High-grade Small Bowel Obstruction Research Articles

Concurrent presentation of unrelated perforated appendicitis and high-grade small bowel obstruction: A case report

Small bowel obstruction and acute perforated appendicitis are common surgical problems independently. At times, acute appendicitis may present with small bowel obstruction due to the localized inflammatory process. This results in mechanical small bowel obstruction usually near the terminal ileum. However, it is extremely rare to have both abdominal processes occurring simultaneously, but not related to one another. In this study, we present a case of a healthy 62-year-old female patient who had concurrent high-grade small bowel obstruction due to a chronic adhesive band and perforated appendicitis, seemingly completely independent of each other.

Case report of rare cause of small bowel obstruction: distal migration of metal biliary stent requiring enterotomy

Endoscopic biliary stent placement is a mainstay in the management of biliary strictures both malignant and benign. Distal stent migration is a known complication of metal biliary stents, however small bowel obstruction or perforation are rare. In this report from a tertiary referral centre, we detail a mid-small bowel obstruction caused by covered metal stent migration requiring a laparotomy and enterotomy for definitive management. A 69-year-old male was admitted to the Sunshine Coast University Hospital with obstructive jaundice on a background of previous metal biliary stent placement. On day 3 of his admission, he developed worsening abdominal pain. Cross-sectional imaging demonstrated distal migration of his stent to his mid-jejunum, causing a high-grade small bowel obstruction. He underwent laparotomy to retrieve the stent. He recovered well and underwent a percutaneous transhepatic cholangiogram with stent replacement. In this case, distal biliary stent migration causes a small bowel obstruction. Whilst uncommon, risk factors including previous intra-abdominal operation can be used to identify patients unlikely to achieve successful expectant management of distal migration.

Non-inflamed appendix with LAMN causing closed-loop small bowel obstruction

Introduction: Low grade appendiceal mucinous neoplasms are generally encountered incidentally in appendicectomies for suspected appendicitis. This case is a documentation of a rare occurrence of LAMN presenting with small bowel obstruction. Case Report: An 83-year-old male presented to the Emergency Department with a three day history of nausea, vomiting, and obstipation and profoundly dehydrated. Computed tomography revealed a high grade small bowel obstruction with 2 transition points in the right iliac fossa, concerning for closed loop obstruction, necessitating an urgent laparotomy. Conclusion: While acute appendicitis is a common cause of emergency abdominal pathology, when coupled with small bowel obstruction, a neoplastic cause should be considered as part of the differential diagnosis.

EGS P31 Small bowel obstruction in an elderly female secondary to congenital Ladd’s band. A rare case presentation

Abstract Background Intestinal malrotation is a congenital anomaly which arises during embryonic development. This can be associated with peritoneal tissue known as Ladd’s bands which can cause predisposition to intestinal obstruction. The incidence of intestinal malrotation is reported to be approximately 0.2% in the adult population [G]. Cases of intestinal obstruction secondary to malrotation commonly present in the paediatric population, but rarely may only be detected at adulthood. We present an elderly women who presented with features suggestive small bowel obstruction. Methods We present a rare case of a 78 year old female presenting with a three day history of coffee-ground vomiting, abdominal pain and dizziness. The patient had a notable background of a hiatus hernia and atrial fibrillation for which she was being treated with edoxaban. An abdominal X-ray film showed faecal loading. CT imaging revealed a high-grade small-bowel obstruction with an acute transitional point at the terminal ileum secondary to congenital Ladd's band which was confirmed at laparotomy. Subsequently, a Ladd’s procedure was performed and the patient was discharged after making a good recovery. Results In this case report, we highlight the importance of considering congenital anomalies in patients presenting with symptoms of bowel obstruction. We discuss the importance of appropriate investigations as well as multidisciplinary care to help facilitate early diagnosis. Conclusions Congenital Ladd’s band is a rare cause of small bowel obstruction in an elderly population. Although the diagnosis of intestinal malrotation can be challenging in adulthood, congenital anomalies should be considered as a differential in patients presenting with symptomatic obstruction.

Deep learning using computed tomography to identify high-risk patients for acute small bowel obstruction: development and validation of a prediction model : a retrospective cohort study.

To build a novel classifier using an optimized 3D-convolutional neural network for predicting high-grade small bowel obstruction (HGSBO). Acute SBO is one of the most common acute abdominal diseases requiring urgent surgery. While artificial intelligence and abdominal computed tomography (CT) have been used to determine surgical treatment, differentiating normal cases, HGSBO requiring emergency surgery, and low-grade SBO (LGSBO) or paralytic ileus is difficult. A deep learning classifier was used to predict high-risk acute SBO patients using CT images at a tertiary hospital. Images from three groups of subjects (normal, nonsurgical, and surgical) were extracted; the dataset used in the study included 578 cases from 250 normal subjects, with 209 HGSBO and 119 LGSBO patients; over 38000 CT images were used. Data were analyzed from 1 June 2022 to 5 February 2023. The classification performance was assessed based on accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve. After fivefold cross-validation, the WideResNet classifier using dual-branch architecture with depth retention pooling achieved an accuracy of 72.6%, an area under receiver operating characteristic of 0.90, a sensitivity of 72.6%, a specificity of 86.3%, a positive predictive value of 74.1%, and a negative predictive value of 86.6% on all the test sets. These results show the satisfactory performance of the deep learning classifier in predicting HGSBO compared to the previous machine learning model. The novel 3D classifier with dual-branch architecture and depth retention pooling based on artificial intelligence algorithms could be a reliable screening and decision-support tool for high-risk patients with SBO.

RENAL8: Hypertonic Bicarbonate during Continuous Renal Replacement Therapy in Acute Liver Failure

Introduction: Acute liver failure (ALF) is particularly alarming when presenting with vasodilated shock and multi-organ system failure. Standard manufactured hemofiltration fluid (sodium [Na+] = 140 mEq/L) would result in hyponatremia in vivo. We present a case study of hypertonic NaHCO3 infusion to address simultaneous serum Na+ target and correction of acidemia during continuous therapy. Case Presentation: A 42-year-old female with a history of seizures, and heavy alcohol use presented from outside the hospital for evaluation of stroke-like symptoms and subsequent mechanical fall. Urgent head CT was non-contributory. She was found to be in acute liver failure with total bilirubin 4.7, AST: 15,525 ALT: 5,727, ammonia 267 umol/L [reference range: 18-72], acetaminophen level 29 mcg/mL [reference range 10-30], Na+ 128 mEq/L, lactate >20 mmol/L, PT INR 8.1, PH 7.0 on blood gas and a negative ethanol level/salicylate/urine drug screen. After emergent intubation for encephalopathy and multiorgan system failure, she required multiple vasopressors (epinephrine, vasopressin, and norepinephrine), and received N-acetylcysteine protocol, with intravenous bicarbonate infusion and broad-spectrum antibiotic. High dose continuous veno-venous hemodiafiltration (CVVHDF) was initiated via Baxter PrisMax platform and global effluent dosing of 58mL/kg/hr with post-filter 3% NaCl at a rate of 100 mL/hr to reach goal serum sodium of 140 mEq/dL. [3% NaCl infusion rate calculation: (target infused Na – 140 mEq/L)/ (513 mEq/L – 140 mEq/L) x hemofiltration rate (mL/h)]. She also received Therapeutic Plasma Exchange for ALF for 5 daily sessions using fresh frozen plasma. She continued to have ongoing acidosis with a lactate of 11.7 mmol/L, and serum bicarbonate of 17 mEq/L. On Hospital Day 6, 3% NaCl was changed to hypertonic NaHCO3 drip [4.2% NaHCO3 solution (500 mEq/L in 1L of D5W) at a rate of 100 mL/hr, replacing 3% NaCl on a 1:1 ratio mL/mL]. After 24 hours she had improvement in metabolic acidosis with improvement in serum bicarbonate from 17 to 24 mEq/L, pH of 7.34 to 7.40; pCO2 32 to 42, HCO3 17 to 25 mmHg and serum Na 133 to 140 mEq/L. Unfortunately, on hospital day 8 developed worsening shock requiring vasopressors; a repeat abdominal imaging noted high-grade small bowel obstruction with ischemic bowel and pneumatosis intestinalis and was transitioned to comfort care. Discussion: While CVVHDF can address elevated ammonia in ALF, infused standard therapy fluid (Na+ = 140 mEq/L) would equilibrate serum Na+ to 133 - 135 mEq/L, in the presence of plasma proteins. Post-filter hypertonic saline infusion during CVVHDF would enable simultaneous clamping of serum Na+ to the appropriate target level. Due to heavier molecular size, 4.2% NaHCo3 results in identical Na+ delivery of 3% saline along with the added benefit of improving acidosis. Clinical studies are desirable to define optimal serum Na+ concentrations during CVVDF in various clinical settings.

P-031 AN UNUSUAL CASE OF AN INCARCERATED 5MM PORT SITE HERNIA FOLLOWING LAPAROSCOPIC FUNDOPLICATION

Abstract Aim Port site hernias are a rare, but recognised risk of laparoscopic surgery. Literature supports fascial closure at port sites of 10mm or greater. However, there are few reported cases of herniation through 5mm port sites. Methods This case report focuses on a 67-year-old female who underwent an uncomplicated primary laparoscopic Toupet's fundoplication. 11 days post procedure she presented with an incarcerated port site hernia. CT scan demonstrated high grade small bowel obstruction with a transition point at the site of the 5mm right sided port. A laparotomy was performed, the hernia reduced, small bowel was viable, and the port site hernia was closed internally using vicryl sutures. Results The incidence of 5mm trocar-site hernias is rare. A recent literature review found only 10 such cases related to general surgery (cholecystectomy:6; appendicectomy: 2; right hemicolectomy: 1; paraesophageal hernia:1). Risk factors for port-site hernias include: high BMI, midline position, size, number and type of trocar tip. The limited current literature identifies excessive trocar manipulation as the major risk factor for developing 5mm port-site hernias, yet routine fascial closure is not supported. Conclusion Herniation at 5mm port sites is rare but attention should be paid when patients present with symptoms suggesting its occurrence.

S3481 Small Bowel Obstruction Caused by Neurofibromatosis

Introduction: We report an unusual case of acute small bowel obstruction in a woman with Neurofibromatosis type 1 (NF1) caused by numerous gastrointestinal neurofibromas. NF1 is an autosomal dominant genetic disorder that is classically characterized by the development of cutaneous neurofibromas, but less commonly, it is associated with a variety of gastrointestinal tumors including plexiform neurofibromas, mucosal ganglioneuromas, and gastrointestinal stromal tumors [1]. Up to 25% of patients with NF1 are reported to have a gastrointestinal tumor of some kind, but it is estimated that only 5% develop gastrointestinal symptoms including bleeding, abdominal pain, abdominal distention, constipation, and very rarely small bowel obstruction (SBO) [2]. Case Description/Methods: Patient is a 26-year-old female with a past medical history significant for poorly controlled Crohn’s disease who presented due to abdominal pain and hematochezia. Physical exam was notable for pain in the right upper quadrant. CT abdomen and pelvis with contrast showed high-grade small bowel obstruction with tethering of small bowel centrally concerning for active Crohn’s disease. Colorectal surgery was consulted and performed laparotomy with ileocecectomy and end ileostomy formation. The terminal ileum and cecum were sent to pathology for further analysis. The pathology report showed “wall thickening with extensive neural hyperplasia (ganglioneuromatosis) and plexiform neurofibromas. The features seen in the resection favor intestinal neurofibromatous proliferations with secondary chronic mucosal changes. There is no transmural inflammation, granulomas or other features typically seen in Crohn's disease.” (Figure) Discussion: This patient was initially thought to have SBO due to Crohn’s disease flare, but pathology report showed that the underlying cause was secondary to plexiform neurofibromas. A systematic review of the literature shows that this is a rare finding as only 25 cases were identified from 1972 to 2013 of NF1 patients who underwent laparotomy for SBO [2]. SBO is a rare but possible manifestation of NF1.Figure 1.: CT Abdomen / Pelvis showing high grade small bowel obstruction.

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.

Small bowel obstruction precipitated by intussusception of Meckel’s diverticulum

Small bowel obstruction (SBO) secondary to intussusception of Meckel’s diverticulum (MD) is a rare cause of acute abdominal pain that may warrant urgent surgical treatment. Volvulus or intussusception of the small bowel with presence of MD as the lead point is the most commonly reported etiology of Meckel’s related obstructions. We report an interesting case of a small bowel obstruction caused by the intussusception of an MD within its own lumen. The case involves a 30-year-old male who presented to the emergency room with acute, severe abdominal pain with an abdominal computed tomography (CT) showing a distal high-grade SBO. Decision was made to take the patient to the operating room urgently due to his clinical examination and radiologic imaging, specifically CT scan. Diagnostic laparoscopy was performed and subsequently converted to an exploratory laparotomy, which revealed the intussuscepted MD with focal necrosis into the distal small bowel causing an SBO. A segmental small bowel resection with hand sewn primary anastomosis was performed. The case presents an interesting challenge in deciding when to take a patient with an SBO to the operating room versus initial conservative management and what the treatment should be if an MD is encountered. In addition, the case emphasizes the importance of history and physical exam findings in coordination with radiologic imaging in helping to make appropriate decisions in a timely manner for operative vs conservative management of an SBO. It reminds us that, Meckel’s diverticulum, although less commonly the cause of a small bowel obstruction in the adult population, needs to be on the differential diagnosis and we need to have a high clinical suspicion for this possibility to ensure appropriate treatment in a timely manner.

EP.WE.620The utility of Computerized Axial Tomography (CT) investigation in two week waits colorectal referral pathway: should it be done more often during the pandemic?

AimColorectal two week wait pathway investigations have been majorly affected due to Covid 19 especially with regards to endoscopy as well as virtual colonoscopy procedures in comparison to CT scan. We aimed to analyze the CT scan findings of colorectal rapid access patients.MethodA total of 1900 patients was referred via the straight to test pathway in the year 2020.A retrospective analysis of CT scan investigation performed in these patients was analyzed.ResultsA total of 90 (4.74%) patients had a CT Scan as part of the work.20 patients (22%) of the CT scan revealed malignancy. 10 patients (50%) had metastatic disease on the scan. Among them, 6 (60%) were due to colorectal primary and another 2 (20%) was due to thoracic cancers. The remaining were diagnosed with widespread metastatic disease of unknown origin. Among the remaining 10 patients, Curative surgery was offered to 5 patients with colorectal primary and one patient with hepatocellular carcinoma. The remaining patients were diagnosed with High grade B cell lymphoma, Neuroendocrine tumor, pancreatic mass and primary renal cell carcinoma. One patient had high grade small bowel obstruction due to a band adhesion resulting in emergency surgery and 5% of the patient needed a vascular referral for Abdominal aneurysm.ConclusionCT scan in two week colorectal referral patients play a significant role in diagnosis of advanced disease. The ease of the procedure makes it more attractive during the pandemic in contrast to endoscopy and virtual-colonoscopy which has been significantly impacted by COVID 19.

Small Bowel Volvulus as Delayed Presentation of Undiagnosed Crohn's Disease: A Case Report.

IntroductionEmergency department (ED) visits related to flare-ups of inflammatory bowel disease (IBD) are becoming more prevalent. There are many potentially dangerous complications and sequelae of uncontrolled IBD.Case ReportWe report a case of a middle-aged woman who presented with a few hours of severe abdominal pain, nausea, and vomiting. Given her hemodynamic instability, she was sent urgently for computed tomography, which showed an incomplete small bowel malrotation, mesenteric volvulus, and high-grade small bowel obstruction with evolving ischemia. The patient underwent exploratory laparotomy to resect most of her small intestines. Biopsies later revealed active Crohn’s disease.ConclusionPatients with flare-ups of IBD are common in the ED, but very few present with a midgut volvulus later in life. Our case is unique and adds to the literature due to the dramatic consequences of undiagnosed Crohn’s disease in a patient with intermittent symptoms and extensive workup spanning over two decades.

Case of Invasive Metastatic Breast Cancer Mimicking Crohn’s Disease

Background: A female patient with a history of stage IIB invasive lobular breast cancer presented with symptoms of partial small bowel obstruction and workup led to a presumptive diagnosis of Crohn’s disease. However, at the time of surgical intervention, she was found to have metastatic lobular breast cancer with carcinomatosis and metastases to the small and large intestines. Summary: Our patient presented at age 55 with intermittent nausea and vomiting, dyspepsia, altered bowel habits, and weight loss. She had a history of invasive lobular carcinoma of the right breast treated with right modified radical mastectomy followed by adjuvant chemoradiation and hormonal therapy 5 years earlier. She was thought to be in remission. Initial workup of her GI complaints was notable for thickening of the sigmoid colon and hepatic flexure on CT scan and stricturing and colitis in these areas on colonoscopy. Mucosal biopsies showed nonspecific active colitis. The patient was treated for a presumptive diagnosis of Crohn’s disease without significant improvement. She was eventually taken for surgery after presenting with a high-grade small bowel obstruction. On exploration, numerous additional small and large bowel strictures, some associated with intraluminal masses, were found and a small bowel resection and ileostomy performed. Pathology revealed metastatic invasive lobular breast carcinoma. Although isolated metastases to the bowel wall are rare, they have been reported secondary to a wide range of malignancies. Breast cancer, especially lobular carcinoma, is one of the most common tumors to metastasize to the GI tract and can present years after the primary cancer diagnosis. Therefore, the differential diagnosis for a patient with signs and symptoms of bowel obstruction and a history of lobular breast cancer should include metastatic disease. Conclusion: Metastatic cancer to the GI tract can mimic Crohn’s disease and should be on the differential in older patients with abdominal complaints, particularly those with a history of breast cancer.

High-grade small-bowel obstruction caused by a migrated lumen-apposing metal stent

High-grade small-bowel obstruction caused by a migrated lumen-apposing metal stent

2461 Atraumatic Chylous Ascites in a Cirrhotic Patient

INTRODUCTION: Only 0.5 to 1% of cirrhotic patients has chylous ascites (CA). CA is a rare form of ascites with milky peritoneal fluid that is rich in triglycerides. One study showed that the incidence is approximately 1/20,000 admissions at a university hospital over a 20 year period. Here, we report a case of atraumatic CA found in a cirrhotic patient. CASE DESCRIPTION/METHODS: A 66 year old man with cirrhosis secondary to alcohol abuse and hepatitis C virus, presented with marked abdominal distention and abdominal pain. On examination, the abdomen was soft, diffusely tender, distended with shifting dullness. Laboratory findings showed anemia, leukocytosis, normal AST, ALT, lipase and INR ratio. Paracentesis was performed and showed milky fluid. Ascites fluid analysis revealed leukocytosis with increased neutrophil count, triglyceride of 284 mg/dl and negative adenosine deaminase level and cytology. The results were consistent with spontaneous bacterial peritonitis and antibiotics was started. However, he deteriorated with intractable vomiting and was found to have high grade small bowel obstruction from CT imaging. He was taken to the OR for laparotomy but continued to deteriorate and expired. DISCUSSION: The most common causes of atraumatic chylous ascites are lymphatic anomalies (32%), malignancy (17%), cirrhosis (11%), Mycobacterium (15%), and a variety of uncommon causes (21%). Our patient had grade 3 ascites by International Ascites Club Grading system, cirrhotic liver with portal hypertension and high grade small bowel obstruction. All of those factors increased the pressure on the intestinal lymphatic system leading to CA. Paracentesis showing triglycerides above 200 mg/dl gives the diagnosis. Management consists of treating the underlying etiology. Pharmacologic treatment with Orlistat and octreotide were reported to be effective in CA. Transjugular intrahepatic portosystemic shunt and peritoneovenous shunting have been used in refractory cases. However, our patient had sepsis from spontaneous bacterial peritonitis with Child Pugh class C, and high grade small bowel obstruction which excluded him from the insertion of shunts. Repeated large-volume paracentesis is a reasonable option for patients who have end-stage disease not amenable to medical or surgical treatment. It is imperative to realize the critical condition in patients with CA as the one year mortality rate is high (69%) and appropriate studies should be done immediately to find and treat the underlying etiology.

2632 Balloon Dilation via Colonoscopy to Treat Small Bowel Obstruction as a Complication of Surgical Resection of Carcinoid Tumor

INTRODUCTION: Metastatic neuroendocrine neoplasms (NENs) are prevalent at initial prognosis. Surgery with the aim to cure is the current recommended guideline. However, there is not data in supporting therapy for complications from surgery. We successfully treated anastomotic stricture using endoscopic dilation, a modality recommended for treating of Crohn’s Disease stricture. CASE DESCRIPTION/METHODS: 69-year-old female with a history of HTN, hypothyroidism and metastatic Small Bowel Carcinoid Tumor s/p small bowel resection complicated by post-op ileus and now high grade small bowel obstruction (SBO). Initially diagnosed with carcinoid with imaging showing 2.2 × 1.4 cm nodularity in small bowel and mesenteric nodal involvement with elevated chromogranin and 5-HIAA. PET scan showed ileocolic mesenteric adenopathy with no hypermetabolic activity noted. Pathology from small bowel resection revealed high grade carcinoid tumor, for which octreotide therapy was initiated. Patient later developed a high grade SBO at the anastomotic site. She underwent colonoscopy and anastomotic stricture with severe stenosis of 3 mm was noted 10 cm from the ileocecal valve. A Visiglide wire was successfully passed through the stricture under fluoroscopic guidance. She was then serially dilated to 12 mm using a pyloric balloon dilator. Improvement in luminal narrowing was noted after dilation. Output from nasogastric tube began to decrease and her abdominal pain slowly improved. A few days later she began moving her bowels and nasogastric tube was removed. She was advanced from liquid to soft diet and was discharged in stable condition. DISCUSSION: Metastatic intestinal and pancreatic NENs represent 40–50% at initial diagnosis. Besides systemic therapies, current consensus guideline for metastatic NENs recommends for surgical resection with locoregional or ablative therapies. One complication of surgical resection is the development of anastomotic strictures. Strictures in the small bowel are commonly seen in Crohn's Disease. Literature has shown great success with endoscopic balloon dilation for the management of Crohn’s associated strictures. However, small bowel strictures as a complication of surgical resection of carcinoid tumors is not well documented. Our case illustrates how using an endoscopic technique known to manage Crohn’s complications can be novel to cases with similar pathophysiology but different etiology.

2681 Emphysematous Gastritis: A Rare Consequence of Small Bowel Obstruction

INTRODUCTION: Emphysematous gastritis is a rare form of gastritis that is characterized by presence of gas in the gastric wall and portal venous system. Prompt diagnosis along with early treatment is key in preventing fatal outcome. Etiology can be ingestion, infectious, mechanical, or ischemic with high mortality. We present a case of emphysematous gastritis in a patient with small bowel obstruction presenting with hematemesis. CASE DESCRIPTION/METHODS: A 70 year African American female with past medical history significant for HTN and Atrial Fibrillation (anticoagulated with Eliquis) presented with complaint of epigastric pain and hematemesis. CT abdomen/Pelvis without contrast showed acute high grade small bowel obstruction at the distal ileum, non-obstructing umbilical hernia and stomach distention with emphysematous gastritis with air in the portal venous system. Patient was hemodynamically stable. Laboratory findings with hemoglobin 13.0 g/dL (11.0-16.2 g/dL), mean corpuscular volume 76.7 fl (80.0—100.0 fl), platelet count 138 K/cmm(140-440L/cmm), white blood cell count 8.2 K/ccm (4.5-11.0 L/cmm) with 32% segmented neutrophils.Patient underwent exploratory laparotomy with release of small bowel obstruction and primary repair of umbilical hernia. Intraoperative Esophagogastrodudenoscopy (EGD) showed diffuse erythema and ulceration in the esophagus, areas of black/purple mucosal discoloration in the gastric cardia, fundus and body with clear demarcation of abnormal and normal tissue at body/antrum. Pylorus was patent with unremarkable first and second part of the duodenum. Findings were consistent with emphysematous gastritis. Patient tolerated the procedure well and was extubated without any hemodynamic decompensation. Broad spectrum antibiotics which were initiated were stopped as blood cultures x 2 had no growth. Patient was discharged from hospital on post op day four with Pantoprazole 40 mg twice daily and follow up endoscopy. DISCUSSION: Emphysematous gastritis is a condition with very high mortality rate of 50-80%. No standardized/definitive approach has been described in the literature though many cases do undergo prompt surgical exploration. Our case portrays a multidisciplinary approach to management of emphysematous gastritis with exploratory laparotomy for small bowel obstruction and intraoperative endoscopy without any need for resection or manipulation of effected area.

A246 High-Grade Small Bowel Obstruction Caused by Adjustable Gastric Band Tubing

There has been a sharp decline in laparoscopic adjustable gastric band (LAGB) placement, making up less than 3% of the US bariatric procedures in 2017. This decline is due to high rate of long-term failure, and myriad of complications including device malfunction, band slippage, esophageal and pouch dilation, and gastric erosion. We present a rare case of high-grade small bowel obstruction caused by gastric band tubing.

2409 A Rare Complication of Gastric Bypass in the Setting of Chronic Liver Disease

INTRODUCTION: Porto-mesenteric venous thrombosis (PMVT) is a known and potentially fatal complication of general surgery. However, it has been rarely reported as a complication of worsening liver disease after undergoing bariatric surgery. This is a case of a patient who presented with mesenteric thrombosis following Roux-en-y gastric bypass (RYGB). CASE DESCRIPTION/METHODS: Patient is a 42-year-old African American female with a history of RYGB who presented with episodes of post-operative abdominal pain for 5 years. She was found to have recurrent high-grade small bowel obstruction's (SBO) necessitating a small bowel resection. Her course was further complicated by intra-abdominal abscesses requiring computed tomography (CT)-guided drainage, and wound dehiscence requiring open surgical intervention and debridement. Four months after discharge, she presented with right-sided abdominal pain and acute encephalopathy. Liver enzymes were elevated. Abdominal ultrasound revealed portal vein thrombosis (PVT). Dual-phase CT of the abdomen revealed sub-acute to chronic complete diffuse mesenteric thrombosis with collateralizations involving the portal, splenic, and distal superior mesenteric veins. Given that previous imaging suggested steatosis and hepatomegaly, sub-acute liver injury secondary to thrombosis was established in the setting of chronic liver disease. The patient's underlying non-alcoholic fatty liver disease was likely worsened by severe malnutrition and short gut syndrome following the RYGB. Her hepatic encephalopathy resolved after initiating lactulose and rifaximin. Outpatient hematology evaluation for all causes of thrombophilia remained inconclusive and the patient had no recurrences of thrombosis. DISCUSSION: RYGB remains the gold standard for bariatric surgery as it results in the most durable weight loss. However, complications may occur such as gastrointestinal leak, fistulas, marginal ulcers, SBO, and dumping syndrome. Mechanisms of thrombosis formation in this setting could be related to intra-operative vascular manipulation, increased intra-abdominal pressure, venous stasis, and possibly deteriorating liver function secondary to rapid weight loss and malnutrition. PMVT hasn't been reported consistently as a complication in various bariatric surgery studies, which leads us to conclude that it's either under or mis-diagnosed. It is extremely important to consider PMVT as a complication of RYGB in patients who have evidence of underlying liver disease prior to undergoing RYGB.

Proximal small bowel obstruction in a patient with cystic fibrosis: a case report

BackgroundAs advancements are made in the management of cystic fibrosis (CF), survival of the CF patient into adulthood has increased, leading to the discovery of previously unknown CF complications. Though gastrointestinal complications of CF, such as distal intestinal obstruction syndrome, are common, this case demonstrates a variant presentation of small bowel obstruction in this population.Case presentationWe describe a 42-year-old male with CF who presented with 2 days of worsening upper abdominal pain, emesis, and loss of bowel function. The patient had no history of any prior abdominal surgeries; however, imaging was concerning for high-grade mechanical small bowel obstruction possibly related to internal hernia. Given leukocytosis and diffusely tender abdomen found on further workup, the decision was made to proceed with diagnostic laparoscopy after a brief period of intravenous fluid resuscitation. Intraoperatively, the transition point was found in the mid-jejunum and was noted to be due to kinking of the bowel causing vascular congestion in the proximal portion. Surgical manipulation of the bowel was required for return of normal perfusion and patency.ConclusionThough the exact mechanism cannot be definitively delineated, we speculate that the increased viscosity and prolonged intestinal transit time, characteristic of CF, resulted in inspissated fecal content in the proximal small bowel, which then acted as a lead point for obstruction. Thus, though small bowel obstruction in patients with CF is often attributed to distal intestinal obstruction syndrome, a broader differential must be considered. Early surgical intervention may be necessary to prevent bowel ischemia and subsequent small bowel resection in a patient presenting with concerning clinical and image findings, as was seen in this patient.