no history of prior laparotomy. Intraoperatively, the entire small bowel was found to be encapsulated by a dense fibrous sac. The peritoneal sac was excised, followed by lysis of the inter-loop adhesions with appendicectomy done at the same time. Discussion: Most patients with abdominal cocoon syndrome present with features of recurrent acute or chronic small bowel obstruction secondary to kinking and/or compression of the intestines within the constricting cocoon. An abdominal mass may also be present due to an encapsulated cluster of dilated small bowel loops. Conclusions: Abdominal cocoon is a rare condition causing intestinal obstruction, and diagnosis requires a high index of suspicion because of the non-specific clinical picture. Contrast-enhanced CT-scan (CT) of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Peritoneal sac excision and adhesiolysis is the treatment, and the outcome is usually satisfactory.

Persistent Bowel Loop in the Left Upper Quadrant: An Indication for Relaparotomy in Paediatric Adhesive Intestinal Obstruction: A Retrospective Cohort Study

Introduction: Abdominal surgery in children is known to contribute to Adhesive Small Bowel Obstruction (ASBO). No X-ray findings have been validated for predicting management in ASBO. Various imaging modalities often cannot predict complications or if a conservative line of management would be successful. Aim: To determine if a persistent prominently dilated small bowel loop in the Left Upper Quadrant (LUQ) on plain X-rays (Omega loop) would suggest early operative intervention. Materials and Methods: A retrospective cohort study was conducted in the Department of Paediatric Surgery, IMCH, Government Medical College, Kozhikode, Kerala, India from January 2016 to December 2018. Diagnosis was based on history, clinical features, and radiologic findings. Demographic, clinical, radiologic, and operative data were collected. After exclusions, the study population was divided into two groups: Group A - ASBO patients with the characteristic Omega loop, and Group B - patients without the Omega loop. Appropriate statistical methods were used to compare the groups, with significance defined as p<0.05. Results: Among the 72 cases of ASBO that met the inclusion criteria, 40 (55%) were successfully managed conservatively, and 32 (45%) required non urgent relaparotomy. The median age was 6.9 years (range: 2-12 years), and 55% were male. Group A comprised 16 patients (22.2%), and the remaining patients were in Group B 56 (77.8%). Group A showed higher rates of failure of conservative management (n=14, p=0.0002), with higher rates of single-band obstruction, bowel loss, perforation, matting of bowel loops, and difficult dissection. The Omega loop had a low sensitivity (43.7%) but high specificity (95%) and positive predictive value (87.5%) for the need for relaparotomy. Conclusion: The Omega loop suggests the possibility of more complications, and therefore, earlier operative intervention should be considered.

S1998 Colonic Merkel Cell Carcinoma of Unknown Primary: Small Cell Carcinoma Outside the Usual

Introduction: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin carcinoma with documented metastases to the liver, lungs, and gastrointestinal (GI) tract. Colonic metastases are rare but seen with recurrent or primary cutaneous lesions. Described is a patient who presented with bowel obstruction with a hepatic flexure MCC of unknown primary (MCCUP). Case Description/Methods: A 69-year-old female with a history of breast, lung, and anal cancer presented to the emergency department with abdominal pain and distension. Computed tomography of her abdomen demonstrated dilated loops of small bowel and a partial obstruction with transition point in the hepatic flexure. Colonoscopy demonstrated a 4 cm mass at the hepatic flexure obstructing the lumen. Biopsy revealed a high-grade neuroendocrine carcinoma. A right colectomy and histopathology confirmed small cell neuroendocrine carcinoma involving the colonic wall into the pericolic adipose tissue with nodal involvement. It was positive on cytokeratin CAM 5.2, synaptophysin, and Merkel cell polyomavirus (MCPvY) and negative on CDX-2 and TTF-1, excluding primary bowel or lung small cell carcinomas, respectively. Dermatologic evaluation did not reveal a primary cutaneous lesion. Genetic testing was unremarkable. Discussion: This is the first case of MCCUP presenting with colonic obstruction; prior described cases of MCC metastatic to the colon were recurrent disease or from primary skin lesions. Because MCC is rare, has non-specific symptoms, and may lack a primary lesion, MCCUP must be distinguished from other small round blue cell malignancies more commonly found in the GI tract. Thus, neuroendocrine, keratin and MCPyV ancillary staining are critical to distinguish MCC from B-cell lymphoma, small cell carcinoma of bowel or lung primary, and other metastatic dermal malignancies. MCPyV testing in the absence of prior diagnosis is uncommon but vital to the workup of neuroendocrine carcinomas when CDX-2 and TTF-1 are negative as MCPyV positive lymph nodes predict worse outcomes such as disease-free survival. In this patient immunosuppression and prior radiation increased the risk of MCC, and even suggest that this might be a colonic primary. Rarely, MCC and MCCUP are root causes of neuroendocrine carcinomas of the GI tract. In immunocompromised patients, biopsy and pathologic staining are necessary to distinguish insidious malignancies. MCPyV analysis is helpful for diagnosing MCCUP and informing its prognosis.

S3344 The Hunt for the Lost Intragastric Balloon and Its Complications

Introduction: Obesity is a global pandemic on the rise, affecting about 40% of adults in the United States. There is a need for minimally invasive methods to aid current standard of care practices. The intragastric balloon (IGB) is a temporary therapy for weight loss, with the FDA approving several devices including the ObalonⓇ in the recent years. In 2021, AGA published clinical practice guidelines on Intragastric Balloons in the management of obesity. Serious adverse events are relatively rare in patients receiving IGB treatment, and include injury to the gastrointestinal (GI) tract, such as perforation (0.3%), esophageal mucosal injury (0.8%), gastric ulcer/bleeding (0.76%), and gastric outlet/bowel obstruction (0.12%). Case Description/Methods: A 47-year-old female with a medical history including two intragastric balloon placements (ObalonⓇ) one year ago, presented with severe acute abdominal pain. Patient’s BMI was 28 kg/m2. Routine labs were unremarkable and vitals were stable. Initial CT Abdomen/pelvis with contrast showed gastric and duodenal thickening; however, imaging failed to comment on a foreign object and location. A gastroscopy was performed subsequently showing one Obalon balloon found in the gastric fundus. The balloon was cut with a needle knife, collapsed and withdrawn with rat tooth forceps. To locate the second balloon, repeat imaging showed dilated bowel loops with a deflated ObalonⓇ lodged in the distal ileum, 7 centimeters proximal to ileocecal valve, resulting in mechanical small bowel obstruction. A colonoscopy was deferred due to concern for risk of perforation given the small bowel obstruction. Subsequently, the patient underwent laparoscopic enterectomy with approximately 5 cm of bowel on either side of the enterotomy with creation of anastomosis and foreign object retrieval. (Figure) Discussion: Intragastric balloons are a minimally invasive therapy for weight loss in conjunction with lifestyle modifications in the war against obesity. We present a rare, yet crucial case report of IGB complication resulting in small bowel obstruction and subsequent need for surgical intervention. IGBs are meant to be a short term, temporary tool for weight loss in obese patients generally BMI ≥ 30. This case highlights the importance of a timely removal, risk of severe complications, and emphasis on the importance of assessing proper indication for placement.Figure 1.: (A) Coronal view of CT scan showing dislodged Intragastric Balloon in the distal ileum (red arrow); (B) XR Abdomen showing radiopaque density overlying the left hemisacrum (red arrow) and dilated small bowel loops; (C) XR Abdomen Complete w/ Decub/Erect showing radiopaque foreign body in the right mid abdomen and second foreign body in the stomach (red arrows).

S2027 Extrinsic Compression of the Hepatic Flexure from Metastatic Cholangiocarcinoma Masquerading as Cecal Bascule

Introduction: Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement. We present a case in which a patient with a hepatic flexure obstruction from extrinsic compression masqueraded as a cecal bascule on imaging. Case Description/Methods: A 66-year-old woman with history of stroke, hypertension, recent obstructive cholestasis due to choledocholithiasis requiring biliary stent placement, presented with 3 days of right sided abdominal pain, 15lb weight loss and 3 weeks of constipation with thin stools. Computed Tomography (CT) revealed dilated loops of distal small bowel and cecum that folded anteriorly and superiorly with extensive pneumatosis (Figure A), consistent with cecal bascule (type III cecal volvulus). The ascending colon was dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized. She had a normal colonoscopy a few months prior. The patient was initially managed conservatively, however a lower gastrointestinal series showed persistent obstruction at the hepatic flexure with bird-beak appearance (Figure B). She underwent an exploratory laparotomy that discovered a mass in the right upper quadrant involving the gallbladder and liver, causing extrinsic compression of the hepatic flexure and numerous omental nodules. Biopsies confirmed metastatic cholangiocarcinoma. The patient began evaluation for cancer staging, but ultimately passed one month after diagnosis. Discussion: The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus, or after abdominal surgery such as open appendectomies which require extensive division of peritoneal attachments to the cecum. Clinical presentation can be variable with abdominal pain, distention and nausea being most common symptoms and ranging to an acute abdomen and perforation. Diagnosis of type III cecal volvulus requires CT imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel as colonoscopic detorsion may lead to recurrence. This is a unique case of an extrinsic malignant obstruction causing a cecal bascule, highlighting the importance of a comprehensive evaluation for underlying etiologies.Figure 1.: A: Cecal bascule with extensive pneumatosis on CT. B: Lower gastrointestinal series showing obstruction at hepatic flexure with bird-beak appearance.

Rapunzel Syndrome: A Case of Trichobezoar with Small Bowel Complications

Introduction Rapunzel syndrome is characterized by a large trichobezoar in the stomach with a tail extending beyond the pylorus into the small bowel, causing mechanical obstruction of the small bowel. A 7-year-old girl presented to the emergency room with severe epigastric pain. Computed tomography suggested trichobezoar causing jejuno-jejunal intussusceptions, bowel wall thickening, and dilated small bowel loops proximal to the obstruction. On laparotomy, two concealed perforations were noted at the duodenojejunal (DJ) junction and 40 cm distal to the DJ junction. An enterotomy incision was given at the antimesenteric border of the distal jejunal perforation site, and the mass was successfully extracted. Primary repair was done at the DJ perforation site, and resection was followed by an end-to-end anastomosis at the distal jejunal perforation site. Surgery confirmed a complex mass of tangled hair within the gastric cavity with a tail extending into the pylorus of the stomach and small intestine, consistent with trichobezoar. Conclusion Computed tomography is superior to other radiological imaging modalities for diagnosing trichobezoars as it helps diagnose and demonstrate mechanical bowel complications.

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

An Unusual Cause of a Cecal “Seesaw” and Pneumatosis Intestinalis

Question: A 66-year-old woman with history of stroke, previous hernia surgery with mesh placement, and obstructive cholestasis due to choledocholithiasis presented with 3 days of right-sided abdominal pain, 15-lb weight loss over 1 month, and 3 weeks of constipation with thin stools. Colonoscopy was normal a few months prior. Her prior episode of choledocholithiasis in 2017 led to endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a double pig-tail stent. She was recently admitted 1 month ago for jaundice and right upper quadrant (RUQ) pain at which time magnetic resonance cholangiopancreatography showed severe intrahepatic and extrahepatic biliary duct dilation but no liver or pancreatic lesions. The cecum was nonspecifically distended and fluid filled. Esophagogastroduodenoscopy revealed a benign-appearing intrinsic duodenal stricture felt to be related to scar tissue from the previous hernia mesh surgery. ERCP revealed an occluded biliary stent that had migrated to the major papilla and a severe burden of choledocholithiasis. The occluded stent was removed, and partial removal of stones was achieved via basket extraction. A new biliary stent was placed with a plan to follow up in 4 weeks for repeat ERCP for further stone extraction and stent removal. Before this appointment she was readmitted for worsening RUQ pain. A computed tomography scan revealed dilated loops of distal small bowel and a dilated cecum that had folded anteriorly and superiorly with extensive pneumatosis. The ascending colon was also dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized, suggesting a transition point. No obvious mass or lesion was noted at the hepatic flexure (Figure A). Despite clinical improvement with conservative management, a lower gastrointestinal series performed a few days later showed persistent severe obstruction at the hepatic flexure with bird-beak appearance (Figure B). What is the most likely explanation for these imaging findings and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The patient’s imaging findings are consistent with cecal bascule (type III cecal volvulus). Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement.1Rabinovici R. Simansky D.A. Kaplan O. et al.Cecal volvulus. Dis Colon Rectum. 1990; 33: 765-769Crossref PubMed Scopus (119) Google Scholar Bascule in French means “seesaw,” describing the pathophysiology of the cecal presentation. Surgical management was indicated given the persistent and severe hepatic flexure stricture seen on lower gastrointestinal series. Exploratory laparotomy revealed numerous omental nodules and a mass was discovered in the RUQ involving the gallbladder and liver that was causing extrinsic compression of the hepatic flexure. The largest nodule was excised and confirmed a diagnosis of metastatic cholangiocarcinoma. A distal loop ileostomy was created to decompress the colon and prevent ongoing colonic obstruction. No colonic resection was necessary. The patient began cancer staging and treatment planning, but unfortunately passed 1 month after diagnosis. This is a unique case of an extrinsic malignant obstruction causing cecal bascule. The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus or after abdominal surgery, such as open appendectomies, which require extensive division of peritoneal attachments to the cecum. Clinical presentation varies with abdominal pain, distention, and nausea being the most common symptoms but can progress to an acute abdomen and perforation.2Lung B.E. Yelika S.B. Murthy A.S. et al.Cecal bascule: a systematic review of the literature.Tech Coloproctol. 2018; 22: 75-80Crossref PubMed Scopus (14) Google Scholar Diagnosis of type III cecal volvulus requires computed tomography imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel because colonoscopic detorsion may lead to recurrence.3Le C.K. Nahirniak P. Qaja E. Cecal volvulus. StatPearls Publishing. StatPearls Website, 2021Google Scholar

MECKELS DIVERTICULUM WITH MESENTERY AS A RARE CAUSE OF CLOSED LOOP OBSTRUCTION-A CASE REPORT

Meckel's Diverticulum is most common congenital anomaly of gastrointestinal tract. It arises from Antimesenteric border of the small bowel [1]. In contradiction, a case encountered at our institution where a 32-y old female presented with complaints of pain abdomen since 3 days, vomiting's since 3 days, obstipation since 3 days and distention since 1 day. On examination abdomen is distended, diffuse tenderness present all over the abdomen with no bowel sounds and collapsed rectum with no fecal staining per rectally. Imaging studies on ultra-sonography shown dilated small bowel loops with max diameter of 3.1cm showing to and fro peristalsis. On CT abdomen multiple dilated small bowel loops with air uid levels with maximum diameter of 4.1cms with collapsed terminal ileum and large bowel. ?Closed Loop Obstruction. Emergency exploratory laparotomy was planned and shown Meckel's diverticulum with mesentery present on anti-mesenteric border with mesentery extending from mesenteric border to tip of Meckel's diverticulum with internal herniation of proximal ileum between the Meckel's and its mesentery causing closed loop obstruction noted at 60cms from IC junction for which herniated bowel loops was released with diverticulectomy followed by anastomoses of proximal and distal ileal loops. Resected Meckel's sent for histopathological examination and cut section showed mucosa, sub-mucosa, muscularis propria and serosa. Mucosa shows chronic nonspecic inammation, sections from the adjacent area's shows hyperplastic mucosa, hypertrophied muscularis layers and serosa with congested blood vessels with feature's consistent with Meckel's diverticulum. Patient was followed for 6 months, and the course was un-eventful.

EP-346 Laparoscopic extraction of a migrated gastric balloon from the terminal ileum causing small bowel obstruction

Abstract Aim Laparoscopic management of small bowel obstruction secondary to a migrated gastric balloon. Method A 57 years old female patient with BMI of 45 presented to ED by central colicky abdominal pain and recurrent attacks of vomiting with absolute constipation since 2 days. The patient had history of insertion of a gastric balloon since a year. On examination: abdomen: lax soft, mild abdominal distension, central abdominal tenderness, no signs of peritonitis. observations: Pulse:122bpm, BP 90/60, RR 25. blood tests: WCC 22.0×10 /L and CRP 129 mg/L. Venous lactate of 4. PMH:DM type 2, Missed appointments for gastric balloon extraction about 6months ago. Admitted under the surgical team resuscitated with IV fluid, IV antibiotics, sepsis 6 protocol activated. AXR: dilated small bowel loops. CT abdomen with I.V and oral contrast revealed impaction of the gastric balloon at the terminal ileum causing high grade small bowel obstruction. Patient had underwent laparoscopic extraction of the migrated gastric balloon from the terminal ileum and primary closure of the ileum by endo-stitch. Patient has smooth recovery postoperatively and discharged home two days after the surgery. This case highlights one of the complication of the gastric balloon which is migration of a gastric balloon into a terminal ileum as a result of missed appointments for its extraction after 6 months time. Conclusion laparoscopic management of SB obstruction in morbid obese patient should be the first choice provided that the surgeon has the required skills and experience.