Etiology Of Small Bowel Obstruction Research Articles

Laparoscopic management of small bowel obstruction secondary to a mesodiverticular band of a Meckel's diverticulum in an adult: A case report and literature review.

The mesodiverticular band (MDB) of a Meckel's diverticulum (MD) is a rare, yet notable etiology of small bowel obstruction (SBO) in adults. Due to the nonspecific symptoms and challenging diagnosis thereof, preoperative clinical suspicion and strategic management are crucial for achieving optimal outcomes. Therefore, we presented a case in which laparoscopic surgery was strategically performed to alleviate ileus, due to a preoperative diagnosis of SBO, suspected to be secondary to an MD with a concomitant MDB. A 32-year-old male patient presented with a half-day's duration of epigastric pain, abdominal distension, and tenderness, resulting in the working diagnosis of SBO. Initial non-contrast computed tomography (CT) revealed SBO without signs of strangulation, postulated to be caused by an MD and concomitant MDB, resulting in conservative management. The symptoms persisted, necessitating contrast-enhanced CT. However, the dilated bowel loop suggestive of an MD that had been observed on non-contrast CT could not be confirmed on contrast-enhanced CT. Decompression therapy using a long tube provided minimal relief, prompting laparoscopic surgery on the 5th day post-admission for diagnostic and therapeutic purposes. An MD resection effectively relieved the SBO. The histopathological analysis revealed a true diverticulum with ectopic pancreatic tissue, confirming the diagnosis of an MD. At the band site, vascular and neural structures were encased in a sheath, consistent with the remnants of the vitelline duct mesentery; and histopathologically diagnosed as an MDB. The postoperative course was uneventful, and the patient was discharged on the 9th day, postoperatively. Decompression therapy and strategic laparoscopic surgery based on the preoperative working diagnosis of SBO yielded favorable outcomes, highlighting the importance of the early clinical suspicion of an MD and a concomitant MDB, as the etiology of SBO. The imaging variability and rarity of an MD in adults emphasizes the need for a heightened awareness and an accurate diagnosis for optimal management. Early intervention should be deliberated for patients with suspected intestinal ischemia. However, this case accentuates the clinical implications of strategic planning and employing minimally invasive techniques in the management of an MD-related SBO in adults.

Incarcerated Intestine by Testicular Mass in Huge Scrotum: A Case Report

Large testicular tumor is not a commonly seen entity in the modern era. While treatment of large testicular tumors is via inguinal radical orchiectomy, large testicular tumors carry the dilemma of delivering these large masses via the inguinal or scrotal approach. Our case was a 90 years old man with obstruction signs and huge scrotum that shows incarcerated large bowel with huge testicular mass, that in his surgery we did Radical Orchiectomy and we replace incarcerated Large Bowel in scrotum and discharge him successfully. Giant testicular cancer is considered one of the largest testicular masses in the world. Delayed seeking medical advice and appropriate management is the major cause behind this rare presentation. Increasing the awareness regarding self-examination and eliminating the stigma is the cornerstone to markedly reduce this type of unusual presentation since any testicular size change and mass can be easily noted by the patient. Surgical exploration and adjuvant chemotherapy seems as a reasonable treatment option in the setting of bilateral intra-abdominal testis tumor in an adult patient. The study underscores the effectiveness of the intervention in promoting preventive behaviours against testicular cancer among university students, laying the groundwork for future educational initiatives. Although testicular cancer (TC) is the most common malignancy in males between the ages of 18 and 50 years, little effort has been made to increase public awareness about TC and testicular self-examinations (TSEs). Intestinal obstruction without a past surgical history of abdominal surgeries or trauma is a rare and challenging clinical situation. This case report describes the presentation, diagnosis, and management of intestinal obstruction in a patient with an uncommon aetiology of small bowel obstruction. Chronic hernia incarceration can lead to weakening and ischemia of the bowel, and minimal trauma can lead to perforation of the weakened segment. In such presentations, bowel resection and repair of the defect with a biological material is safe and feasible.

Small bowel obstruction in infants due to complicated Meckel’s diverticulum: A case series

Objectives: Our purpose is to illustrate the radiological aspects of Meckel’s diverticulum as an etiology of small bowel obstruction in infants. Material: We report a group of 4 patients with Meckel’s diverticulum complicated with small bowel obstruction that underwent surgery. We reviewed patient records, clinical presentation, ultrasound and CT imaging and intraoperative findings. Results: All included patients presented symptoms of bowel obstruction, one patient presented acute abdomen symptoms. The median age of our group was 5 years, all patients were males. All patients underwent radiological explorations. Ultrasound showed small bowel dilatation in all cases, and CT scan confirmed small bowel obstruction with ischemic complications in one patient. All of the 4 patients had laparotomy with the finding of MD responsible of small bowel obstruction in all cases, with on case of perforated loop and latero-caecal abscess. The obstruction was secondary to fibrous adhesions in three cases and the omphalomesenteric duct in one cases. All the patients had normal evolution with no post-operative complications. Conclusion: Meckel’s diverticulum represents a rare embryological remnant. It is a differential diagnosis in pediatric bowel obstruction and remains an intraoperative surprise despite the very abvanced imaging studies.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study.

Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

Understanding the physiology of bowel obstruction and its implications for patient assessment and management

Bowel obstruction causes acute abdominal pain, and, if untreated, leads to strangulation of the bowel and may lead to the patient's death. The aetiology of small bowel obstruction and large bowel obstruction can involve mechanical (dynamic) or non-mechanical (adynamic) causes, as well as pseudo-obstruction, abdominal hernias and postoperative ileus. Assessment techniques include history taking, physical examination, imaging, biochemistry and endoscopic assessment. Intervention options include symptomatic, endoscopic and conservative management, as well as surgical treatment and palliative care. Clinical nurse specialists in colorectal, stoma and palliative care play essential roles in meeting the holistic needs of these patients.

Non-operative management of small bowel obstruction in virgin abdomen: a systematic review.

The aim of this study was to systematically review the feasibility and safety of non-operative management of small bowel obstruction (SBO) in virgin abdomen. A systematic review was performed through December 2019. The primary outcome was the resolution of non-operative management of SBO in virgin abdomen. Secondary outcomes were the etiology of SBO and findings of exploratory laparotomy. Six studies were included in the analysis. Of the 442 patients, 2 with metastatic cancer received palliative care, and the management in 26 was not reported, so these patients were excluded. A total of 414 patients were ultimately analyzed, including 203 patients (49%) who were managed non-operatively and 211 (51%) who underwent surgical management. Of the 203 managed non-operatively, the condition of 194 (96%) was resolved without further intervention. The remaining 9 (5%) patients failed non-operative management and ultimately required surgery. Of the 211 patients who underwent surgical exploration, only 137 had their intraoperative findings reported. Adhesions (n = 67; 49%) were the main cause, followed by malignancy (n = 14; 10%) and others (n = 33; 24%). No cause was found in 23 patients (17%). In highly select cases of SBO with virgin abdomen, non-operative management can be attempted if patients are clinically stable and computed tomography does not demonstrate concerning features or obvious pathology. Further well-designed prospective studies will be required prior to the introduction of this concept in clinical practice, as current evidence remains heterogeneous.

Diagnosis of single adhesive bands versus matted adhesions in small bowel obstructions: a radiological predictive score

The objective was to develop a radiological score obtained from multi-detector computed tomography (MDCT) to differentiate between single band adhesion (SBA) and matted adhesions (MA) as the etiology of small bowel obstruction (SBO). All consecutive patients who underwent surgery from January 2013 to June 2018 for adhesion-induced SBO were retrospectively included. Among the 193 patients having surgery for SBO, 119 (61.6%) had SBA and 74 (38.4%) had MA surgically proven. In multivariate analysis, the presence of a beak sign (OR = 3.47, CI [1.26; 9.53], p = 0.02), a closed loop (OR = 11.37, CI [1.84; 70.39], p = 0.009), focal mesenteric haziness (OR = 3.71, CI [1.33; 10.34], p = 0.01) and focal and diffuse peritoneal fluid (OR = 4.30, CI [1.45; 12.73], p = 0.009 and OR = 6.34, CI [1.77; 22.59], p = 0.004, respectively) were significantly associated with SBA. Conversely, the presence of diffuse mesenteric fluid without focal fluid (OR = 0.23, CI [0.06; 0.92], p = 0.04) and an increase of the diameter of the most dilated loop (OR = 0.94, CI [0.90; 0.99], p = 0.02) were inversely associated with SBA. Using the significant predictive factors of SBA, we built a composite score to radiologically predict the etiology of SBO. The area under the receiver operating characteristic (ROC) curve of the score was 0.8274. For a cut-off score of -0.523, sensitivity, specificity and the percentage of patients correctly classified were 78.4%, 84.6% and 80%, respectively. If the score is ≥ 7, the probability that the mechanism of SBO is not SBA was 100%. The present score, validated in a different population, could be a significant tool in the decision for surgical management.

Intravenous Contrast Agent in Abdominal CT: Is It Really Needed to Identify the Cause of Bowel Obstruction? Proof of Concept.

Background To compare sensitivity of unenhanced computed tomography (CT) and contrast-enhanced CT for the identification of the etiology of bowel obstruction. Materials and Methods We retrospectively evaluated abdominal CT scans of patients operated for bowel obstruction from March 2013 to October 2017. Two radiologists evaluated CT scans before and after contrast agent in two reading sessions. Then, we calculated sensitivity of CT in the diagnosis of bowel obstruction and determined in which cases the etiology of bowel obstruction was detected on both unenhanced and enhanced CT or on enhanced CT only. The reference standard was defined as the final diagnosis obtained after surgery. Results Eighteen patients (mean age 72 ± 15 years, age range 37-88 years) were included in the study. Sensitivity of unenhanced CT and enhanced CT was not significantly different in either small bowel obstruction (64%, 7/11 patients vs. 73%, 8/11 patients; P = 0.6547) or large bowel obstruction (71%, 5/7 patients vs. 100%, 7/7 patients; P = 0.1410). Adhesions were identified on unenhanced CT as the etiology of small bowel obstruction in 80% (4/5) of patients. Tumors were identified on unenhanced CT as the etiology of large bowel obstruction in 67% (4/6) of patients. Conclusion In the diagnosis of small bowel obstruction due to adhesions with normal bowel wall thickening and when a neoplasm is identified as the etiology of large bowel obstruction on unenhanced CT, an intravenous contrast agent may be avoided for the identification of the etiology. In remaining cases, contrast agent is still recommended.

Urachal Cyst Causing Small Bowel Obstruction in an Adult with a Virgin Abdomen.

Introduction. A patent urachus is a rare congenital or acquired pathology, which can lead to complications later in life. We describe a case of urachal cystitis as the etiology of small bowel obstruction in an adult without prior intra-abdominal surgery. Case Report. A 64-year-old male presented to the acute care surgery team with a 5-day history of right lower quadrant abdominal pain, distention, nausea, and vomiting. He had a two-month history of urinary retention and his past medical history was significant for benign prostate hyperplasia. On exam, he had evidence of small bowel obstruction. Computed tomography revealed high-grade small bowel obstruction secondary to presumed ruptured appendicitis. In the operating room, an infected urachal cyst was identified with adhesions to the proximal ileum. After lysis of adhesions and resection of the cyst, the patient was subsequently discharged without further issues. Conclusion. Although rare, urachal pathology should be considered in the differential diagnosis when evaluating a patient with small bowel obstruction without prior intraabdominal surgery, hernia, or malignancy.

Role of 2-D reformatted images of MDCT in evaluation of small bowel obstruction: A case series

The availability of multidetector computed tomography (MDCT) scanners, coupled with imaging workstations that allow multiplanar and three-dimensional (3D) evaluation of isotropic data sets, have allowed improved depiction and characterization of small bowel obstruction (SBO). In this article, we present a series of five cases and emphasize that addition of coronal images to axial images enhance the identification of site and etiology of SBO especially in unusual cases of SBO.

Etiology of Small Bowel Obstruction in a Culturally Diverse Patient Population

Etiology of Small Bowel Obstruction in a Culturally Diverse Patient Population

Etiology of Small Bowel Obstruction in a Culturally Diverse Patient Population

Background & Aims: Small bowel obstructions (SBO) are a major cause of morbidity and recurrent hospitalizations worldwide. The leading cause of SBO in the western world is adhesions. The goal of this study was to determine the etiologies of SBO in a large, universityaffiliated hospital with a culturally, ethnically and socioeconomically diverse patient population. Methods: Systematic chart review of all patients hospitalized at Elmhurst Hospital Center with the discharge diagnosis of “bowel obstruction” between January 2005 and October 2012 was conducted. Patients with the diagnosis of SBO were selected from this group. Our cohort included 348 patients accounting for 405 admissions for SBO. Data collected included demographic profile, length of stay, hypothesized etiology of SBO and type of management. Because all data had skewed distributions, we calculated medians and compared several parameters. Results: The etiologies of SBO were found to be adhesions (56%), hernia (10.3%), Crohn’s disease (5.7%), neoplasia (4.9%), tuberculosis (0.9%) and miscellaneous (22.2%). Surgical management was more frequent when a hernia (61.1%) or malignancy causing obstruction (59%) was the cause of SBO. Medical management was more common in Crohn’s disease (72%). Patients with hernia, malignancy or adhesions were older and had a longer median hospital stay after surgical management. There was no specific gender predilection for any cause of SBO except for Crohn’s (predominantly male). Ethnicity of the patient population was white (12.1%), African American (7.9%), Hispanic (48.4%) and Asian/others (31.6%). Conclusion: Adhesions were the most common cause of SBO according to our study (56%), a finding consistent with other studies in the developed countries (70% as per current literature). Hernia was the second most common cause of SBO in our study, unlike other studies in western countries where malignant mass or Crohn’s disease have been found to be the second most common cause. This could be attributed to the cultural diversity in our population group. The prominence of hernias as an etiology of SBO in developing countries has been attributed to the infrequency of elective hernia repair in those areas.

The role of laparoscopy in the management of acute small-bowel obstruction: a review of over 2,000 cases

Adhesive small-bowel obstruction (SBO) contributes significantly to emergency surgical workload. Laparotomy remains the standard approach. Despite published reports with high success rates and low morbidity, acute SBO is still considered by many a relative contraindication to laparoscopy. Our aim was to review the available literature and define important outcomes such as feasibility, safety, iatrogenic bowel injury, and benefits to patients with acute SBO who are approached laparoscopically. A systematic literature search was carried out using the Medline database and the search terms "laparoscopy" or "laparoscopic approach" and "bowel obstruction." Only adult studies published in English between 1990 and 2010 were included. Studies were excluded if data specific to outcomes for laparoscopic management of acute SBO could not be extracted. Twenty-nine studies were identified. A laparoscopic approach was attempted in 2,005 patients with acute SBO. Adhesions were the most common etiology (84.9%). Laparoscopy was completed in 1,284 cases (64%), 6.7% were lap-assisted, and 0.3% were converted to hernia repair. The overall conversion rate to midline laparotomy was 29% (580/2,005). Dense adhesions, bowel resection, unidentified pathology, and iatrogenic injury accounted for the majority of conversions. When the etiology of SBO was a single-band adhesion, the success rate was 73.4%. Morbidity was 14.8% (283/1,906) and mortality was 1.5% (29/1,951). The enterotomy rate was 6.6% (110/1,673). The majority were recognized and converted to laparotomy. Laparoscopy was associated with reduced morbidity and length of stay. Laparoscopy is a feasible and effective treatment for acute SBO with acceptable morbidity. Further studies are required to determine its impact on recurrent SBO.

An uncommon etiology of small bowel obstruction: Gallstone ileus

Gallstone ileus is a rare etiology of small bowel obstruction, occurring typically in the elderly population. The delay in diagnosis often results in significant morbidity and mortality. Here, we describe a case of 67 year old woman who presented with non specific abdominal symptoms and on evaluation was found to have small bowel obstruction caused by wedging of a large gallstone at the terminal ileum.

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en- Y gastric bypass

Background Mesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en- Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population. Methods The records of 702 consecutive patients undergoing primary laparoscopic Roux-en- Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO. Results Of the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus. Conclusion SBO due to MIH after laparoscopic Roux-en- Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.

Internal hernia associated with Meckel's diverticulum in 2 pediatric patients

We report 2 pediatric cases of small bowel obstruction due to a Meckel's diverticulum complicated with internal hernia. Abdominal multidetector computed tomograms with multiple planar reconstructions revealed a bridge-like lesion with inconspicuous mucosal folds in the right lower quadrant formed by adhesion of the tip of Meckel's diverticulum with the adjacent mesentery, with ileal loops converging at the “bridge” and engorged mesenteric vessels. These 2 cases highlight the feasibility of multidetector computed tomography, especially in the ED, in revealing this unusual etiology of small bowel obstruction.

P80: Biliopancreatic limb obstruction after laparoscopic Roux-en-Y gastric bypass for morbid obesity

The etiology of small bowel obstruction (SBO) after Roux-en-Y Gastric Bypass (RYGB) is largely determined by approach; internal hernia is the most common cause after laparoscopic RYGB vs. adhesions following open RYGB. Obstruction of the biliopancreatic limb (BPO) is uncommon after either approach

Reoperation for Small Bowel Obstruction-How Critical Is the Timing?

The timing of reoperation for small bowel obstruction is a topic of significant debate. Any patient with evidence of strangulation should undergo urgent surgical intervention. However, predicting strangulation can be difficult. Because of this, previous authors have recommended everything from emergency operation for all patients presenting with small bowel obstruction to periods of observation that extend up to 14 days. Over the past century, the primary etiology of small bowel obstruction has shifted from hernias to postoperative adhesive disease, leading to a shift in the management paradigm. To manage small bowel obstruction successfully today, the clinician must distinguish the patient requiring urgent operation from those who benefit from nonoperative management. Furthermore, the clinician must be able to determine the appropriate length of time for conservative management. In this article we review the significant body of literature on this topic including the diagnostic workup and timing of potential operative intervention in the patient with small bowel obstruction.

Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images?

Feasibility of diagnosing small bowel obstruction on multidetector-row computed tomography (MDCT) using coronal reformations alone is evaluated. Three radiologists with subspecialty training in abdominal imaging reviewed abdominopelvic CT of 67 patients in consensus. Thirty-four patients had surgically proven small bowel obstruction. The remaining 33 patients had CT for other reasons and had no intestinal obstruction. The images were displayed in either axial or coronal planes and were reviewed on separate days . Each CT was evaluated for the presence of small bowel obstruction and its etiology when applicable. Thirty-three (100%) of 33 patients were correctly diagnosed not to have intestinal obstruction on coronal images. Thirty-four (100%) of 34 patients were correctly diagnosed to have small bowel obstruction on both forms of image display. There were five patients where the final surgical diagnosis for the etiology of small bowel obstruction did not agree with the interpretation of either the coronal or axial images; however, in all five patients, the interpretations of axial and coronal images were similar. In only one patient, the etiology of small bowel obstruction based on the coronal images did not agree with that of axial images and the surgical result; however, the site of small bowel obstruction was correctly diagnosed. There were approximately 20% fewer images in the coronal reformation data set, and the radiologists found review of these images to be easier for localizing the zone of transition in small bowel obstruction. Very high diagnostic accuracy can be achieved based on coronal reformations alone, and this form of image display may potentially be substituted for the conventional axial images. Since there are fewer images to review when the studies are displayed in coronal plane, this may positively impact radiologist workflow.

Small bowel obstruction in patients previously operated on for colorectal cancer.

To find out the incidence, aetiology, and outcome of patients operated on for small bowel obstruction after previous operation for colorectal cancer. Retrospective cohort study. District hospital serving a defined population, Norway. 472 consecutive patients operated on for colorectal cancer, followed up for a median of 5.5 years (range 2.0-16.8) or until death; 351 had had a resection with curative intent, and 121 a palliative operation. Incidence and aetiology of small bowel obstruction, postoperative mortality, and long term survival. Small bowel obstruction necessitated operation in 36/351 (10%) after resection with curative intent, and in 5/121 (4%) after a palliative operation. The causes of obstruction were benign adhesions (n=21), local recurrence (n=17) and peritoneal carcinomatosis (n=3). One patient died of a myocardial infarction and six of cancer within 30 days of the operation for small bowel obstruction. The estimated median survival after the operation for small bowel benign obstruction was 1.9 years (SE=0.6) compared with 0.36 years (SE=0.04) for malignant obstruction (p=0.0007, logrank test). Late small bowel obstruction by adhesions was associated with higher blood loss during the primary operation (p=0.02). None of the 62 patients who took thiazide diuretics at the time of the primary operation later developed obstructive adhesions. 41/472 patients (9%) developed small bowel obstruction after the primary operation for colorectal cancer. The aetiology was benign in 21 and malignant in 20 patients. Survival after operation for the obstruction was far better with benign than with malignant obstruction.