High-grade Bowel Obstruction Research Articles

Food Bolus Ileus as a Cause of High-Grade Bowel Obstruction: A Case Report

Small bowel obstruction is often caused by previous surgical scar or cancer. High grade bowel obstruction secondary to food bolus impaction is very rare especially in a young patient who has otherwise no medical or surgical history. We are presenting a unique case in a young male who presented with acute abdomen with initial CT scan suggestive of Meckel’s diverticulitis. During exploratory laparotomy, patient was found to have a severe degree of bowel obstruction with one definitive transition point caused by food bolus impaction. Food bolus ileus is a rare cause of bowel obstruction requiring surgical intervention. However, definitive intervention should not be delayed when patients present with concerning clinical signs.

Current diagnosis and image-guided reduction for intussusception in children.

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

A Volvulating Affair

An elderly gentleman presented with a recurrent history of sudden onset abdominal distension and vomiting. He was assessed and diagnosed with a sigmoid volvulus based on his clinical findings and plain abdominal films (Figure 1). A decompression was attempted, unsuccessfully. He was evaluated further, and a CT scan revealed a high-grade bowel obstruction to an abrupt transition point at the splenic flexure due to a mass, with presence of gas in wall of the transverse colon indicating evolving bowel wall ischaemia and/or impending perforation (Figure 2). An extended right hemi-colectomy was performed and histology aided in staging this to be a T3 No Mx adenocarcinoma of the colon. This was an atypical presentation of a colonic malignancy, due to its classical appearance of a sigmoid volvulus.

Small Bowel Obstruction: A Unique Presentation of Metastatic Esophageal Carcinoma

Introduction: Esophageal cancer is known to metastasize to various organs, but its initial presentation as a small bowel obstruction (SBO) appears to be a unique occurrence. We report the case of a patient who presented with an SBO and further work up identified metastatic esophageal squamous cell carcinoma as its likely source. Case Report: A frail 77-year-old male presented with a two-week history of progressive abdominal discomfort. He denied recent vomiting, diarrhea, or GI bleeding, and he initially reported no dysphagia. He was a life-long smoker with a medical history of anemia with recent transfusion, and diverticulosis. His surgical history included an appendectomy, a left inguinal hernia repair, and a left upper extremity amputation secondary to infection from a brown recluse spider bite. Except for a hemoglobin level of 8.6 g/dL, the patient's lab values were relatively unremarkable. His abdomen was softly distended, and without appreciable masses or significant tenderness. An abdominal CT scan, however, showed a high-grade bowel obstruction. Conservative management failed to relieve the patient's worsening symptoms. He then underwent an exploratory laparotomy and an obstructive mass with adhesions necessitated the resection of approximately 12 cm of small bowel. Microscopic examination of the resected specimen identified poorly differentiated carcinoma with squamous differentiation. A subsequent CT of chest revealed a 2.7 × 1.6 cm mid-esophageal mass along with left axillary lymphadenopathy. Upon further questioning, the patient stated he had experienced mild dysphagia and some weight loss over a few months prior to his presentation. The patient thereafter underwent an EGD that demonstrated an ulcerative lesion at the mid esophagus. Biopsies confirmed invasive squamous cell carcinoma as the source of both the primary malignancy and the small bowel obstruction. Discussion: It is rare for metastases to the small bowel to present with clinically significant symptoms. In fact, they are often merely a finding on autopsy. Even more unusual are intestinal metastases as the causative agent of an SBO prior to an established diagnosis of the primary cancer. In this unique case, our patient arrived at the hospital, not with dysphagia suggesting esophageal cancer, but with typical SBO symptoms. Thus, the metastatic lesion of undiagnosed esophageal carcinoma first presented as a symptomatic obstruction of the small bowel. Consequently, while there are of course more common causes, it is still prudent to keep in mind metastatic disease in the evaluation of intestinal obstruction, even in the absence of established diagnosis of a primary cancer.

Extragenital adenosarcoma: A case report, review of the literature, and management discussion

Background Müllerian adenosarcoma is a rare mixed epithelial–mesenchymal tumor. An extragenital site of origin and sarcomatous overgrowth are associated with aggressive clinical behavior. Case We present a rare case of extragenital adenosarcoma with sarcomatous overgrowth and coexistent endometriosis. She was treated with initial cytoreductive surgery and chemotherapy. She underwent a second surgery for management of a high-grade bowel obstruction, due to pathologically confirmed recurrent intraperitoneal adenosarcoma. A complete clinical response was achieved with liposomal doxorubicin, and the patient remains disease-free eighteen months after completion of chemotherapy. Conclusion Liposomal doxorubicin appears to be an active agent for the treatment of adenosarcoma with sarcomatous overgrowth. In addition, we conclude from our review of all reported cases of extragenital adenosarcoma that concurrent endometriosis may represent a favorable prognostic factor.

Survival with surgical versus medical treatment of patients with bowel obstruction secondary to ovarian cancer recurrence: A 15-year experience

e16515 Background: To compare the impact of surgical versus medical management on the survival of patients presenting with small bowel obstruction (SBO) secondary to recurrent ovarian cancer. Methods: The Institutional Review Board approved a retrospective chart review of all patients with SBO due to recurrent ovarian cancer at the University of Wisconsin Hospital between January 1, 1992, and December 31, 2007. The data abstracted from patient charts included demographics, primary cancer characteristics, detailed clinical information at the time of SBO, management strategy, and outcome. Univariate analysis was performed with Cox proportional hazard model and Kaplan-Meier curves were generated for survival. Results: 71 patients met our search criteria, 6 were excluded because of a paucity of medical information. Of the 65 patients in our study, the median age was 53 years. 86% of the patients had stage III/IV ovarian cancer, while 14% had stage I/II. The median time from tumor recurrence to bowel obstruction was 17 months. 41% of patients presented with high grade bowel obstruction while 69% were low grade. 36 (55%) of patients underwent surgery for management of bowel obstruction and the remaining 29 (45%) were managed conservatively with various medical approaches. Two-year survival for the surgically managed patients was 38% compared to 18% for those who received medical treatment (p = 0.07). There was no difference in survival for patients based on histology (p = 0.38), grade (p = 0.077), grade of SBO (p = 0.56). Patients with stage I/II had a median survival of 50 months versus stage III/IV at 3.5 months (p = 0.01). Median survival for patients without ascites at time of SBO was 9.5 months while those with ascites was 3 months (p = 0.0004). Patients without abdominal or pelvic mass on CT had a median survival of 60 months; patients with any mass noted had a median survival of 3.6 months; patients with liver and lung metastases was 3 months (p = 0.001). Conclusions: In patients with bowel obstruction due to ovarian cancer recurrence; early stage at diagnosis, the absence of ascites, and lack of abdominal/pelvic mass or distant metastases significantly lengthens survival. There is a trend towards the superiority of surgical management in these patients. No significant financial relationships to disclose.

Jejunal Diverticular Disease with Unborn Enterolith Presenting as a Small Bowel Obstruction: A Case Report

Jejunal diverticuli are rare and usually asymptomatic. More commonly, they are seen as incidental findings on CT images, enteroclysis, or during surgery. Complications such as bleeding, perforation, obstruction, malabsorption, diverticulitis, blind loop syndrome, volvulus, and intussusception may warrant surgical intervention. An interesting case of an unborn enterolith (enclosed calculus) from a jejunal diverticulum presenting as a small bowel obstruction is presented. The patient is a 66-year- old woman with no prior history of abdominal surgery who presented with a high-grade bowel obstruction. CT with intravenous barium contrast confirmed the presence of a transition point from dilated to decompressed small bowel in the mid jejunum. At laparotomy, a freely mobile mass was found in this area leading to the bowel obstruction. The mass was removed by making a small enterotomy in the jejunum. While running the small bowel proximally, a small segment of jejunum, approximately 8 cm, containing several diverticuli was found. This bowel obstruction was the result of an unborn enterolith from this segment of bowel. The patient's hospitalization was benign and she was discharged home on postoperative day 4.

Adjuvant therapy for colon cancer.

Adjuvant therapy for colon cancer is now a mature and widely accepted standard of care for patients with resected large bowel tumors: adjuvant therapy for stage III colon cancer has also been shown to be highly cost-effective. The cost of 5-FU/levamisole therapy for stage III colon cancer per year of life saved is less than $ 5,000, which represents a favorable cost-benefit relationship for a medical intervention. The clinician managing a patient with colon cancer at the present time has several options for therapy. In patients with stage III colon cancer, therapy with 5-FU-based regimens clearly increases overall and disease-free survival. It is also clear that the results that have been obtained are not perfect; therefore, the first option of therapy should always be an ongoing clinical trial. Many such trials are available, and Table 7 lists currently active studies in the United States. The clinician managing a patient with stage III colon cancer who is not in a clinical trial may choose a variety of regimens administered for durations of 6 to 12 months (Table 8). The preponderance of evidence suggests that 5-FU plus levamisole for 12 months is equal in efficacy to 5-FU plus leucovorin-based regimens given for a shorter period of time. A clinician may still choose the 5-FU plus levamisole regimen because of the decreased oral, myelosuppressive, and diarrheal toxicities associated with that regimen as opposed to the 5-FU/leucovorin regimens. Portal vein infusion of fluorinated pyrimidines still must be considered investigational. Finally, although we cannot be absolutely sure about the benefit of adjuvant therapy in patients with resected node-negative colon cancer, the NSABP data suggest that some benefit may be seen in these patients. It is known that patients with stage II cancers demonstrating high-grade bowel obstruction or bowel perforation have poor prognoses with surgery alone. Such patients may be good candidates for adjuvant therapy. Also, a major effort to define high risk and low risk for recurrence in patients with stage II colon cancer by analyzing molecular genetic factors (tumor ploidy and alternations in tumor suppressor genes) may lead to a selection of Dukes B patients definitely requiring adjuvant therapy.