History Of Small Bowel Obstruction Research Articles

Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction.

Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5days of non-operative management. This study evaluated the factors associated with operative management. This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24h or death. At baseline (N = 360), mean age was 65.9years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1-2days. 55.6% had successful non-operative management at discharge (median length of stay 3days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06-4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21-0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89days: small bowel resection (55/160) was 4.9days (median = 4), compared to patients without resection (3.4days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07-1.35). A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3days.

S3211 Weight Loss, Ascites, and Diarrhea as the Presenting Symptoms for Pseudo-Pseudo Meigs Syndrome

Introduction: Pseudo-pseudo Meigs syndrome (PPMS) is a rare presentation of systemic lupus erythematous (SLE) characterized by ascites, pleural effusion, and elevated CA-125 level. Case Description/Methods: A 30-year-old woman with SLE and history of small bowel obstruction presented with diarrhea, weight loss, anasarca, and alopecia. She was initially tachycardic and hypertensive. Her exam revealed profound anasarca with ascites and bilateral pleural effusions. Labs were notable for Cr=5.65 mg/dL (baseline 0.7 mg/dL), spot protein/creatinine=3.9, ferritin=554.6 ng/ml, ESR=145 mm/Hr, CRP=6 mm/Hr, C3=49 mg/dL, C4=19 mg/dL, unremarkable FSH and LH, +ANA, dsDNA 356 U/ml, and +pANCA/MPO. Outpatient workup showed elevated CA-125 to 260.8 U/mL but ovarian malignancy was ruled out by MRI and CT abdomen/pelvis. Transvaginal ultrasound was normal. Inflammatory bowel disease was ruled out by EGD and colonoscopy during a previous hospitalization. Renal ultrasound showed bilateral hydronephrosis. The patient underwent a paracentesis (SAAG 1.3), and thoracentesis that showed total serum protein 4.2 g/dl, pleural fluid LDH 67 U/L, no serum LDH or pleural protein available. Kidney biopsy demonstrated class IV / V lupus nephritis. She was treated with a three-day course of pulse dose methylprednisolone followed by prednisone, hydroxychloroquine, and furosemide infusion. Her symptoms mostly resolved and CA-125 trended down to 27 U/mL. Discussion: PPMS is a rare condition with few cases reported in the literature. This case illustrates the challenges of evaluating abdominal symptoms and ascites in patients with SLE, and the importance of a kidney biopsy in the evaluation of nephrotic range proteinuria. Due to infrequency and concern for malignancy due to elevated CA-125 level, patients with this syndrome undergo extensive workup. CA-125 has been shown to be elevated due to inflammatory markers enhancing its expression in peritoneal mesothelial cells. Prior publications have shown the correlation of CA-125 with extent of serositis in PPMS. Additionally, our patient has many other clinical features reported in PPMS patients including elevated ferritin, alopecia, and positive pANCA. CT scan of abdomen and pelvis is essential in the workup of this syndrome to rule out ovarian malignancy. Moreover, imaging may exclude mesenteric vasculitis, an uncommon feature of SLE which can be seen as targetoid lesions of the bowel on CT scan. Steroids are the treatment for PPMS.

Transabdominal approach associated with increased long-term laparotomy complications after open abdominal aortic aneurysm repair

ObjectiveAlthough the transabdominal approach (TAA) and lateral approach (LA) to open abdominal aortic aneurysm repair (OAR) are both acceptable and widely used, a paucity of data evaluating subsequent postoperative laparotomy-associated complications (LCs) is available. The aim of the present study was to establish the incidence of LCs after OAR and determine which approach was associated with an increase in long-term LCs. MethodsAn institutional database for OAR (2010-2019) was queried, excluding urgent and emergent cases. The primary endpoint was long-term LCs, defined as any complication related to entry into the abdomen. The LA included retroperitoneal and thoracoabdominal approaches and the TAA included all patients with midline incisions. A Kaplan-Meier analysis was used to estimate the freedom from LCs, and the Fine-Gray method was used to determine the predictors of LCs, with death as a competing risk. ResultsA total of 241 patients (mean age, 70.0 ± 9.1 years; 71.7% men) had undergone OAR, 91 via a TAA and 150 via a LA. The patients in the TAA group were significantly younger (age, 66.7 ± 8.9 vs 72.1 ± 8.7 years; P < .001), more likely to be male (83.5% vs 64.7%; P = .002), and more likely to have a history of small bowel obstruction (SBO; 3.3% vs 0%; P = .025). Patients in the LA group were more likely to have required a supraceliac clamp (20.7% vs 1.1%; P < .001). No difference was found in the incidence of perioperative complications or long-term mortality. The most common LCs were hernia (TAA, 26.4%; LA, 11.3%; P = .003), SBO (TAA, 8.8%, LA, 1.3%; P = .005), and other (TAA, 13.2%; LA, 2.0%; P = .001), which included evisceration, bowel ischemia, splenic injuries requiring reintervention, enterocutaneous fistula, internal hernia, and retrograde ejaculation. Operative LCs were more common in the TAA group (17.6% vs 2.7%; P < .001). The unadjusted 1-, 3-, and 5-year freedom from LCs was 77.7% (95% confidence interval [CI], 66.0%-85.8%), 60.5% (95% CI, 46.5%-71.9%), and 54.0% (95% CI, 38.8%-67.0%) for TAA and 94.8% (95% CI, 88.8%-97.7%), 82.2% (95% CI, 72.2%-88.9%), and 79.1% (95% CI, 68.4%-86.5%) for LA, respectively (log-rank P < .001). The predictors for LCs were a history of SBO (P = .001), increasing body mass index (P = .005), and the use of the TAA (P < .001). ConclusionsUse of the TAA was an independent predictor of long-term LCs after OAR, along with an increasing body mass index and a history of SBO. In patients with amenable anatomy, the LA is favorable for preventing long-term LCs, especially in high-risk patients.

Laparotomy- and groin-associated complications are common after aortofemoral bypass and contribute to reintervention

BackgroundDespite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention. MethodsInstitutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications. ResultsThere were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P < .01) and aortounifemoral bypass (P < .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004). ConclusionsWhereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.

377 Developing a Nomogram to Enhance Point-of-Care Ultrasound Utility in Predicting Small Bowel Obstruction Diagnosis and Outcome

Predicting the diagnosis and a need for surgical intervention in patients with small bowel obstruction (SBO) can assist with emergency physicians’ decisions in selecting appropriate management strategy in the ED. We developed and validated a unique nomogram for the prediction of SBO diagnosis based on clinical features and point-of-care ultrasound (POCUS) findings. We used data from a prospective cohort of patients in a single-institution database that consisted of 125 patients with suspected SBO who underwent POCUS evaluation in the ED of a tertiary academic center. Patients’ demographic and clinical data were collected, including age, sex, history of SBO, comorbidities, prior abdominal surgery, and clinician’s pre-test probability of SBO was surveyed prior to POCUS or CT scan results. Data from this cohort were analyzed to develop a nomogram integrating age, sex, comorbidities, prior abdominal surgery, physician’s pre-test probability, and POCUS findings to determine post-test risk of SBO. The associations of relevant clinical and demographical variables and POCUS findings with SBO diagnosis were assessed using Cox proportional hazards regression models. The discriminative ability of the nomogram was tested using C statistics, calibration plots, and Kaplan-Meier curves. The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO, and (10% [12/125]) underwent a surgical intervention. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: dilated loop of small bowel of at least 2.5 cm (hazard ratio [HR], 0.10; 95% CI, 0.04-0.16; P < .001), positive inter-luminal fluid (HR, 2.10; 95% CI, 0.96-3.24; P < .001), clinician’s high pretest probability (HR, 2.42; 95% CI, 0.36-4.48; P=0.021), and patient age (HR, 0.03; 95% CI, -0.00 to 0.07; P = 0.08). The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C statistic of 0.89 for the SBO diagnosis. A unique nomogram was developed to utilize the function of patient age, POCUS findings of small bowel > 2.5 cm in diameter, inter-luminal fluid, and pretest probability before POCUS to accurately predict the diagnosis of SBO. The nomogram was able to stratify patients into prognostic groups and performed well on internal validation. The nomogram should be prospectively validated in a novel cohort of patients at risk for SBO.

2085 Suspected Crohn’s in Acute Salmonella Enterocolitis: A Journey of Differentiating Two Common Terminal Ileitis Etiologies

INTRODUCTION: Terminal ileitis signifies a generalized inflammatory process in the most distal portion of the small bowel, with an expansive range of underlying etiologies including Crohn’s disease and salmonella. Although stool cultures may reveal a salmonella infection, the diagnosis becomes more difficult if stool cultures are positive but patients do not respond to antibiotics. Treating such pathology with two potential underlying etiologies may lead to further complications, specifically, when administering corticosteroids and immunotherapy for an autoimmune disorder may conflict with active treatment against an acute infection. Our case presents a patient who had known salmonella positive stool cultures but inconsistent colonoscopy and pathology results. He ultimately improved with steroid and anti-TNF therapy. CASE DESCRIPTION/METHODS: A 29-year-old male with history of small bowel obstruction of unclear etiology five months prior, presented with acute on chronic diarrhea and abdominal pain. He denied any recent sick contacts, ingestion of raw or undercooked food, or personal or family history of inflammatory bowel disease (IBD). A CT scan identified terminal ileitis. Stool cultures returned positive for salmonella. Despite treatment with ciprofloxacin, patient’s symptoms persisted. Colonoscopy revealed diffuse inflammation and ulceration of the terminal ileum without stricture, with extension into the ascending and transverse colon. Preliminary biopsy revealed reduction in goblet cells. The patient was treated with solumedrol and subsequent infliximab due to the high suspicion of underlying IBD pathology after receiving a course of antibiotics. Though his hospital course was complicated by partial small bowel obstruction, his symptoms ultimately resolved. DISCUSSION: Terminal ileitis secondary to Crohn’s disease and salmonella may overlap in presentation which can complicate therapy. In this case, it is probable that there was a component of IBD superimposed with a bacterial infection, given the acute on chronic nature of his symptoms. In the case of superimposed infection, antibiotics should be initiated prior to prescribing immunosuppressive therapy that could allow further invasion. However, waiting to initiate immunosuppressants must be balanced with a patient’s worsening clinical picture and complications such as small bowel obstruction.

Utility of plain abdominal radiography in adult ED patients with suspected constipation

BackgroundAbdominal radiographs are often obtained in ED patients with suspected constipation, although their utility in adults is not well understood. We sought to compare ED management when an abdominal radiograph is and is not obtained. MethodsWe performed a retrospective chart review study of adult ED patients with a chief complaint of constipation from 2010 through 2016. Trained abstractors recorded radiologic tests ordered, treatments received, and final diagnosis. We determined the physician interpretation of the abdominal radiograph and its use in clinical decision making. ResultsOf 1142 eligible patients, 481 (42%) patients underwent abdominal radiography. Stool burden rated moderate or large was observed in 271 patients (46%). Sixteen patients (3%) were diagnosed with small bowel obstruction; 15/16 of these patients had high risk features such as old age, complex surgical history, history of small bowel obstruction, abdominal malignancy, or presented with vomiting or inability to pass flatus. Of the 197 patients with no or mild stool burden or normal radiograph, 109 (55%) were diagnosed with constipation and 89 (45%) received constipation treatment in the ED. Conversely, of the 271 patients with moderate or greater stool burden, 114 (42%) received no treatment for constipation in the ED and 104 (38%) were prescribed no discharge medications for constipation; 77 of these 271 patients (28%) were diagnosed with something other than constipation. ConclusionPlain abdominal radiography did not appear to significantly affect the ED management of patients presenting with constipation; it was common for patients to receive treatment that was in direct opposition to radiographic findings. Though a small number of patients had concerning diagnoses identified on plain radiography, the history and physical examination should have sufficiently excluded simple constipation, prompting an alternate diagnostic approach. Fecal loading on radiography does not preclude a more serious diagnosis. In conclusion, abdominal radiography appears to have low value in patients with constipation.

Point of Care Ultrasound Illustrating Small Bowel Obstruction

History of present illness: A 38-year-old female presented to the emergency department (ED) with abdominal pain, vomiting and constipation for one day. She had a history of hysterectomy and oophorectomy secondary to severe endometriosis three years prior to her visit. She also reported a history of small bowel obstruction (SBO) which was managed conservatively. Her vitals were unremarkable except for mild tachycardia. Point of Care Ultrasound (POCUS) was performed which showed severely dilated loops of bowel with concern for SBO. A CT scan was performed to confirm the diagnosis and identify the cause and the level of the obstruction. The patient’s CT scan confirmed the SBO and found a transition point near the terminal ilium. Significant findings: POCUS of the small bowel illustrated significantly dilated loops of bowel (white line), thickened bowel wall (white arrow) and to-and-fro peristalsis, consistent with small bowel obstruction. Discussion: Approximately two percent of patients who present to the ED with abdominal pain are diagnosed with SBO.1-2 POCUS has been shown to have a sensitivity of 92.4% and specificity of 96.6% for the diagnosis of SBO.3 The proper way to scan patients with suspected SBO is by using the curvilinear probe (3-5 MHz) across the entire abdomen. Pathologic findings include bowel dilatation (which can be measured from the inner wall to the inner wall of the small bowel) greater than 2.5cm. Other positive findings include to-and- fro peristalsis, mesenteric thickening and thickening of valvulae conniventes. Wall thickening greater than 3 mm and free fluid between bowel loops may suggest bowel ischemia.4 Despite the high diagnostic accuracy of the POCUS, it can be operator dependent and is limited by the ability to accurately identify a transition point. CT scan also has the advantage of determining the underlying cause and identifying the exact location of the obstruction.5 Given the findings and diagnosis, this patient was admitted to the surgical ward and managed conservatively. She improved the next day and diet was advanced. She was discharged home on hospital day 3 after resolution of her symptoms. Topics: Point of care ultrasound, small bowel obstruction.

Emergency department patients with small bowel obstruction: What is the anticipated clinical course?

Emergency physicians (EPs) often care for patients with acute small bowel obstruction. While some patients require exploratory laparotomy, others are managed successfully with supportive care. We aimed to determine features that predict the need for operative management in emergency department (ED) patients with small bowel obstruction (SBO). We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period. We evaluated demographic characters (prior SBO, prior abdominal surgery, active malignancy) and clinical findings (leukocytosis and lactic acid) to determine features associated with the need for urgent operative intervention. Patients with a prior SBO were less likely to undergo operative intervention [20.3% (42/207)] compared to those without a prior SBO [35.2% (57/162)]. Abnormal bloodwork was not associated with need for operative intervention. 68% of patients with CT scan findings of both an SBO and a hernia, however, were operatively managed. Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization. Abnormal bloodwork was not associated with operative intervention. The CT finding of a hernia, however, predicted the need for operative intervention, while other findings (ascites, duodenal thickening) did not. Further research would be helpful to construct a prediction rule, which could help community EPs determine which patients may benefit from expedited transfer for operative management, and which patients could be safely managed conservatively as an initial treatment strategy.

Reduced-Volume Oral Sulfate Split Colon-Cleansing Preparation Versus Conventional Preparation with PEG 3350: A Head to Head Comparison on Prep Quality and Patient Satisfaction

Introduction: One of the major barriers to optimal colorectal screening is good compliance with bowel preparation. Sub-optimal or poor bowel preparation results from an inability to complete the bowel prep. In this study, we compare reduced-volume oral sulfate split colon-cleansing preparation versus conventional preparation with PEG 3350. The intent is to provide a head to head comparison on prep quality and patient satisfaction. Methods: In this prospective trial, consecutive patients undergoing colonoscopy were divided in two arms. Group A received reduced volume oral sulfate split colon-cleansing preparation. Group B received conventional preparation with PEG 3350. Exclusion criteria were subjects with Inflammatory Bowel Disease, prior history of colonic resection, gastroparesis or prior history of small bowel obstruction. Bowel prep was graded segmentally using the Boston bowel preparation scale. Patient satisfaction was graded using a patient questionnaire. Results: Group A had 48 subjects compared to Group B with 67 subjects. Group A had 44% males and Group B had 39%. Average age was 61 years and 56 years in group A and B respectively. Race and age were matched in both groups. Group A had average excellent bowel prep rate of 83% in total score (83% in the right, 92%in transverse and left colon.) Group B had average excellent prep rate of 34% in total score (46% in the right, 40 %in transverse and 42 % in left colon). Group A had bowel prep experience rated as “easy” in 33%. Group B had bowel prep experience rated as “easy” in 19%. No side effects related to bowel prep were reported in 67% and 46% of study population in Group A and B respectively. Statistical analysis was not performed due to the small number of subjects in both arms. Conclusion: This study suggests improved bowel preparation rates and better patient satisfaction in reduced volume oral sulfate split colon-cleansing preparation compared to conventional preparation with PEG 3350. A follow up study to look at polyp detection rates in the two types of prep is planned.

An Unusual Case of Terminal Ileitis and Stricture that Mimicked Crohnʼs Disease

Purpose: Chronic inflammation in the terminal ileum (TI) suggests a cause for the patient's symptoms, especially when the clinical suspicion is Crohn's disease. Non-steroidal anti-inflammatory drugs, lymphoid hyperplasia, intestinal infections, lymphoma, infections and ulcerative colitis (UC) are some of the other causes of terminal ileitis. This is an unusual case of a 41-year-old multiparous female with past medical history of small bowel obstruction and colitis who presented with a 5-day history of crampy abdominal pain, nausea, vomiting, and diarrhea. On the CT scan of the abdomen she was found to have small bowel obstruction with segmental enteritis in close proximity to the terminal ileum. She was started on IV antibiotics and steroids, kept NPO and NG tube was placed to relieve the obstruction. Due to little improvement in the obstruction, she underwent exploratory laparotomy with resection of the narrowed small bowel segment with side to side anastomosis and appendectomy. Patient was started on temporary parenteral feeding, and continued on IV steroids for management of suspected inflammatory bowel disease. Strangely, the pathology results for the small bowel resection specimens showed presence of endometriosis in both the appendix and terminal small bowel segment without any evidence of inflammatory bowel disease. Her steroids were soon tapered off and with tolerance of oral feeds patient was discharged from the hospital with outpatient gynecology follow-up for management of endometriosis. Ileal endometriosis should be carefully considered in the differential diagnosis of Crohn's disease in menstruating females, especially the ones who are nulliparous and have dysmenorrhea, dyspareunia, dyschezia, menometrorrhagia, or other peri-menstrual symptoms. This case exemplifies the importance to not mistake endometriosis for Crohn's disease as they each have different therapeutic management.

Delayed Distal Small Bowel Obstruction from a Detached PEG Tube Bumper

Case: A 90-year-old woman with advanced dementia was initially admitted from a nursing facility after pulling out her PEG tube which had been placed two years prior. It was noted that as she pulled out the tube, the most distal part of the tube including the bumper had fragmented off and could not be retrieved. A replacement gastrostomy tube could not be placed at the bedside. The patient was unable to provide any additional history. Past medical and surgical history was significant for a history of small bowel obstruction requiring a small bowel resection and lysis of adhesions. She was also status post hysterectomy and cholecystectomy. On examination, she appeared comfortable. The abdomen was soft and nontender with good bowel sounds. Abdominal xray showed no obstruction. A new PEG was placed endoscopically; however, the old bumper was not seen during this exam. The patient was soon discharged back to her nursing facility. Eleven months later, she returned with several episodes of vomiting and abdominal discomfort. Vital signs were stable. The abdomen was mildly distended but soft with good bowel sounds. Labs were unremarkable except for a WBC of 12.8 with a mild neutrophilic predominance. CT imaging showed the old PEG bumper in the distal small bowel causing a partial small bowel obstruction. The patient went to surgery soon afterwards where the button was found distal to her small bowel anastomosis. The button was gently brought back to the anastomotic area where there was a redundant area of bowel. This section of bowel, now containing the button, was resected. Discussion: While inward migration of PEG tubes causing a proximal small bowel obstruction is relatively common and easily managed, our case highlights an unusual and late complication of PEG tubes where obstruction occurs because of migration of a detached PEG button to the distal small bowel. While literature suggests that most patients should be able to pass the button spontaneously, there have been several reports of the PEG button causing small bowel obstruction in patients who underwent PEG removal by the “cut and push” method in which the PEG tube is cut at skin level and the remnant pushed into the stomach, to be passed naturally by the patient. Perforation of the small bowel caused by the PEG remnant has also been described. Fortunately, PEG tubes are available today which can be easily removed at the bedside with external traction, eliminating the need for a “cut and push” approach. Our case highlights the importance of confirming the removal of all parts of a PEG tube to avoid unnecessary patient morbidity and that symptoms of obstruction caused by a lodged PEG button can be delayed for several months.

A Fatal Case of Adynamic Ileus Following Initiation of Clozapine

Back to table of contents Previous article Next article Communications and UpdatesFull AccessA Fatal Case of Adynamic Ileus Following Initiation of ClozapineSarah M. Fayad, M.D., and Dawn M. Bruijnzeel, M.D.Sarah M. FayadGainesville, Fla.Search for more papers by this author, M.D., and Dawn M. BruijnzeelGainesville, Fla.Search for more papers by this author, M.D.Published Online:1 May 2012https://doi.org/10.1176/appi.ajp.2012.11111625AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In patients with treatment-refractory schizophrenia, clozapine is considered the most effective anti-psychotic medication (1). However, it has side effects that can limit its usage (2). A seldom-encountered but significant side effect is adynamic ileus. We present here the case of a patient with schizophrenia who developed adynamic ileus within 9 days of initiation of clozapine.Case Report“Mr. B.,” a 65-year-old man with schizophrenia, was involuntarily admitted for psychotic exacerbation. On admission, he was taking 30 mg/day of olanzapine to abate symptoms of psychosis, aggression, and dangerous wandering. Despite intensive case management and adequate trials with haloperidol, risperidone, and olanzapine, he was refractory to treatment and required annual hospitalizations. Mr. B had not had a previous trial of clozapine. After obtaining informed consent, we initiated treatment with clozapine and increased the dosage by 12.5 mg/day, while olanzapine was gradually reduced with plans to discontinue. Docusate sodium, 100 mg b.i.d., was initiated prophylactically. He was not taking additional anticholinergic medications.Shortly after the initiation of clozapine, Mr. B complained of malaise and anorexia followed by nausea, vomiting, and diarrhea. Nine days after initiation of clozapine, which was now at a dosage of 100 mg/day and the olanzapine dosage at 10 mg/day, he became tachypneic and hypotensive. He was transferred to the intensive care unit, treated with pressors, and intubated.Mr. B's medical history included gastroesophageal reflux disease, a prostatetectomy for benign prostatic hyperplasia, and a remote history of small bowel obstruction that was managed conservatively, while olanzapine was continued for treatment of psychosis.While in the intensive care unit, a CT scan of the abdomen led to the diagnosis of adynamic ileus. A chest X-ray revealed an infiltrate suggestive of aspiration, and colonoscopy demonstrated diverticulosis without evidence of malignancy. Clozapine was discontinued, and olanzapine, which had been discontinued during evaluation in the intensive care unit, was restarted. The patient stabilized after 3 weeks and was returned to the psychiatric unit.Within 10 days, the patient again developed diarrhea, tachypnea, and tachycardia requiring medical stabilization. He died 3 days later. Although an autopsy was not performed, it was suspected that he died from complications of ileus.DiscussionAdynamic ileus is an infrequently encountered but serious complication of clozapine with a mortality rate approaching 28% (3). Anticholinergic effects are thought to be the cause (4). One study found that the median time from the first dose of clozapine to onset of ileus was greater than 1,500 days (4). In this case, the patient developed ileus within 9 days of initiation of clozapine and died 5 weeks later. He had no known risk factors for ileus such as malignancy or recent surgery; however, he was taking olanzapine, another highly anticholinergic medication, at the time of decompensation. It is possible that the combination of these two drugs, even for a brief duration for cross-tapering, contributed to this patient's rapid development of ileus and subsequent death. This case highlights the importance of carefully monitoring patients taking clozapine for potentially fatal gastrointestinal side effects, especially when treatment includes other anticholinergics, as this may result in serious consequences in a much shorter time frame than the literature has suggested (4).Gainesville, Fla.The authors report no financial relationships with commercial interests.Accepted for publication in February 2012.

Internal supravesical hernia as a rare cauase of intestinal obstruction: a case report

IntroductionSupravesical hernias develop at the supravesical fossa between the remnants of the urachus and the left or right umbilical artery. They are often the cause of intestinal obstruction. We describe the anatomical variant of the supravesical hernia in this case and discuss the pre-operative findings revealed by computed tomography. We discuss diagnostic and therapeutic procedures, and review other anatomical variants.Case presentationA 60-year-old Senegalese man was admitted with a two-day history of small bowel obstruction. A physical examination showed abdominal distension. An abdominal X-ray revealed dilated small bowel loops. A computed tomography scan showed an image at the left iliac fossa that suggested an intussusception. A median laparotomy showed a left lateral internal supravesical hernia. The hernia was reduced and the defect was closed. The patient recovered uneventfully.ConclusionsSupravesical hernia is a possible cause of intestinal obstruction and diagnosis is very often made intraoperatively. Morphological examinations, such as computed tomography scanning, can lead to a preoperative diagnosis. Laparoscopy may be useful for diagnosis and therapy.

What is the Rate of Small Bowel Obstruction after Colectomy?

The rate of small bowel obstruction (SBO) after colectomy is unknown. Given the large number of colectomies performed in the United States, elucidating SBO rates, outcomes, and identifying predictors of readmission is important. Using the California Inpatient File, we identified all patients readmitted with a principle diagnosis of SBO at least once in the 3 years after colectomy (n = 4555). Patients admitted with a diagnosis of SBO in the 3 years before surgery were excluded. Overall, 10 per cent of patients were readmitted for SBO at least once after colectomy. Approximately 58 per cent were readmitted in the first year and 22 per cent of these patients required surgery. The most common operation performed was lysis of adhesions. Median length of stay was twice as long in the surgery group versus the no surgery group (12 vs 6 days). Overall mortality was higher in the nonsurgery group compared with the surgery group (33% vs 21%, P < 0.001) and highest in the elderly (44% vs 30%, P < 0.001). One in 10 patients without a history of SBO who undergoes a colectomy will be readmitted at least once in the subsequent 3 years for SBO, and there is a high mortality rate in this group, especially in the elderly.

Findings of Endometriosis by Capsule Endoscopy

Purpose: A 17 year old female was seen in consultation for multiple episodes of intermittent small bowel obstruction. Methods: Each time the patient improved with conservative management. Upper and lower endoscopies were non diagnostic. A small bowel follow through x-ray was reported as normal. There was no evidence of inflammatory bowel disease. The patient then underwent a capsule endoscopy. The capsule study revealed a mass lesion in the distal ileum. The overlying mucosa appeard normal. Some of the images suggest a central depression. There was no ulceration or bleeding. The capsule was retained at the site for approximately 45 minutes and then spontaneously passed. The patient was subsequently referred for exploratory laparotomy. She underwent a partial ileal resection to remove the mass. Histopathology revealed small bowel endometriosis. Results: Endometriosis is a relatively common condition characterized by implantation and proliferation of endometrial glands outside the uterus affecting 8% to 15% of women. Intestinal involvement is relatively common. It is reported in 12% to 37% of individuals with the disease. Of these cases, only 7% involve the small bowel. Most small bowel cases involve the distal ileum. Conclusion: To our knowledge there are no reports of finding of endometriosis by capsule endoscopy. Search was made on PubMed and the capsuleendoscopy.org atlas websites. Our case represents an advance case where the lesion appeared as a mass leading to intermittent small bowel obstruction. Since small bowel endometriosis is relatively rare, more subtle findings will be documented as more cases are diagnosed. We suspect that many cases of ileal endometriosis may not yield any luminal findings by capsule endoscopy. One must have a high index of suspicion in the subgroup of patients that this disorder afflicts. A normal small bowel capsule endoscopy does not rule out endometriosis of the small bowel. We don't belive that possible small bowel endometriosis is an indication to perform capsule endoscopy. History of small bowel obstruction should not preculde capsule endoscopy. Many times it may lead to a definitive diagnosis.Figure: Ileal mass-endometriosis.