High-grade Small Bowel Obstruction Research Articles

Therapeutic Laparoscopy for High-Grade Intestinal Obstruction

Abstract Background: High-grade intestinal obstruction with massive abdominal distension is considered to be an absolute contraindication to laparoscopy. However, improvements in skill level and operator experience makes therapeutic laparoscopy in the above context possible.1–3 Aim: To present video material demonstrating the diagnostic and therapeutic value of laparoscopy, for nonadhesive, high-grade intestinal obstruction, in children. Methods: Two patients, a 4- and a 15-year-old, with no previous abdominal surgery, present with a 24-hour history of abdominal colic, bile-stained vomiting, and massive distension. Abdominal X-ray confirms high-grade distal small bowel obstruction. Emergency laparoscopy via an umbilical (10 mm) and 2 suprapubic ports (5 mm) established the cause of obstruction to be caused by a vitello-diverticular band and a constrictive Meckel's band with volvulus, respectively. A therapeutic division of the band and unravelling of the Meckel's instantly relieved the obstruction. Both d...

Management of High-Grade Small-Bowel Obstruction

Management of High-Grade Small-Bowel Obstruction

Management of High-Grade Small-Bowel Obstruction—Reply

Management of High-Grade Small-Bowel Obstruction—Reply

Medical Management of Malignant Bowel Obstruction: Case Discussions and Review of Literature (713)

1.Discuss three causes of malignant bowel obstruction.2.Recognize the role of medical management of malignant bowel obstruction.3.Review two cases of malignant bowel obstruction that were successfully managed averting the need for surgery. I. Background. Malignant bowel obstruction is one of the most serious complications of colorectal and ovarian cancers. It is often caused by the presence of peritoneal carcinomatosis, intraluminal obstruction, extramural obstruction, secondary to tumor infiltration of the mesenteric plexus or secondary to adverse effects of medications including opioids, anticholinergics, and chemotherapy. Its onset is insidious, extending over many weeks or months with the symptoms of nausea, vomiting, and constipation gradually worsening. II. Case Description. Patient 1 is a 53-year-old female with a history of advanced ovarian cancer who was admitted with nausea, vomiting, and constipation for four days. She reported small bowel movements for the past month with severe abdominal pain. Physical and radiologic examinations were consistent with a cachectic, dehydrated female with high grade small bowel obstruction secondary to peritoneal carcinomatosis. She was treated with a combination of reglan, corticosteroids, octreotide, scopolamine patch, and an aggressive bowel regimen. Her pain was well controlled with an opioid PCA. There was a dramatic response in 24 hours with decreased nasogastric secretions and several bowel movements enabling discharge 3 days after admission. Patient 2 is a 61-year-old with advanced pancreatic cancer who was admitted with severe abdominal pain, nausea and vomiting. Physical and radiologic evaluations were consistent with a high jejunoileal obstruction. She was treated with reglan, corticosteroids, octreotide, and a bowel regimen. The obstruction relieved after 4 days and the patient was able to be discharged home on the fifth day after admission. III. Conclusion. Management of malignant bowel obstruction is one of the most challenging aspects of advanced cancer care. We emphasize medical management in these patients with advanced malignancies as it shortens length of hospital stay and reduces morbidity associated with surgical procedures. The main goal is palliation of symptoms in order to improve a patient's quality of life.

Bilateral obturator hernia with intestinal obstruction: repair with a cigar roll technique

Obturator hernia is an exceedingly rare pelvic hernia that occurs primarily in multiparous, elderly thin (>70 years of age) females. Here, we report a case of bilateral obturator hernia in an elderly female with high-grade small bowel obstruction repaired with a novel "cigar roll" technique.

Nonoperative Management of Patients With a Diagnosis of High-grade Small Bowel Obstruction by Computed Tomography

To determine the natural history and treatment of high-grade small bowel obstruction (HGSBO). Small bowel obstruction is a frequent complication of abdominal surgery. Complete and strangulating obstructions are managed operatively while partial obstructions receive a trial of nonoperative therapy. The management and outcome of patients with HGSBO diagnosed by computed tomography (CT) has not been examined. Retrospective medical record review. Outcomes for nonoperative vs operative management were analyzed using Fisher exact and log-rank tests. Tertiary care referral center. One thousand five hundred sixty-eight consecutive patients admitted from the emergency department with a diagnosis of small bowel obstruction between 2000 and 2005 by CT criteria. Recurrence of symptoms and complications. One hundred forty-five patients (9%) with HGSBO were identified, with 88% follow-up (median, 332 days; range, 4-2067 days). Sixty-six (46%) were successfully managed nonoperatively while 79 (54%) required an operation. Length of stay and complications were significantly increased in the operative group (4.7 days vs 10.8 days and 3% vs 23%; P < .001). Nonoperative management was associated with a higher recurrence rate (24% vs 9%; P < .005) and shorter time to recurrence (39 days vs 105 days; P < .005) compared with operative intervention. Computed tomography signs of ischemia, admission laboratory results, and presence of cancer or inflammatory bowel disease were not predictive of an operation. Patients with HGSBO by CT can be managed safely with nonoperative therapy; however, they have a significantly higher rate of recurrence requiring readmission or operation within 5 years.

A Case of Strongyloidiasis Presenting as a High-Output Small Bowel Obstruction in a 22 Year-Old Female

Purpose: A previously healthy 22 year-old woman, a recent immigrant from Liberia, presented with a two week history of epigastric pain, abdominal distension, and intractable nausea and vomiting. Her physical exam was remarkable for a distended and diffusely tender abdomen. Laboratory results included a WBC of 29,400. Abdominal and chest x-rays were unremarkable. Serial CT scans done at the time of admission and 5 days later showed marked interval thickening of the entire small bowel. The patient deteriorated clinically, becoming hypotensive and hyponatremic, and was transferred to the ICU. A nasogastric tube was placed and was draining between 8-10 L/day of bilious fluid. Based on an initial clinical suspicion for an obstructing mass, an upper endoscopy was performed. The EGD showed no obstruction but revealed diffuse areas of gastric and duodenal edema with yellow-white plaques. Gastric and duodenal biopsies identified numerous larval forms of Strongyloides stercoralis. Stool studies confirmed these findings. Oral ivermectin therapy was initiated, however, the patient did not initially improve. After the addition of oral albendazole and the continuation of three weeks of therapy, the patient showed clinical improvement and eventual recovery. The presentation of Stronglyoidiasis mimicking high-grade small bowel obstruction has been infrequently described in case reports and literature reviews (1,2,3,4). In this case, the patient's bowel obstruction caused life-threatening fluid losses. Oral albendazole was added to oral ivermectin after the patient did not initially demonstrate clinical improvement. Ultimately, the patient's nasogastric tube had to be clamped for several hours each day in the hopes of improving absorption of the medications. Our case illustrates an unusual presentation of Strongyloides stercoralis causing, in effect, a high-grade small bowel obstruction with significant fluid losses. It took 3 weeks of daily double therapy with oral ivermectin and albendazole for complete recovery of our patient.

Post-traumatic Subserosal Small Bowel Herniation Leading to Obstruction in a Child with Acute Spinal Cord Injury.

The presentation of small bowel injury from lap belt use varies substantially, ranging from gross hemodynamic instability to insidious physiologic deterioration to simple failure of improvement. Rarely does small bowel injury manifest as an obstruction. This paper describes one such occurrence; in this case, herniation of intact mucosa/submucosa through a serosal tear caused a high-grade small bowel obstruction in a pediatric patient with an acute spinal cord injury and a virgin abdomen.

Intestinal Occlusion Caused by Meckelʼs Diverticulum with Ileoileal Intussusception in an Elderly Patient: A Rare Case Report

Purpose: We present a successfully treated case of small bowel obstruction secondary to Meckel's diverticulum with ileoileal intussusception. A 75 year old male with chronic constipation presented with confusion, vomiting and diarrhea. On admission he had hypotension, tachycardia and tachypnea. There were some rhonchi and few crackles in both lungs. His abdomen was diffusely distended, non-tender with normal bowel sounds. Investigations revealed WBC of 6300/mm3 (78% neutrophils), CK: 605 U/L (N: 22–269 U/L), arterial blood gas showed hypoxemia, blood urea nitrogen of 77 mg/dl (N: 7–18 mg/dl) and Creatinine of 3.9 mg/dl (0.5–1.2 mg/dl). Hepatic panel and serum electrolytes were normal. Chest radiograph showed bilateral infiltrates and abdominal CT revealed high grade distal partial small bowel obstruction. He was started on Piperacillin/tazobactam and Zithromax for sepsis secondary to aspiration pneumonia, fluid resuscitation and nasogastric suction for partial small bowel obstruction. His blood cultures and urine culture were negative. C. difficile toxin, mycoplasma and legionella were negative. Repeated abdominal CT showed high grade small bowel obstruction proximal to the middle ileum with moderate wall thickening. Laprotomy showed small bowel obstruction secondary to Meckel's diverticulum with ileoileal intussusception. A small bowel resection was performed and the patient recovered very well. Discussion: Meckel's diverticulum, the most common congenital anomaly of the gastrointestinal tract, occurs in 1–3% of the population. Majority of patients with Meckel's diverticulum are asymptomatic and only less than 5% of these patients have clinical presentations, such as intestinal obstruction, intussusceptions, inflammation and bleeding. Further, symptomatic Meckel's diverticulum is primarily found in pediatric age and virtually nonexistent in elderly. It is difficult to diagnose Meckel's diverticulum before operation. Meckel's diverticulum should be searched in the laparotomy due to acute abdomen and it can be the cause of serious abdominal complications. We considered our case interesting because of its rarity and of preoperative diagnosis difficulty.

Tuberculosis Enteritis Presenting as a Small Bowel Obstruction

c i T s c f o r g c w c E 25-year-old healthy Indian woman presented with feer, chills, night sweats, nausea, vomiting, abdominal istention, and severe abdominal pain for 2 days. She ad intermittent abdominal pain and 60-pound weight oss for the 6 months since her arrival from India. On xamination she was afebrile, tachycardic, and had a oft, distended abdomen with diffuse tenderness, reound, and guarding. A chest x-ray showed no abnoralities. CT scan of the abdomen showed high-grade bstruction (A) with the transition point at the ilealecal region and lymphadenopathy. There was an abnorally thickened cecum (B). The patient had leukocytois of 20,000 and 47% bandemia. Because her bdominal examination worsened, she was taken to the perating room to relieve the obstruction. Our differenial diagnosis was high-grade small bowel obstruction rom previous perforated appendicitis with abscess foration, a malignant lymphoma, or tuberculosis. At laprotomy, a phlegmous process involving part of the ce-

Falciform Ligament Hernia after Laparoscopic Cholecystectomy: A Rare Case and Review of the Literature

The occurrence of an internal hernia through a congenital or iatrogenic defect in the falciform ligament is extremely rare. In the era of minimally invasive surgery, we present an unusual case of small bowel obstruction after laparoscopic cholecystectomy. An 85-year-old white male presented to the emergency room 2 weeks after an uneventful cholecystectomy and complaining of a colicky, nonradiating right upper quadrant abdominal pain. Hydroxyiminodiacetic acid (HIDA) scan and endoscopic retrograde cholangiopancreatography (ERCP) performed revealed an open ductal system. Abdominal computed tomography (CT) scan was suggestive of a high-grade small bowel obstruction. Exploratory laparotomy revealed a herniated loop of distal ileum, passing from right to left through a defect in the falciform ligament created by the subxyphoid trochar. The surgeon should consider dividing the inferior leaf of the free edge of the falciform ligament, including the round ligament, should an aperture be created during laparoscopic port placement.

Frequency and Relevance of the “Small-Bowel Feces” Sign on CT in Patients with Small-Bowel Obstruction

We sought to determine the incidence of the "small-bowel feces" sign (SBFS) in patients with small-bowel obstruction (SBO) and whether it can be used to accurately locate the point of obstruction. From November 2002 until March 2003, 34 consecutive adult patients with CT findings of small-bowel obstruction were prospectively evaluated. The CT findings used to diagnose small-bowel obstruction were a dilated proximal small bowel and a collapsed distal small bowel and colon. CT scans were evaluated to determine the degree of obstruction (mild, moderate, or high-grade), the presence or absence of the SBFS (defined as particulate-type material in the dilated small bowel), the location of the SBFS in relation to the transition zone, and the cause of the obstruction. Mild obstruction was defined as a slight discrepancy between the caliber of the proximal and that of the distal small bowel; moderate SBO was defined as a discrepancy of 50% or more between the calibers of the proximal and the distal small bowel; and high-grade SBO was considered to be present if the distal small bowel and the colon had collapsed. The cause of the obstruction was determined from surgical findings or a combination of CT findings, follow-up barium studies, and clinical assessment. The SBFS was present in 19 (55.9%) of 34 patients with SBO. The degree of SBO was mild in six, moderate in 11, and high-grade in 17 of the patients. The SBFS was present in one of the six patients (16.6%) with mild, eight (72.7%) of the 11 with moderate, and 10 (58.8%) of the 17 with high-grade SBO. In all patients in whom the SBFS was present, the particulate material could be traced to the point of transition and was most conspicuous in the transition zone. The length of fecallike material ranged from 2 to 25 cm and was longer in moderate and high-grade SBO than in mild SBO. The cause of the SBO was an adhesion in 20 patients, a hernia in four patients, Crohn's disease in four patients, a tumor in three patients, and other miscellaneous causes in three patients. When present on CT, the SBFS can be used to help locate the transition zone in patients with SBO. The sign is present more frequently in patients with moderate and high degrees of SBO.

The relevance of free fluid between intestinal loops detected by sonography in the clinical assessment of small bowel obstruction in adults

Introduction: The main role of the radiologist in the management of patients with suspicion of small bowel obstruction is to help triage patients into those that need immediate surgical intervention from those that require medical therapy or delayed surgery. Ultrasound examination is usually considered not helpful in bowel obstruction because of air in the intestinal lumen that interferes the evaluation of the intestinal loops, however recently some Authors attested the increasing important role of sonography in the acute abdominal disease. Aim of our report is to demonstrate the value of free fluid detected by US in differentiating between low and high-grade small bowel obstruction. Materials and methods: The study is based on 742 consecutive patients who presented symptoms of the acute abdomen; all patients had undergone initial serial abdominal plain film and US examinations prior to any medical intervention. We reviewed the imaging findings of 150 cases in whom small bowel obstruction was clinically suspected and confirmed at surgery. We consider the following radiographic and US findings: dilatation of small bowel loops; bowel wall thickness; presence of air–fluid levels; thickness of valvulae conniventes; evidence of peristalsis; presence and echogenicity of extraluminal fluid. We looked at the value of extraluminal peritoneal fluid at US examination in differentiating low and high-grade small bowel obstruction based on the surgical outcome. Results: In 46 patients altered peristaltic activity, thin bowel walls, fluid filled loops with hyperechoic spots in the bowel segment proximal to obstruction were noted at US, whereas radiographic features were: moderate dilatation of small bowel loops, with thin bowel wall and evidence of numerous and subtle valvulae conniventes; presence of air–fluid levels was also noted. In 70 other patients, US examination revealed all the findings described in the precedent cases and also the presence of free extraluminal fluid; abdominal plain film showed an increased dilatation of small bowel loops with moderate thickened wall and air–fluid levels. In 34 other patients US examination revealed the presence of thick-walled loops, hypoperistalsis and a larger amount of free extraluminal fluid. Radiographic findings in these patients were: horizontal featured and markedly dilated small bowel loops presenting parietal thickness, presence of intraluminal fluid stasis and evidence of thickened, sparse and incomplete valvulae conniventes. At surgery etiology of small bowel obstructions was various, but most of cases related to adhesions (70 cases). The presence of extraluminal fluid were confirmed at surgery in 104 patients. Conclusions: Our experience using sonography in suspicion of SBO (small bowel obstruction) suggests the usefulness of this imaging modality to differentiate a functional or obstructive ileus, demonstrating the evidence of intestinal peristalsis. Furthermore, the presence of a large amount of fluid between dilated small bowel loops suggests worsening mechanical small bowel obstruction, that requires not a medical therapy but immediate surgery.

Helical CT in the diagnosis of small bowel obstruction.

With recent technologic developments, the role of computed tomography (CT) in the diagnosis of bowel obstruction has expanded. CT is recommended when clinical and initial radiographic findings remain indeterminate or strangulation is suspected. This modality clearly demonstrates pathologic processes involving the bowel wall as well as the mesentery, mesenteric vessels, and peritoneal cavity. CT should be performed with intravenous injection of contrast material, and use of thin sections is recommended to evaluate a particular region of interest. CT is reported to have a sensitivity of 78%-100% for the detection of complete or high-grade small bowel obstruction but may not allow accurate diagnosis in cases involving incomplete obstruction. In such cases, the use of adjunct enteroclysis is indicated. Furthermore, multiplanar reformatted imaging may help identify the site, level, and cause of obstruction when axial CT findings are indeterminate. CT can also demonstrate findings that indicate the presence of closed-loop obstruction or strangulation, both of which necessitate emergency exploratory laparotomy. Unfortunately, these pathologic conditions may be missed, and patients with suspected severe obstruction or bowel ischemia in whom CT and clinical findings are widely disparate must also undergo laparotomy. In general, however, CT allows appropriate and timely management of these emergency cases.

“Nonspecific abdominal gas pattern”: An interpretation whose time is gone

S everal reports have addressed the need for radiologists to be clear and pertinent in their interpretation or reporting of radiologic procedures (1-5). Imprecise or poorly understood reports can adversely affect the workup and management of patients. Plain abdominal radiography (PAP,) is one of the more frequently requested examinations in emergency medicine. In our experience, emergency physicians frequently utilize the term "nonspecific abdominal gas pattern" in their preliminary interpretations when, in fact, they mean that the bowel gas pattern is normal (6). A recent survey of community-based teaching hospital radiologists showed that 70% of the radiologists used this term (7); 65% of these radiologists considered this to be "normal or probably normal," 22% interpreted this as "cannot tell if normal or abnormal," and 13% defined this term as "abnormal but cannot tell if it is mechanical obstruction or adynamic ileus." O f the referring physicians in the same survey who received the report, 44% defined it as "normal," 51% defined it as "normal or abnormal," and 5% defined it as "abnormal, representing either mechanical obstruction or adynamic ileus." Some did not know what the term meant. It is obvious that the term has a wide range of meaning for both radiologists and referring clinicians. At one extreme, it appears to signify a normal condition; whereas, at the other extreme, it is perceived as a pathologic state such as obstruction. Few other radiologic interpretations have more consistent disagreement about their meaning both among radiologists and between radiologists and referring clinicians. Prior communications have called for the abandonment of the term "nonspecific abdominal gas pattern" (7, 8), and yet the term continues to be used. It is pertinent to consider why this is so. Is it because radiologists and emergency physicians do not read the literature, or is it because a "nonspecific" intestinal gas pattern really exists? My experience suggests that there is a group of patients whose abdominal radiographs do not fit the definition of "normal," "probable small bowel obstruction" and "definite small bowel obstruction" gas patterns. This is likely why there is difficulty in "ignoring" or abandoning this interpretation in the absence of an applicable alternative recommendation. How does one report this intestinal gas pattern, and what are its clinical implications? A recent report of a blinded analysis of plain radiographic abdominal examinations in the diagnosis of small bowel obstruction (SBO) by experienced gastrointestinal radiologists showed a sensitivity of 66% (9). This report differed from other studies in that the PAR patterns were defined, and a follow-up for every defined interpretive category was given. In this report, 62% of the patients clinically suspected of SBO were, in fact, not obstructed. O f "normal" plain radiographic interpretations, 21% had low-grade SBO. O f the so-called "abnormal but nonspecific" plain radiographic interpretations, 13% had lowgrade and 9% had high-grade SBO. The investigators defined the latter pattern as borderline or slightly dilated (2.5-3 cm) small bowel with more than two air fluid levels. O f the "probable" SBO plain radiographic interpretations, 37% had low-grade SBO and 16% had high-grade SBO. O f the "definite" SBO interpretations, 26% had lowgrade SBO and 23% had high-grade SBO; 13% had complete SBO. This report clearly showed that there is a pattern which is neither normal nor fits the categories of probably or definitely obstructed. Gammill and Nice (10) recognized this pattern to mean ileus (i.e., the small bowel is unable to push fluid along). Indeed, the word "ileus" means stasis and does not differentiate between mechanical and nonmechanical causes. Our acceptance of the term "ileus" to mean an adynamic etiology when, in fact, it simply means stasis that can result from any cause may be part of the problem. Plain radiographic examination has remained a mainstay in the evaluation of patients with suspected intestinal obstruction because of its ready availability, its relative cheapness, and its acceptable clinical record. It is the usual starting point in the radiologist's involvement in the workup of this group of patients. The interpretation "nonspecific abdominal gas pattern" should be avoided. I propose the term "mild small bowel stasis." If the term "nonspecific abdominal gas pattern" is used, it should be qualified as abnormal and should be followed by a specific recommendat ion for

Detection of intestinal ischemia in patients with acute small-bowel obstruction due to adhesions or hernia: efficacy of CT.

The purpose of this study was to determine whether CT can be used to diagnose ischemia of the small intestine in patients with small-bowel obstruction due to adhesions or hernia. During a 12-month period, 60 patients underwent surgery for complete or high-grade small-bowel obstruction due to adhesions or hernia, and 29 (48%) had evidence of associated intestinal ischemia. All of these patients had been preoperatively diagnosed by CT as having high-grade small-bowel obstruction. At the same time, a prospective determination was made based on the CT as to whether there was any associated intestinal ischemia. All CT scans were performed within 24 hours of the operation. A CT diagnosis of ischemia was based on the presence of two or more of the following signs: bowel-wall thickening, high attenuation of the bowel wall on unenhanced CT scans, mesenteric edema or fluid, asymmetric bowel-wall enhancement on i.v. contrast-enhanced CT scans, pneumatosis, or portal venous gas. Results of the CT examination and surgical findings were then compared. Further evaluation was done with a retrospective multivariate discriminant analysis. Ischemia was prospectively diagnosed on the basis of CT findings in 41 (68%) of the 60 patients. There were no false-negative CT diagnoses (sensitivity, 100%); however, there were 12 CT diagnoses that were false-positive (specificity, 61%). The multivariate analysis corroborated the prospective results by showing high sensitivity (90%) and diminished specificity (50-64%). Bowel-wall thickening and high attenuation of the bowel wall were the most important signs of ischemia on unenhanced CT scans, whereas abnormal bowel-wall enhancement and mesenteric fluid correlated best on enhanced CT examinations. CT is a sensitive but not completely specific preoperative indicator of intestinal ischemia in patients with small-bowel obstruction due to hernias or adhesions.

Obstruction of the small intestine: accuracy and role of CT in diagnosis.

The reliability of abdominal computed tomography (CT) in the assessment of varying degrees of small bowel obstruction (SBO) was evaluated by using results at enteroclysis and clinical outcome as standards of reference. A blinded retrospective analysis was performed of the studies of 55 patients who underwent both CT and enteroclysis in the course of assessment for suspected SBO. Nine patients had no obstruction, 40 patients had obstruction due to adhesions, and six patients had tumor-related obstruction. CT results were used to identify correctly 63% (29 of 46) of those who had SBO and 78% (seven of nine) of the patients who did not. The overall accuracy of the CT interpretations to help establish diagnosis was 65% (36 of 55). When obstructions were classified into low- and high-grade partial obstruction, CT results could be used to identify correctly 81% (17 of 21) of high-grade SBOs and 48% (12 of 25) of low-grade SBOs. The procedure yielded two false-positive and 13 false-negative results for patients with low-grade obstruction, revealed masses in all six cases with tumor-related obstruction, and helped predict the correct cause in all true-positive cases.