Ileocaecal Junction Research Articles

Non-Hodgkin’s lymphoma as a cause of intussusception: a case report

Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment. This condition is frequent in children and presents with the classic triad of cramping abdominal pain, bloody diarrhea and a palpable tender mass. Secondary intussusception is caused by organic lesions, such as Meckel’s diverticulum, benign and malignant lesions, metastatic neoplasms or sometimes iatrogenically. Surgery is the definitive treatment of secondary intussusception. Formal bowel resection with oncological principles is followed for every case where a malignancy is suspected. A ten-year-old female presented to the casualty with severe pain in abdomen associated with 1 episode of blood in stools diagnosed with intussusception. She was taken for emergency laparotomy, and no lead point was identified. She presented with recurrent intussusception and was taken for re-exploration, when a definitive approach was opted for, and she underwent a resection of the obstructed bowel at the ileo-caecal junction and an ileo-ascending anastomosis. On histopathology, the ileo-caecal junction showed a proliferative, circumferential mass which was confirmed to be a diffuse large B cell lymphoma. It is uncommon for pediatric intussusception to result from a neoplasm. It takes imaging modalities to make the diagnosis. Surgical intervention is required as soon as a suspicion is raised in order to avoid consequences such gut necrosis and ischemia.

Mucinous carcinoma of the appendix: a case report

Mucinous carcinoma of the appendix is ​​​​a rare malignant tumor of the appendix. Incidence ranges about 0.01-0.2% in cases of malignancy in the gastrointestinal tract. Clinically, the symptoms appear to resemble acute appendicitis. The diagnosis was established at intraoperative time. Studies on this case are still few. A 69-year-old man complained of lower right abdominal pain since 6 days before going to Sanjiwani hospital. The patient also complained of fever, nausea, decreased appetite and constipation. Examination results temperature 37.6 0C, McBurney sign (+), rebound tenderness (+), localized defense on lower right abdomen. Ultrasound examination of the abdomen with an impression of the end tubular structure, a peristaltic diameter of 0.87 cm accompanied by a fluid collection, suspicious of appendicitis with perforation. Inflamed appendix and localized mucin were found at ileocaecal junction intraoperatively. The patient underwent a right hemicolectomy. Histopathological examination revealed a morphological picture suitable for mucinous carcinoma of the appendix. Mucinous carcinoma of the appendix is ​​​​a rare malignant tumor of appendix. Patients can have the same symptoms as appendicitis. Ultrasound investigations can find a picture like appendicitis. Mucinous carcinoma of the appendix is ​​more frequently found intraoperatively. Histopathological examination is necessary to determine a definitive diagnosis of mucinous carcinoma of the appendix. In high grade appendiceal mucinous neoplasm (HAMN) a right hemicolectomy can be performed and continued with adjuvant chemotherapy.

Developmental morpho-analysis of the caecum in Japanese quail embryos (Coturnix coturnix japonica).

In the current study, we are focusing on the microanatomical structure of quail caecum during the prehatching time to try to understand the function and the role of each cell-built quail caecum reaching how caecum plays an essential role in immunity and absorption. The morpho-developmental features of the quail caecum were described in detail daily from the third incubation day (ID) till hatching time, investigating the gross morphology, microscopic, and ultrastructure using light and scanning electron microscope. The embryonic caecum appeared grossly as two lateral outpocketings with blinded ends, emerging laterally at the junction between the small and large intestine (the ileocaecal junction). The primordia of two caeca, represented by two lateral swellings from the hindgut on the fourth ID, continued growing till the day of hatching, where the caecal wall consisted of three apparent layers: mucosa, musculosa, and serosa. At the time of hatching, the quail caecum was still not fully mature and will continue growing posthatching. The findings in this study can be applied in further studies intended to understand the physiological mechanisms of the caecum during prehatching and posthatching periods. RESEARCH HIGHLIGHTS: Caecum is one of the hindgut derivatives that started as two lateral swellings. The caecal wall consisted of three layers; mucosa, musculosa, and serosa. The caecum plays an essential role in immunity maintenance. Caecum continues to grow posthatching as it is not fully mature at hatching time.

EXAGGERATED CAECUM WITH ABERRANT APPENDIX- A CASE REPORT

Introduction: Depending on shape, four types of caecum are known out of which exaggerated caecum is of rare type. In this type the right saccule of caecum overgrows and left saccule is atrophied. In normal anatomy the appendicular orifice is situated about 2.5 cm below and behind the ileocaecal Orifice. Methodology: The right iliac fossa was dissected to note for the position of Appendix with respect to iliocaecal junction in a formalin fixed cadaver. Result: An exaggerated caecum with aberrant appendix was found, with the base of appendix above the ileocaecal junction, a large right sacculation and an absent left sacculation of the Caecum was also observed. Conclusion: An exaggerated caecum in itself is uncommon but along with the positional variation in the base of appendix it becomes a rare finding. The knowledge about this variation will be useful to surgeons while operating in this region.

Strangulation of the caecum by a pedunculated lipoma in a Rocky Mountain Horse gelding

SummaryA 19‐year‐old Rocky Mountain Horse gelding was presented for emergency evaluation of colic. A pedunculated lipoma was found to be strangulating the caecum and ileocaecal junction at surgery. Following the resolution of the incarceration, it was found that the pedicle originated on the jejunal mesentery, but the stalk did not appear long enough to have formed a half‐hitch around both the caecum and ileum. The horse was euthanised due to complete caecal devitalisation. A second pedunculated lipoma was identified at necropsy, located on the transverse colon with an area of ischaemia on the mesenteric pedicle (the abnormal stalk of tissue connecting the lipoma to the colonic mesentery), consistent with pressure from being entwined with the jejunal mesenteric pedicle. This report is the first to describe caecal and ileal incarceration and strangulation by a pedunculated lipoma in a horse.

First Report of Resection and Anastomosis in a Strangulated Hernia in Reda Bolo Regional General Hospital Southwest Sumba: A Case Report

Background: Hernia is a protrusion or abnormal opening on the abdominal wall fascia due to anatomical weakening. Several cases may progress into a strangulated case leading to necrosis, which requires immediate diagnosis and intervention to prevent complications. Case presentation: A 62-year-old woman presented with abdominal pain in all areas and decreased appetite. The patient also complained of not defecating for the last two days. Physical examinations showed abdominal distention and diminished bowel sounds. Abdominal radiographs showed features of intestinal obstruction. The patient then underwent exploratory laparotomy, which showed strangulated hernia and necrotic ileum. Intestinal resection followed by end-to-side anastomosis was conducted and the patient was strictly monitored postoperatively. No complication and/or significant findings during the postoperative period. Discussion: Resection and anastomosis in strangulated hernia are interventions conducted following the finding of necrotic ileum for 10 cm with ileocaecal junction coils. Conclusion: This case is considered a rare case in Southwest Sumba. The patient was treated with limited facilities but had a remarkable outcome.

The appendix conduit with a conflict of interests – An alternate strategy

Conventionally the split appendix has been used to address the need for dual conduits such as the Mitrofanoff and the ACE, however limited by its length. We present a video demonstration of an alternate solution. Size-12 Nelaton catheter introduced via appendicular stump and skirted along the lateral wall of the caecum. Ethicon Endopath 35mm Linear Stapler was used to create a caecal tube of about 3cm based on the appendicular stump. From September 2019-January 2023, 6-patients, aged 5-18 years with a diagnoses of 4-spinal dysraphisms, 1-cloacal anomaly, and 1-urogenital sinus were included. 5-45 months. Two patients had ACE site infection which resolved with antibiotics. One developed a stomal granuloma treated effectively with silver nitrate. All are clean with no stomal leaks and experience easy intubation. Alternatives to the split appendix include the Monti ACE, and Caecostomy tube/caecal flap when limited by appendicular length. The technique described is easy and quick however care must be taken to keep away from the ileo-caecal junction and to keep the tube length as short as possible or needed to preserve vascularity. The stapled caecal tube ACE is easy, quick, and safe especially when limited by appendicular length.

Assessment of CT perfusion indices of the clinicoradiological response to anti-tubercular therapy in patients with intestinal tuberculosis

To explore the possibility of using a novel technique, CT perfusion imaging, to monitor the response to anti-tubercular therapy (ATT) in patients with intestinal tuberculosis. A prospective observational study was performed in adults with treatment naive-intestinal tuberculosis. Clinical, endoscopic, and conventional radiological findings of patients were compared at baseline and post-ATT. CT perfusion imaging was performed with recording of six perfusion parameters (blood flow, blood volume, mean transit time, time to peak, maximum peak intensity, and permeability/blood flow extraction). Twenty-two patients (13 women, 59%) with a median age of 25 years were recruited. The terminal ileum and ileocaecal junction were the most frequent sites of involvement (59%), with multiple segments of the intestine being involved in 16 patients (73%). Median duration of ATT was 6 months (range 6-10 months). Complete clinical response was observed in 22/22 (100%) patients, endoscopic response in 12/12 (100%) patients, and radiological response in 10/13 (76%) patients. There was a significant decrease in mean blood flow, blood volume, maximum peak intensity, and an increase in mean transit time and time to peak on follow-up CT perfusion imaging performed after 6 months of ATT. Significant alterations in CT perfusion parameters were demonstrated following treatment, consistent with a decline in inflammation and vascularity. CT perfusion imaging of the bowel is a novel means to assess the radiological response to ATT in intestinal tuberculosis, although at the cost of a higher dose of radiation exposure.

Submucosal Lipoma in a 72 Year Old Lady Causing Obstruction: A Case Report

Lipomas of the large intestine are less frequently encountered with a frequency ranging from 0.2 to 4.4 %. Lipomas of the gastrointestinal tract are rare conditions first described by Baurer in 17571. We here describe a case of a 72-year-old female with complaints of colicky right abdominal pain for a 1-month duration. Contrast enhance CT imaging revealed a non- uniform wall thickness with irregular narrowing of lumen of intestine. She underwent right hemicolectomy in view of obstruction. Gross examination revealed a large polypoidal mass arising from the mucosa at the ileocaecal junction. Histopathological examination revealed it to be a submucosal lipoma.

P279 Ileo-caecal stenosis in Crohn's disease: correlation between imaging, biology and endoscopy : preliminary results of a prospective study

Abstract Background Stenosis is the most common complication of Crohn's disease (CD). Imaging of the ileo-caecal junction is mainly based on endoscopy, ultrasound, CT-enteroclysis or entero-MRI. The aim was to evaluate the performance of digestive ultrasound in the monitoring of Crohn's disease.The purpose of this work is to show the performance of digestive ultrasound and fecal calprotectin in the monitoring of CD. We compared the results of digestive ultrasound, enteroscan or enteroIRM with endoscopy and biology Methods This is a prospective study including 42 patients, spanning between July 2021 and July 2022. Clinical, biological, radiological and endoscopic data were studied. Khi-2 test was used with a value of p<0.05 which was considered statistically significant. Results We included 42 patients in our study, divided into 18 men 24 women (sex ratio M/F is 0.75), mean age was 43.2 years, with a CD of L1 or L3 location, according to the Montreal classification were prospectively included. The main risk factor found was smoking in 61.9% of patients. The majority of patients (80.95%, n = 34) had koenig syndrome. All patients underwent digestive ultrasound, CT-enteroclysis and colonoscopy with an average delay of 15 days between the examinations. Digestive ultrasound showed intestinal thickening in 85.71% (n=36), of the small intestines in 57.14% of patients and localized at the terminal ileum (21.42%). Loss of stratification was found in 40.47% of patients, ileo-caecal stenosis in 57.14%, a directed fistula in 23.80% of patients, a deep collection in 28.57% (n=10). The CT-enteroclysis showed stenosing thickening of the ileo-caecal junction in 66.67% (n=28), a deep collection in 38.09%, a combed aspect of the mesentery in 33.33% and intestinal thickening associated with a fistulous path in 35.71%. Colonoscopy was performed with catheterisation of the last ileal loop in the majority of patients (73.80%, n=31). It showed ulcerations in 88.09% (70.5% deep and 17.6% superficial) and a stenosis that could not be crossed by the colonoscope in 40.47% (n=17). The mean level of faecal calprotectin was 532.5 with a standard deviation of 265.1 reflecting moderate to severe disease activity. There was a correlation between ultrasound and endoscopy in 71.4% of cases (n=30). There was significant correlation between endoscopic and ultrasound inflammatory activity (p=0.01) and between the location of intestinal thickening and ulcerations on endoscopy (p=0.01). Conclusion Ultrasound is non-radiating, reproducible and available, coupled with fecal calprotectin constitutes an accessible and easy monitoring tool. Our preliminary results are satisfactory and the study is still in progress to confirm the interest of ultrasound in the follow-up of patients with CD.

AN INTERESTING CASE OF MECKELS DIVERTICULUM CAUSING INTESTINAL OBSTRUCTION

Meckels diverticulum is a persistent remnant of the vitellointestinal duct, and is one the most commonly diagnosed congenital surgical conditions. It occurs in 2% of the population, is usually two inches long, two feet proximal from the ileocaecal junction and in approximately 20% cases it is seen to contain heterotropic epithelium. Its most common clinical presentations are usually in the form of haemorrhage, diverticulitis and rarely may complicate causing intestinal obstruction. We hereby present one such case of intestinal obstruction in a young adult male, secondary to small bowel volvulus around a vitellointestinal band extending from a meckels diverticulum to the anterior abdominal wall. The presentation and management of this case, which had presented to the Emergency Department of our hospital, is elaborated in detail.

Histomorphological, immunohistochemical, and ultrastructural study on ontogeny of ileocaecal lymphoglandular complexes in prenatal and postnatal Indian buffalo: An innate mucosal immune barrier.

The present study was conducted on prenatal and postnatal development of lymphoglandular complexes (LGCs) in ileocaecal region of buffalo fetuses (n=15) ranging from 11.5cm curved crown rump length (CVRL) (80 days) to 100 cm CVRL (299 days) and neonatal buffalo calves (n=10). The fetuses were categorized into three groups based on their CVRL. LGC formation was not evident in ileocaecal junction up to 32 cm CVRL (145 days). At 35 cm CVRL (152 days), diffuse lymphocytes were scattered around the base of glands that encircled them. At 54 cm CVRL (195 days), lymphoid aggregates were present in submucosa around deep submucosal glands and formed primordia of LGCs in ileocaeccal orifice region. At 100 cm CVRL (299 days), these complexes were completely visible grossly. The distinguished lymphoid nodules in submucosa were invaded by submucosal extensions of overlying mucosal glands to form a large clear complex of glands and lymphoid nodules called as "Lymphoglandular complex" at this stage. It is the first report of prenatal development of LGCs in large intestine of buffaloes. Abundant CD3+ T cells were observed towards periphery of LGC. In neonates, these complexes were uniform, few with demarcation into dark and light zones that is, germinal center formation. Lymphocytes interspersed in lamina propria were mainly CD3+ T lymphocytes. In conclusion, the development of LGCs in ileocaecal region started prenatally in terms of all its cellular components into completely developed and immunocompetent to generate mucosal immunity.

A Fortunate Twist

Question: A 37-year-old Chinese woman was presented with a 1-day history of colicky central abdominal pain associated with 5 episodes of vomiting and diarrhea. It was the third day of her menstrual cycle. On examination, the abdomen had generalized distension without tenderness. There were no significant constitutional symptoms or family history of bowel malignancy, or personal history of inflammatory bowel disease. Her past medical and surgical history reveals a previous large left endometriotic cyst of 14 cm in 2010 for which she underwent a laparoscopic cystectomy, as well as primary subfertility for which she was undergoing her third cycle of in vitro fertilization (IVF) at the time of presentation. Initial blood investigations revealed elevated white cell count of 17,500/mm3, a normal hemoglobin of 15.4 g/dL, and borderline raised C-reactive protein of 36.2 mg/dL. Computed tomography scan of the abdomen and pelvis revealed small bowel obstruction with transition points at the terminal/distal ileum where enhancing intramural lesions has resulted in luminal narrowing and bulging at the ileocaecal junction (Figure A). There were also several small lesions indeterminate for peritoneal nodules. The patient was offered diagnostic laparoscopy with potential for laparotomy and bowel resection to relieve the obstruction. What do you think the final diagnosis was? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. During diagnostic laparoscopy, hemorrhagic ascites was noted, which was sent for cytology. A decision was made to convert to a laparotomy in view of limited workspace due to the grossly dilated bowel loops. Intraoperative findings were significant for 2 lesions – 1 in the terminal ileum and the other in the ileocaecal valve (Figures B and C), causing small bowel obstruction. Three peritoneal nodules were noted, biopsied, and sent for histology (Figure D). A limited right hemicolectomy was performed to remove the lesions causing obstruction. The patient made a full recovery 6 days after surgery and was discharged well. Histology reports for both the peritoneal nodules and the right hemicolectomy specimen were consistent with endometriosis. Endometriosis is a common gynecologic condition where endometrium, which usually lines the uterine cavity, is found in other areas of the body. When endometrial tissue starts to grow in the ovaries or fallopian tubes, this may result in blockages in the fallopian tubes, which may form scar tissue and reduce the fertility of a woman. Such patients can be offered IVF. However, there is a potential risk of worsening endometriosis due to ovarian hyperstimulation syndrome.1Seyer-Hansen M. Egekvist A. Forman A. et al.Risk of bowel obstruction during IVF treatment of patients with deep infiltrating endometriosis.Acta Obstet Gynecol Scand. 2018; 97: 47-52Crossref PubMed Scopus (17) Google Scholar Although uncommon, gastrointestinal tract involvement by endometriosis can occur with 90% of lesions localized to the terminal ileum, sigmoid colon, or rectum. However, acute bowel obstruction as a complication of bowel endometriosis is rare and only accounts for <1% of most presentations.2De Ceglie A. Bilardi C. Blanchi S. et al.Acute small bowel obstruction caused by endometriosis: a case report and review of the literature.World J Gastroenterol. 2008; 14: 3430-3434Crossref PubMed Scopus (79) Google Scholar In this case vignette, the initial top differential was that of a neoplastic lesion with peritoneal metastases. In retrospect, endometriosis involving the gastrointestinal tract should have been considered as a differential diagnosis. The patient had a known history of endometriosis with history of colicky abdominal pain during menstruation that could well be related to intermittent subacute bowel obstruction caused by bowel endometriosis. The patient was also undergoing IVF, which could lead to ovarian hyperstimulation syndrome and increase symptoms related to endometriosis. Other rare manifestations of symptomatic endometriosis during IVF treatment include that of thoracic endometriosis as well as urogenital endometriosis, which can cause ureteral obstruction.3Ponticelli C. Graziani G. Montanari E. Ureteral endometriosis: a rare and underdiagnosed cause of kidney dysfunction.Nephron Clin Practice. 2010; 114: c89-c94Crossref PubMed Scopus (0) Google Scholar

Targeted colonic release formulations of mesalazine – A clinical pharmaco-scintigraphic proof-of-concept study in healthy subjects and patients with mildly active ulcerative colitis

Colonic targeting of orally applied therapeutic drugs remains a challenge. Tablet coatings relying on gastrointestinal pH and colonic bacterial enzymes as triggers in association with an inner alkaline layer are expected to improve targeting efficiency. Mesalazine release from three differently coated tablets labelled with 1 MBq 153Sm was characterised in a single centre, open-label, parallel group study in nineteen healthy subjects and seven patients with mildly active ulcerative colitis. Two semi-organic and one aqueous-based outer coating with different ratios of enteric polymer and resistant starch were tested. All coatings showed comparable release lagtimes in biorelevant dissolution media and were not affected by neutron-activation of the samarium tracer. Mesalazine pharmacokinetics and gamma scintigraphy were used to characterise drug release, anatomical site of tablet disintegration and gastrointestinal transit. Initial tablet disintegration occurred at the ileo-caecal junction or beyond in 92 % of the subjects. Time to initial tablet disintegration was inversely correlated with maximal plasma concentrations and systemic mesalazine exposure. Although high inter-subject variability precluded detection of differences between solvent types and different enteric polymer to polysaccharide ratios, the dual pH and enzymatic triggered release system in combination with an inner alkaline layer promoted mesalazine release at the target site with high accuracy.

Anatomical deviations in the position of vermiform appendix: the cadaveric study

Vermiform appendix is the only organ in the body that has no constant anatomical position. It is so named because of its worm like appearance. Most common surgical cause of abdominal pain is appendicitis; its diagnosis is affected by anatomical variations of the vermiform appendix, because this is the most variable abdominal organ in terms of position and organ relations. Aim of the study was to examine anatomical features and different positions of the vermiform appendix in human cadavers. Material and methods. This study was carried on 45 human cadavers irrespective of sex and age from the Department of Anatomy at Andhra Pradesh over a period of 12 months. Results. Mean length of appendix was found to be 3.98 ± 1.27 cm. Mean outer girth was 2.17 ± 0.26 cm. Mean distance of vermiform appendix from ileocaecal junction was found to be 2.11 ± 0.43 cm. Commonest position was retrocaecal (44 %), followed by pelvic (21 %), postileal (9 %), subcaecal (13 %) and midinguinal (10 %). Conclusions. Variations in position of vermiform appendix will help the surgeons to make a diagnosis of appendicitis and aware about appendiceal rupture.

The spectrum of sonographic findings in enteric fever cases of paediatrics age group in Gurugram region of Haryana, India

There is always need for the earliest diagnosis of enteric fever to start the appropriate treatment for this life threatening illness. The diagnosis becomes difficult because of inherent limitation due to the long standing vague complaints. Some findings like acalculus cholecystitis, hepato-splenomegaly, enlarged mesenteric lymph nodes (MLN) and free fluid can easily be picked up by ultrasonography (USG). USG is easily available, without any ionizing radiation, non-invasive and economical. Hemoculture and Widal tests are time consuming and the cost is quite high. The study was conducted with 100 paediatric patients aged 1-year to 15-year. All were having enteric fever based on typhi dot-IgM presented to the paediatric department of the hospital. USG was conducted for the evaluation of the various relevant findings. Blood samples for CBC, LFT and blood culture were taken on the same day as that of USG evaluation. USG evaluation of confirmed enteric fever cases revealed that 25% had gall bladder findings, 23% had hepato-splenomegaly, 11% had hepatomegaly, 1% had enlarged mesenteric lymph nodes (MLN) and 3% had thickened caecum wall and ileocaecal junction. USG can diagnose many findings which are related to enteric fever and are helpful in starting the early management. Hemoculture and other investigations may delay the treatment which can lead to various complications.

Atypical presentation of small bowel lymphoma as surgical emergency

Gastrointestinal tract is the most frequent site of extranodal involvement by non-Hodgkin's lymphoma, though extranodal lymphoma may arise anywhere outside lymph nodes, stomach is the most commonly involved organ followed by the small intestine, pharynx, colon, and rarely, esophagus. 26 year old male with history of pain abdomen for 3 days, involving whole abdomen, associated with bilious vomiting, non passage of flatus and stools for 2 days. Patient also had multiple spikes of high grade fever associated with chills and rigors for 2 days. Abdominal examination revealed features of peritonitis. CXR revealed free gas under diaphragm. Patient planned for emergency exploratory laparotomy. Intraoperatively stricture perforation proximal to ileocaecal junction noted. Resection of stricture segment with ileo-ascending anastomosis performed. Biopsy revealed Diffuse large B cell lymphoma. 52 year male with history of central abdominal distension for 4 days with multiple episodes of bilious vomiting and non passage of flatus and stools for 2 days. Abdominal examination revealed marked abdominal distension with generalised tenderness and exaggerated bowel sounds. Abdomen X Ray revealed multiple air fluid levels. Intraoperatively growth of 8×5 cm present 10 cms proximal to ileocaecal junction. Resection of diseased segment with ileoascending anastomosis performed. Biopsy of resected segment revealed Diffuse large B cell lymphoma. Patient started on R-CHOP regimen, doing well. Here we present two cases of Diffuse large B cell lymphoma showing bimodal presentation with rare clinical presentation, one as a perforation and other as obstruction.

1074 Gallstone Ileus: Two Decades After Cholecystectomy

Abstract Introduction Gallstone ileus is a rare complication of gallstones that occurs in 1%-4% of all cases of bowel obstruction. We present a surprising case of gallstone ileus causing small bowel obstruction 19 years after open cholecystectomy. Case Report A 77-year-old male presented with a 3-day history of abdominal pain, 4 episodes of vomiting and absolute constipation. He had a surgical background of an open cholecystectomy and open appendicectomy 19 years and 45 years ago respectively. Medically, he had well-controlled hypertension and experienced a TIA 5 years prior. Computed Tomography Scan of the abdomen and pelvis revealed features consistent with an obstructing, heterogenous opacity in the distal small bowel without pneumobilia. The patient subsequently underwent diagnostic laparoscopy. Intraoperatively, an obstructing gallstone, measuring 4 cm, was found 50cm proximal to the ileocaecal junction, with dilatation of the proximal small bowel and distal collapse. Enterotomy and removal of the stone was done. Post-operatively, this gentleman recovered without complications and was discharged home two days later after being able to tolerate a solid diet. Conclusions This is the second reported case of gallstone ileus in a patient with previous cholecystectomy about two decades ago, according to our literature search. Although extremely rare, absence of the gallbladder does not exclude the possibility of gallstone ileus.

Adenocarcinoma ileum: a rare cause of ileal stricture mimicking intestinal tuberculosis: a case report and literature review

One of the commonest causes of small intestinal obstruction in India is tuberculosis. The terminal ileum and ileocaecal junction are the most common sites of small bowel involvement, and the most common abnormality is short-segment strictures. We report a patient who presented with small intestinal obstruction due to a solitary ileal stricture, but turned out to be a rare condition that can mimic intestinal tuberculosis. A 60-years-old man, with recurrent episodes of pain abdomen for 1 year, presented to our surgical emergency with evidence of small intestinal obstruction. A CT scan revealed a short segment stricture (2.7 cm) in mid ileal loop with luminal narrowing and marked proximal dilation of proximal ileal loops with a few sub centimetric mesenteric lymph nodes. On laparotomy with a suspected diagnosis of intestinal tuberculosis, it turned to be an adenocarcinoma of the ileum- a rare condition that can mimic intestinal tuberculosis. One of the commonest causes of small intestinal obstruction in India is abdominal tuberculosis. However, all cases of small intestinal obstruction are not tuberculosis. Adenocarcinoma of ileum is a very rare entity. This case report shows that a surgeon should have a high index of suspicion in an elderly patient presenting with small intestinal obstruction, with CT demonstrating isolated short-segment small bowel thickening, as it could be a presentation of obstructing type adenocarcinoma of the small intestine.

Diabetic diarrhoea: A study on gastrointestinal motility, pH levels and autonomic function.

Chronic diarrhoea is a common, but poorly investigated diabetes complication. Autonomic neuropathy is a leading pathophysiological theory founded on old, small studies. Studies of gastrointestinal motility and pH levels are lacking. Using new diagnostic methods, we aimed to find out if diabetic diarrhoea was associated with alterations in gastrointestinal motility, pH levels and autonomic function. Fifty-seven patients (42 women, 46 with type 1 diabetes) were prospectively included. Symptoms were evaluated with the gastrointestinal symptom rating scale, defining ≥4 points as cases with diarrhoea. Patients scoring <4 were used as controls. We used the wireless motility capsule to measure gastrointestinal transit times, pH levels and contractility parameters. Autonomic function was assessed by measuring heart rate variability, baroreflex sensitivity and orthostatic hypotension. Seventeen patients (30%) had diarrhoea. Compared with controls, cases had slower gastric emptying (21:46 vs. 4:14, h:min, p = 0.03) and faster colonic transit (18:37 vs. 54:25, p < 0.001). Cases had increased intraluminal pH in the antrum (2.4 vs. 1.2, p = 0.009), caecum (7.3 vs. 6.4, p = 0.008) and entire colon (7.1 vs. 6.7, p = 0.05). They also had a decreased pH difference across the pylorus (3.3 vs. 4.9, p = 0.004) and ileocaecal junction (0.6 vs 1.0, p = 0.009). The groups did not differ in autonomic function, but diastolic blood pressure drop correlated rs = -0.34 (p = 0.04) with colonic transit time. Patients with diabetic diarrhoea had altered gastrointestinal transit and intraluminal pH levels, but minimal changes in autonomic function. Our results suggest that tests of gastrointestinal function are clinically useful in diabetic diarrhoea.