Dilated Loops Research Articles

Complete Radiological Findings in Gallstone Ileus

A 79 year old female causcasian patient with a background history of type II diabetes mellitus, hypertension and hypercholesterolaemia, presented with a 1 day history of bilateral flank and lower abdominal pain and a few episodes of vomiting. Of note, there was no history of constipation or obstipation. Clinical exam on presentation showed no localizing abdominal signs. The patient was also found to be dehydrated and hyperglycaemic. A plain radiograph of the abdomen was performed (Fig. 1A). This demonstrated the 'Rigler Triad' of dilated small bowel loops in the left upper quadrant (arrow), linear lucencies in the right upper quadrant, corresponding to the anatomic location of the liver, suggesting pneumobilia (arrowhead) as well as a partly calcified ovoid density in the left lower quadrant (curved arrow). If these are present, it is considered to be sufficient for diagnosis in the correct clinical scenario.1-3 Esophago-gastro-duodenoscopy was then performed which suggested the presence of a fistula originating from the first/second part of the duodenum and a barium meal was subsequently performed to further confirm the findings of endoscopy and to delineate the anatomy of the fistula (Fig. 1B). A fistulous tract was demonstrated between the junction of the first and second parts of duodenum and the gallbladder neck, with subsequent filling of barium into the proximal common bile duct from the cystic duct as well as the gallbladder body. Figure 1 Abdominal radiograph and barium meal. (A) Abdominal radiograph demonstrating the 'Rigler Triad' of dilated small bowel loops in the left upper quadrant (arrow), linear lucencies in the right upper quadrant, corresponding to the anatomic location of the ... CT of the abdomen and pelvis was subsequently performed which demonstrated an acute small bowel obstruction (blue arrowhead) secondary to an intraluminal obstructing gallstone (blue arrow) in the proximal ileum (Fig. 2). Figure 2 Contrast enhanced CT of the abdomen and pelvis demonstrating acute small intestinal obstruction (blue arrowhead) secondary to an intraluminal obstructing gallstone (blue arrow) in the proximal ileum. The transition point was located in the left hemipelvis, in a location corresponding to the calcified density seen previously on plain radiography. A diagnosis of gallstone ileus was made and the patient was referred to the gastro-intestinal surgeons. The diagnosis was confirmed at laparotomy and an enterolithotomy was performed (Fig. 3). Figure 3 Photograph taken at the laparotomy and enterolithotomy demonstrating the large obstructing gallstone impacted in the distal ileum.

An Intriguing Tale of a Patient Passing Copious Amounts of Watery Stools

Introduction:C. difficile is one of the commonly diagnosed infectious causes of acute diarrhea in hospital settings. Other non-infectious causes of acute diarrhea often get overlooked especially when a diagnosis as common as C. difficile colitis has been made. Case Report: 78-year-old male with a history of HTN, hyperlipidemia, lung cancer s/p resection and metastatic gastric cancer (on chemotherapy) was transferred to our tertiary medical center for ICU care. He carried a diagnosis of first episode of fulminant C. difficile colitis and was suspected of harboring a hyper virulent strain at the outside facility. The patient had already finished 10 days of metronidazole therapy but still had high volume watery diarrhea with more than 20 bowel movements a day. This led to progressive dehydration, acute kidney injury and hemodynamic instability needing pressor support and Continuous venous hemofiltration (CVVH) for first few days in our ICU. Stool studies were redone besides other metabolic work-up. Abdominal imaging showed mildly dilated bowel loops. Oral vancomycin was added to his regimen besides aggressive IV hydration and supportive management. In spite of optimal medical support, the diarrhea persisted with clinical deterioration. We rescrutinized his recent medications to discover that he had finished recently his second cycle of chemotherapy (epirubicin, oxaliplatin and capecitabine) around three weeks ago for management of gastric cancer. The patient revealed further that he had milder self limiting episode of watery diarrhea after the first cycle of chemotherapy also. Keeping a possibility of chemotherapy induced diarrhea, we added octeotride to his regimen to achieve a rapid and gratifying response over next few days. The patient was finally transitioned to oral loperamide and discharged to home with complete remission of his diarrhea symptoms. Discussion: Chemotherapy-induced diarrhea (CID) has been described in cancer management with fluoropyrimidines (like 5-fluorouracil), capecitabine and irinotecan. The proposed mechanism of CID is direct toxicity to rapidly dividing crypt cells of the intestinal epithelium, and the destruction and/or augmentation of intestinal enzymes. This disrupts the balance between absorptive and secretory capacity, and alters the osmotic gradients in the gut, thereby leading to increased secretion of fluids and electrolytes in the stool. Despite the life threatening severity of CID, it is often under-recognized, as was the case in our patient.

Primary Pancreatic Cancer Presenting as Recurrent Small Bowel Obstruction

Purpose: A 73 year old male presented with a 2-month history of intermittent, diffuse abdominal pain and distension with non-bloody diarrhea. He also noted an unintentional 40-pound weight loss. Recent past medical history was pertinent for treatment of three partial small bowel obstructions over the past year, thought to be from adhesions from a prior umbilical hernia surgery. These episodes resolved with non-operative management. He had a full colonoscopy screening 7 years ago that revealed an ascending colon tubular adenoma which was excised endoscopically and was without evidence of dysplasia or malignancy. Upon admission, abdominal plain films showed dilated small bowel loops. The patient was treated with bowel rest, hydration, and nasogastric decompression with minimal improvement. Computer tomography (CT) of the abdomen and pelvis was obtained which showed a small bowel obstruction with transition point in the ileum. Interestingly, there was also a 2 x 3 cm hypodense mass in the tail of the pancreas. He was treated medically and scheduled for small bowel series and endoscopic ultrasonography (EUS)-guided biopsy of the mass. Investigations for neuroendocrine tumors and infectious diarrhea were unremarkable. Unfortunately, he developed worsening small bowel dilatation warranting exploratory laparotomy. A stricture was seen at the distal jejunum. The patient underwent segmental small bowel resection with end-to-end anastomosis. Pathology of the specimen revealed moderately differentiated adenocarcinoma extending from serosa to mucosa. Immunohistochemical stains suggested a foregut phenotype. A clinical diagnosis of primary pancreatic cancer was established. The patient underwent chemotherapy and developed an obstructive liver enzyme pattern on blood chemistry. Abdominal ultrasonography revealed common bile duct dilatation and CT revealed tumor progression to the head and body of pancreas. He was then performed an endoscopic retrograde cholangiopancreatography with palliative stent placement. Pancreatic cancer commonly presents with chronic epigastric pain, weight loss, and jaundice. It is an unusual feature to have small bowel metastasis presenting with recurrent small bowel obstruction. Although EUS-guided fine needle aspiration is the best modality to obtain a tissue diagnosis, worsening small bowel obstruction would preclude the procedure and prompt exploratory laparotomy for the timely diagnosis and management in this patient. Furthermore, while surgery is the only curative treatment, patients with distant metastases or major vascular involvement are considered unresectable and should receive chemotherapy.

First Case of a New Variant of the APC Gene in a Patient with Newly Diagnosed Attenuated FAP

Introduction: Familial adenomatous polyposis (FAP) represents about 1% of all colon cancer and is caused by germline mutations in the adenomatous polyposis coli (APC) gene. The clinical manifestation includes classic FAP, attenuated FAP (AFAP), Gardner Syndrome and Turcot Syndrome. We present a patient with newly diagnosed AFAP due to a new variant resulting in the substitution of valine for isoleucine at amino acid position 1746 (I1746V) of the APC protein. Case Presentation: This is a 52-year-old woman with past medical history significant for coronary artery disease, hypertension and uncontrolled diabetes who presented for evaluation of abdominal pain, nausea, vomiting, diarrhea, and bloating for several years which had worsened. CT showed a dilated stomach and small bowel loops without evidence of obstruction. Upper endoscopy was unremarkable. Colonoscopy revealed >40 polyps varying in sizes (5-20 mm) and shapes (flat, umbilicated, and sessile) throughout the entire colon with predominant sessile serrated adenomas interspersed with tubular adenomas and hyperplastic polyps. She had three colonoscopies with removal of >10 polyps at each session but continued to have multiple flat polyps throughout the colon. She had an older sister with history of colonic polyps and another sister who died from an unknown cancer. She was referred for genetic counseling with normal MYH testing but was found to have the first reported APC variant (I1746V) due to the substitution of valine for isoleucine at amino acid position 1746 of the APC protein. Given this variant was the first ever identified the effect on the function of the APC protein is unknown. Hence, it is unclear what the significance of this finding is in regard to her risk of colon cancer. However, since the lifetime risk of colon cancer for AFAP in other APC abnormalities is high, she was referred for evaluation of a subtotal colectomy. Discussion: Multiple APC mutations have been found since the identification of the APC gene as the cause of FAP. We now report the first case of a new APC variant (I1746V) in a patient with newly diagnosed AFAP. Management of this patient was challenging given the lack of data on the significance and risk of colon cancer for this new variant. However, given the lifetime risk of colon cancer in patients with FAP and AFAP is 80-100% and the young age of the patient a subtotal colectomy was recommended. Conclusion: The availability of genetic testing has allowed for the detection of new genetic variants. However, it is unclear how these variants translate phenotypically. More studies will be needed to evaluate the effects of these variants in order to provide the best management practice for these patients.

Meconium Peritonitis with Intestinal Atresia Mimicking Huge Tumor in a Preterm Neonate

A late-preterm female neonate was transferred to our hospital for evaluation of an abnormal cystic lesion noted on prenatal ultrasound. There were no other prenatal insults and the physical examination was unremarkable except for abdominal distension and mild tachypnea. Abdominal computed tomography with intravenous contrast material revealed a huge cystic lesion occupying almost the whole abdomen, encircled with minimal calcification (Figure). Intra-abdominal tumor or ovarian cyst was suspected, and exploratory laparotomy showed dilated bowel loops with no visible intra-abdominal tumor or cyst.

CT findings of small bowel strangulation: the importance of contrast enhancement

The purpose of this study is to illustrate computed tomography (CT) findings suggestive of small bowel strangulation. We have performed the precontrast and postcontrast CT with single and multidetector CT scanners and evaluated the bowel wall changes and mesentery changes and correlated them with the operative findings. The direct CT findings suggestive of small bowel strangulation included high-density bowel wall on precontrast scans; lack of, or diminished contrast enhancement of the involved bowel wall; localized mesenteric fluid accumulation (mesenteric congestion); and localized pneumatosis. The indirect CT signs included C- or U-shaped loops with mesenteric vessels converging toward the obstruction site, ascites, target sign, two adjacent collapsed round loops, and whirl sign. We particularly emphasize the importance of contrast enhancement of bowel mucosa for early diagnosis to differentiate strangulation from a mechanical obstruction without bowel ischemia, and also the importance to differentiate proximal secondary gas-filled dilated small bowel loops from distal primary involved fluid-filled small bowel loops because these two types of small bowel loops are present in the single peritoneal cavity. As early recognition of small bowel strangulation may help improve the patient outcome because the involved bowel loops can be preserved without resection, it is essential to become familiar with the CT signs suggested small bowel obstruction strangulation.

Congenital Right Bochdalek Hernia Presenting as Emergency in Old Age: A Case Report

Congenital diaphragmatic hernias (CDHs) are known to present even after the neonatal period. Posterolateral Bochdalek hernias account for the majority of cases. About 85% tend to occur on the left side, while the right side accounts for roughly 13% of the cases. We present a case of a right-sided Bochdalek hernia in an elderly man who was asymptomatic for 60years of life. The patient presented with vague right upper abdominal discomfort, and ultrasound abdomen revealed herniation of the small bowel into right hemithorax, showing sluggish peristalsis, raising a suspicion of impaired vascularity. He subsequently underwent contrast CT, which confirmed herniation of small bowel loops into right thorax with normal vascularity but dilatation of bowel loops and a possibility of closed-loop obstruction. He was taken up for emergency surgery. The patient had uneventful recovery.

Right Hemicolectomy for Intestinal Obstruction Due to Yersinia pseudotuberculosis: A Histopathological Surprise

A 56-year-old man was diagnosed to be having enteric fever elsewhere and put on antibiotics. Despite therapy over 3months, this patient had recurrent bouts of fever with chills, tiredness, and lower abdominal pain, distension, and vomiting with which he was admitted to our hospital. CT abdomen and pelvis showed significant wall thickening in the cecum and terminal ileum, with marked luminal narrowing and marked dilatation of proximal small bowel loops. Clinically a diagnosis of intestinal obstruction was made and the patient underwent exploratory laparotomy and right hemicolectomy. Histopathological examination showed necrotizing enteritis with necrotizing mesenteric lymphadenitis consistent with Yersinia pseudotuberculosis. We report a rare and possibly the first case of intestinal obstruction due to Yersinia infection, requiring right hemicolectomy.

T cell lymphoma—presentation as cecal gangrene

Editor, Although the gastrointestinal tract is the most common site of extranodal lymphoma, colorectal lymphomas account for only 15 % to 20 % of these [1]. A 29-year-old man, with no previous comorbid illness, presented with severe lower abdominal pain, fever and vomiting for 2 days. On evaluation, he had signs of peritonitis, hemodynamic shock and lactic acidosis. The differential diagnoses were appendicular perforation, with a lesser possibility of obstructed ileocecal tuberculosis with perforation or enteric fever perforation. X-ray abdomen showed dilated bowel loops and the ultrasound reported thickened bowel loops in the right iliac fossa with moderate free fluid in the peritoneal cavity. In view of his deteriorating general condition, a CT scan abdomen was not done and he underwent an emergency laparotomy. Intraoperatively, we found two large areas of cecal gangrene with imminent perforation. There were few enlarged pericecal lymph nodes but there was no obvious mass lesion. The cecal wall was thickened and edematous. There was approximately 200 mL of serosanguinous fluid in the peritoneal cavity. We performed a right hemicolectomy and ileotransverse anastomosis as there was no fecal contamination. He made an uneventful recovery. The gross specimen (Fig. 1a) showed congested, dusky, outer surface of the cecum and proximal colon with the mucosal surface appearing dark brown, ulcerated, edematous and focally lined by exudate and small nodules, 0.1 cm to 0.5 cm in diameter. Microscopy (Fig. 1b) showed a patchy, focally perivascular infiltrate of medium-sized lymphoid cells with vesicular nuclei accompanied by transmural acute inflammation, edema and patchy foci of necrosis of the cecal wall. Few enlarged pericecal lymph nodes, largest 1.5 cm in diameter, were found. These were replaced by an atypical infiltrate which was positive for CD3, TIA1, CD8 and granzyme B, and focally positive for CD56 and CD30. There were no features of enteropathy. Immunohistochemistry for Epstein-Barr virus latent membrane protein was negative. The final report was high grade peripheral Tcell lymphoma of cytotoxic T/NK cell phenotype of the cecum, with regional lymph nodes. Further investigations included complete blood count, LDH levels in serum, HIV serology, abdominal and chest imaging to look for hepatosplenomegaly, intraabdominal, retroperitoneal or mediastinal lymphadenopathy and bone marrow biopsy. The bone marrow was free of disease. Abdominal and chest imaging did not reveal hepatosplenomegaly or lymphadenopathy elsewhere. Postoperative colonoscopy was not done. Our patient fulfilled the Dawsons criteria needed to identify a primary GI lymphoma [2]:

Plain abdominal radiographs in patients with Crohn’s disease: Radiological findings and diagnostic value

To determine the diagnostic yield and clinical value of plain film of the abdomen (PFA) in Crohn's disease (CD) patients and to determine whether performance of PFA yields definitive diagnostic information or whether additional imaging examinations are required. One hundred and seventy-seven CD patients underwent 643 PFAs during the period September 1992 to August 2008. Two radiologists blinded to the clinical details independently evaluated individual PFAs and/or their reports for abnormal findings using the following criteria: normal, small bowel (SB) findings; colonic findings, acute CD complications, extra-colonic findings; global assessment/impression. The results of additional imaging studies performed within 5 days of PFA were recorded and findings were analysed. A mean of 3.6 (range 1-22) PFAs was performed per patient during the study period. Almost 70% of films were normal (n = 449). SB abnormalities were detected in 21.8% (n = 140) PFAs; most commonly dilated loops (18.8%, n = 121) and mucosal oedema (5%, n = 32). Colonic abnormalities were present in 11.4% (n = 73); most commonly mucosal oedema (7.5%, n = 48) and dilated loops (5%, n = 32). Four cases of pneumoperitoneum were detected. There was no case of toxic megacolon. There was one case in which intra-abdominal abscess/collection was suspected and two cases of obstruction/ileus. Extracolonic findings (renal calculi, sacro-iliitis, etc.) were identified in 7.5% (n = 48). PFAs were followed by additional abdominal imaging within 5 days of PFA in 273/643 (42.5%) of cases. Despite the high rates of utilization of PFA in CD patients, there is a low incidence of abnormal findings (32.5%). Many of the findings are non-specific and clinically irrelevant and PFA is frequently followed by additional abdominal imaging examinations.

Unusual Abdominal Pain and Vomiting

Unusual Abdominal Pain and Vomiting

Acute abdomen in a septuagenarian

A 72-year-old lady presented with abdominal pain and distention of 3 days duration. She did not pass flatus and stools and had few episodes of bilious vomiting for 2 days. She had no past history of abdominal pain or surgery. Coronal CT scan section of abdomen (Fig. 1) showed classical Rigler’s triad of pneumobilia, dilatation of small bowel loops and ectopic gallstone which is characteristic of gallstone ileus [1]. At surgery, the stone was 6 cm × 4 cm in size without any facets. The obstruction was at the midjejunal level. Often gallstones causing gallstone ileus enter the bowel through cholecystoduodenal fistula. Management is mainly surgical enterolithotomy. During surgery the finding of facets in the retrieved gallstones may indicate presence of other stones. Due to the emergent nature, patient’s old age and the complex mass involving the gallbladder and the cholecystoduodenal fistula cholecystectomy and fistula repair can be done at a later date once the patient recovers. Nearly 17% of them present with recurrent gallstone ileus or other biliary complications [2]. Hence interval cholecystectomy and fistula repair is prudent. Other treatment option is enteroscopic removal.

A change on an electrocardiogram not to be missed

An 80 year old woman with a history of severe vascular dementia presented to the acute surgical unit. A collateral history given by staff at her nursing home stated she had had seven days of abdominal pain associated with vomiting. She had not opened her bowels for many days. Medical history included stroke and hypertension. She had no surgical history. At the time she was taking aspirin, ramipril, and simvastatin. On examination her pulse rate was regular at 98 beats/min, blood pressure was 132/84 mm Hg, respiratory rate was 12 breaths/min, she had a temperature of 37.1°C, and her oxygen saturations were 96% on room air. Her abdomen was visibly distended and felt firm on palpation, but neither guarding nor organomegaly was detected. A plain abdominal radiograph showed dilated bowel loops. A computed tomography scan did not show evidence of mechanical bowel obstruction. She was treated for pseudo-obstruction with a nasogastric tube and intravenous fluids. After conservative management, an electrolyte abnormality was noted from the blood test results. Arterial blood …

A duplication cyst masquerading as a meckel's diverticulum

Gastrointestinal tract duplication cysts are rare congenital malformations, usually presenting in infancy or early childhood with a variety of symptoms within the GI tract. Sources of GI bleeding can present a diagnostic dilemma despite conventional radiological & endoscopic investigations. We present an unusual case of a 13 year old boy, who presented with an acute abdomen and malaena with contrasting radiological and operative findings. A 13 year old boy was referred to our hospital with a 2 week history of severe central abdominal pain and 2 episodes of malaena. On assessment he appeared well and was haemodynamically stable. On physical examination his abdomen was tender centrally. Digital rectal examination was normal. Blood tests revealed a Haemoglobin of 7.2 with a MCV of 58.3. Abdominal X-ray showed faecal loading. An ultrasound scan of his abdomen found an abnormally dilated fluid-filled loop in the right iliac fossa extending into the pelvis. An MRI scan with Haste sequences was undertaken for additional clarity, and this favoured a Meckel9s appearance. A laparotomy revealed a large 30 cm long cystic lesion in the mesentery of the ileum. The ileum was extremely adherent to this cyst, thus en bloc ileal resection was performed with primary anastomosis. The boy was discharged uneventfully on post-operative day 3. Histology confirmed a congenital duplication cyst with heterotopic gastric glands. This demonstrated an area of haemorrhage subserosally. Alimentary tract duplications are rare childhood anomalies, but may cause intestinal obstruction, intussusception, haemorrhage or perforation. They are most commonly located in the ileum, but can occur anywhere from pharynx to rectum. They are lined by intestinal tract mucosa and share a common smooth muscle wall and blood supply with adjacent bowel wall, with which they can communicate. Malignant change has rarely been reported in adults, in particular within rectal duplication cysts. The duplication cyst attached to this boy9s ileum revealed gastric mucosa, which contains acid-secreting parietal cells resulting in peptic-ulcer type ulceration and bleeding. Intestinal duplication cysts should be considered in the differential diagnosis of GI bleeding in children. Complete excision is the treatment of choice.

Jejunal tuberculosis in a 10-year-old girl

Abdominal tuberculosis in children usually presents with involvement of the peritoneum, lymph nodes or gastro-intestinal tract. Disease of the gastro-intestinal tract is commonest in the ileocaecal region. A 10-year-old girl presented with abdominal pain and fever of 15 days duration. Abdominal CT detected dilated small bowel loops with enlarged mesenteric nodes and barium meal follow-through demonstrated a small annular stricture in the jejunum, suggestive of jejunal tuberculosis. She was treated with anti-tuberculous chemotherapy and corticosteroids, to which she made a good response. Tuberculosis of the jejunum is rare in children.

Color Doppler Twinkling Artifacts in Small-Bowel Bezoars

Small-bowel bezoars usually form in the stomach and may subsequently cause small-bowel obstruction. Bezoars associated with small-bowel obstruction have been accurately diagnosed by computed tomography, although some case reports have described the specific sonographic findings of small-bowel bezoars. Bezoars can be overlooked by sonographic examination if a dilated small-bowel loop contains a large amount of air. Twinkling artifacts on color Doppler images appear as rapidly fluctuating red and blue signals behind certain strongly reflecting structures. In this series, we hypothesize that twinkling artifacts might appear in small-bowel bezoars, and we describe the presence of twinkling artifacts in 3 cases of small-bowel bezoars presenting as small-bowel obstruction.

A rare case of necrotising enterocolitis (NEC) in a full-term infant at 12 hours of age before the introduction of enteral feed (EF)

We observed a case of NEC in a male term infant (TI), weighing 4.3 kg He was born by emergency caesarean section for fetal distress following an uneventful antenatal course. Offensive liquor was noted at delivery without other septic risk factors. He was born in poor condition but responded promptly to IPPV and was spontaneously breathing at 3 min age. APGARS were 4, 7 & 8 at 1, 5 &10 min respectively. He was admitted to NICU for persistent tachypnoea, requiring CPAP support. He received saline boluses for poor peripheral perfusion and was commenced on IV benzylpenicillin and gentamicin for presumed sepsis. He was noted to have bilious aspirates and brown-stools at 12 h age. Examination revealed mild abdominal distension with associated tenderness. Abdominal X-ray showed dilated bowel loops, widespread pneumatosis and portal-tract air. Blood indices were unremarkable. Exploratory laparotomy D1 confirmed NEC involving the entire colon and no malrotation. An ileostomy and mucus fistula were fashioned and no bowel resected He made an uneventful recovery. He was commenced on parenteral nutrition, kept nil-by-mouth and received a 10-day-course of antibiotics, including metroniadazole. Blood culture was negative and congenital heart disease (CHD) excluded. EF was initiated on D11 using breast milk and gradually increased. EF was changed to Pepti-junior on D24 due to high stoma losses and positive reducing substance. Full EF was established on D27. NEC is predominately a disease of preterm infants. Nonetheless, there have been documented cases in TI accounting for 10% neonatal NEC. It tends to involve TI with known risk factors e.g. intrauterine growth restriction, birth asphyxia, CHD, hypothyroidism, polycythaemia, sepsis and umbilical lines and EF introduced. Although the pathogenesis remains elusive, three major factors, pathogenic organism, EF, and bowel compromise, coalesce in at-risk neonates to produce bowel injury. There are minor variations in the clinical presentation in preterm- and term-NEC. The onset tends to be earlier in TI without outstanding thrombocytopenia and acidosis. This case report highlights the enigmatic presentation of term-NEC and need for vigilance in TI presenting with early respiratory distress/mild sepsis.

Chronic Diarrhea in Children

Chronic Diarrhea in Children

Chronic Rejection in a Small Bowel Transplant with Successful Revision of the Allograft by Segmental Resection: Case Report

An 8-year-old girl was admitted for severe electrolyte imbalance and for hyponatremic seizure. In July 2005, at 3 years of age, she underwent isolated small-bowel transplantation of 100 cm ileum from her father. Her own bowel was only 50 cm of proximal jejunum which had been directly connected to the anus due to extended total aganglionosis. The graft was placed into the middle of her remaining bowel, using the splenic artery and vein as feeding vessels with saving of the spleen. Daclizumab induction and tacrolimus monotherapy were applied for immunosuppression. Two acute cellular rejection episodes, E on day 10 and 4 years after transplantation, were successfully treated with OKT-3 and recombinant antithymocyte globulin, respectively. However, because of intermittent bowel dysfunction, she was hospitalized several times for hydration and metabolic care. On admission, her abdomen was moderately distended, and a simple abdominal film showed a fixed dilated loop. Colonoscopy could not pass the narrowed lumen, with stiffness at the anastomosis between the graft and the distal bowel. Endoscopic biopsy at the entrance to the stricture showed a nonspecific inflammatory reaction with fibrosis. Similar findings on a gastrograffin enema suggested chronic rejection (CR). On laparotomy, an irregularly narrowed fibrotic loop was noticed at the distal part of the graft, proximal to the anastomosis. We performed a 20-cm segmental resection with an end-to-end anastomosis. Histopathologic findings showed CR with fibrosis and hyalinization of the entire bowel wall and vessel walls with mild cellular infiltrations. She recovered in 10 days. The graft may have been saved, but intermittent requirement of hydration over the following months suggested progressive graft dysfunction. A case of segmental involvement of CR with subsequent successful graft salvage by partial resection is rare in the literature.

APPLE PEEL JEJUNAL ATRESIA IN A NEONATE: A RARE CAUSE OF INTESTINAL OBSTRUCTION

A preterm baby was born with antenatal diagnosis of upper gut obstruction. Postnatal abdominal x-ray showed triple gas shadows and ultrasound scan showed few dilated bowel loops. Laparotomy revealed apple peel deformity type of jejuno ileal atresia. Tapering duodeno-jejunoplasty with end to side anastomosis and transgastric feeding jejunostomy was carried out. Gradually feeds were introduced. Apple peel jejunal atresia classified as type iii-b jejunoileal atresia, is a rare malformation with a high incidence of mortality and morbidity. We are reporting a case of apple peel jejunal atresia in a preterm baby with survival.