Including Bowel Obstruction Research Articles

Malignancy predictors and treatment strategies for adult intestinal intussusception.

Intussusception in adult patients is a rare medical finding, which is accompanied by an underlying tumor in some cases. However, no accepted method has been established to identify patients at risk for tumor-related intussusception. This study aimed to identify imaging features as predictors for tumor-related intussusception.CT images of patients with confirmed intussusception were retrospectively acquired between 01/2008 and 12/2022. Available follow-up images and medical health records were evaluated to identify various imaging features, the cause of intussusception, and treatment strategies. Imaging interpretation was conducted by two blinded radiologists. A third radiologist was consulted in cases of disagreement.A total of 71 consecutive patients were included in this study (42 males, 29 females) with a median age of 56 years (interquartile range: 40.5-73.8 years). Enteroenteric intussusceptions in the small bowel were the most common type observed in adult patients. In contrast, colocolic intussusception was more frequently associated with malignancy, and this association was statistically significant (p < 0.05). Among the malignant tumors, adenocarcinoma was the most common, followed by metastases and lymphoma. Additionally, bowel obstruction and wall thickening were significantly correlated with malignancy (p < 0.05). The high negative predictive values (NPVs) and high specificities for ileus (NPV 88.5%, specificity 82.1%), bowel wall thickening (NPV 90.9%, specificity 71.4%), and acute abdomen (NPV 84.6%, specificity 78.8%) suggest that the absence of these features strongly predicts a low probability of malignancy in cases of adult intussusception.Active surveillance with follow-up exams is suitable for asymptomatic and transient intussusception when imaging features suggest a low likelihood of a neoplasm. Additionally, malignancy predictors such as ileus and thickening of the bowel wall in the affected segment could guide tailored treatment. Surgical interventions are essential for symptomatic cases, with adenocarcinoma being the most common malignancy found in colocolic intussusceptions.Intussusception in adults is rare and is often associated with underlying tumors, particularly in colocolic intussusceptions. Key imaging predictors for malignancy include bowel obstruction, wall thickening in the affected segment, and the presence of acute abdomen, with high NPVs and specificities indicating low malignancy risk when these features are absent. Active surveillance is recommended for asymptomatic cases with low neoplasm probability, while surgical intervention is the method of choice for symptomatic patients. · Reschke P, Le Hong QA, Gruenewald LD et al. Malignancy predictors and treatment strategies for adult intestinal intussusception. Fortschr Röntgenstr 2024; DOI 10.1055/a-2434-7932.

Treatment of Renal Artery Aneurysm by ex situ Repair and Autotransplantation: A Nationwide Cohort Study

Introduction: Renal artery aneurysm (RAA) is a rare vascular disease with a mortality rate of up to 80% upon rupture. This study aimed to investigate the safety and efficacy of ex situ repair and autotransplantation for endovascularly untreatable RAA. Methods: A retrospective nationwide cohort study was conducted in RAA patients undergoing ex situ repair and autotransplantation in the Netherlands. Surgical techniques, postoperative complications, and graft outcomes were assessed. Results: Ex situ repair was performed in 9 patients with 11 RAAs. Eight RAAs were located at the first bifurcation, one on the main trunk, one on the first branch, and one on the second branch. Nephrectomy was performed via laparoscopy (n = 7), robotic-assisted laparoscopy (n = 1), and laparotomy (n = 1). Postoperative complications were recorded in 4 patients, including bowel obstruction, delirium, pneumonia, and hydronephrosis due to double-J dislocation. The median estimated glomerular filtration rate was 83 mL/min/1.73 m2 pretransplant and 88 mL/min/1.73 m2 posttransplant. By an average follow-up of 32 months, 2 patients had died due to lung adenocarcinoma and stroke, while all autotransplanted kidneys had good patency and remained functional. Conclusions: Ex situ repair and autotransplantation are safe and feasible for endovascularly untreatable RAA cases. Larger cohorts with longer follow-up periods are necessary to further evaluate the role of this surgical approach.

Readmission rates following major colorectal surgery

BackgroundReadmissions following colorectal surgery (CRS) have negative clinical, psychological and financial implications. Identifying patients at risk of readmission remains challenging. AimsTo determine factors predictive of those likely to require readmission at 40-days following major CRS and to identify novel strategies capable of reducing readmissions. MethodsConsecutive patients were studied from a prospectively maintained database. All patients were operated on by a single surgeon in a high-volume centre. Where applicable, photography was recorded by patients and emailed directly to the institutional email of the consultant surgeon. Data was recorded and analysed using descriptive statistics. Results515 patients were included over a 15-year period (2007-2022). The mean age at surgery was 64 years (18-93). The majority of patients were male (56.9%, n=293) and underwent cancer surgery (58.2%, n=299). Overall, 55 patients were readmitted within 40 days of major CRS (10.7%). Patients with pre-treatment diagnoses of heart failure (P=0.012), ischemic heart disease (P=0.002), renal impairment (P<0.001), atrial fibrillation (P=0.006), hypercholesterolemia (P=0.001), asthma (P=0.013) and hypertension (P=0.001) were more likely to require readmission. The majority of patients were readmitted for definitive management of surgical site issues (SSIs) (43.7% n=24). Other reasons included bowel obstruction (9.1%, n=5), pelvic sepsis (7.3%, n=4) and gastrointestinal upset (7.3%, n=4). ConclusionThis series demonstrated that patients with cardiopulmonary comorbidities were more likely to be readmitted following major CRS and most readmissions are SSI related. Readmissions for SSIs can be reduced by patients sending photography to the treating surgeon which could reduce readmissions and A&E attendances.

Symptomatic congenital Morgagni hernia presenting as a dyspnea in elderly patient

Morgagni’s hernia is a very uncommon congenital diaphragmatic hernia. A few patients may remain asymptomatic until adulthood. Clinical presentation may include bowel obstruction, chest pain or dyspnea. Here we present a case of symptomatic Morgagni hernia diagnosed in a 64 years' female. A 64-year-old female patient, go to the consultation with a private doctor due to 10 years of evolution of respiratory symptoms due to respiratory symptoms, whose thoracic computed tomography revealed a large Morgagni’s hernia, containing colon. She underwent an elective laparoscopic repair with mesh. Morgagni hernias are mostly diagnosed incidentally on a chest radiograph or can present with cardiorespiratory or abdominal symptoms. Our case was an adult who was diagnosed to have Morgagni hernia presenting with chest symptoms. The investigation of choice to diagnose and evaluate this condition is CT of chest and repair of hernia. Thoracic computed tomography is the best imaging study for its diagnosis. Laparoscopic repair is safe and allows symptomatic relief and incarceration risk reduction.

A Second Reported Case of Catabacter hongkongensis Bactermia in the United States

Abstract Catabacter hongkongensis is a rare bacterium that was first described in 2007. Since that time, there have been less than 20 case reports worldwide. This bacterium inhabits the gastrointestinal tract, and therefore, most cases present with gastrointestinal pathology, including bowel obstruction, acute cholecystitis, and colonic perforation. The treatment is typically surgical intervention and antibiotics. Here, we present a case of C. hongkongensis in a patient undergoing treatment for breast cancer who presented with acute appendicitis.

The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - A prospective safety and efficacy study for the Bakri balloon.

Empty pelvis syndrome (EPS) is a source of considerable morbidity following total pelvic exenteration. None of the available methods have been universally successful in mitigating this problem. The aim of this work was to evaluate the safety and efficacy of the obstetric Bakri balloon in preventing empty pelvis syndrome. This study was a combined prospective and retrospective study of all total pelvic exenterations for rectal cancers from a single institution performed between October 2013 and May 2022. Since December 2019 the Bakri balloon was used in all patients who provided consent. EPS within 90 days was the primary end point, and included bowel obstruction, pelvic collection and entero-perineal fistula. Comparison with those patients who did not have a Bakri balloon was performed. Seventy-five patients with a Bakri balloon were compared with 96 patients without a balloon placed after pelvic exenteration. No patient experienced an untoward complication from balloon deployment. The incidence of EPS was 13.3% and 22.9% in the Bakri and no Bakri cohorts, respectively (p= 0.110). Every component of EPS was proportionally lower, without statistical significance. Based on point estimates, the number needed to treat to prevent EPS using the Bakri balloon was 10. Use of the Bakri balloon was safe without serious adverse events. The incidence of EPS after total pelvic exenteration was not statistically different with the use of the Bakri balloon despite a 9.6% reduction. A larger comparative study is needed to evaluate the efficacy of the balloon.

Rapunzel Syndrome in a Teenage Girl: A Case Report

Trichobezoars are concretions of retained, undigested material, mostly hair or hair-like fibers in the stomach. Rapunzel syndrome is the condition when trichobezoars extend into the small bowel, leading to various complications including bowel obstruction, and perforation due to pressure necrosis. We present an interesting case of trichobezoar in a 15-year-old female patient, who presented with abdominal pain for one month duration. The exam was notable for a firm palpable mass in the epigastric area associated with localized tenderness and guarding. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar, dilated duodenal loops, and clumping of proximal jejunal loops. Upper gastrointestinal endoscopy showed a trichobezoar extending from the oesophagogastric junction to the pylorus. Endoscopic removal of the trichobezoar was not successful. An elective laparotomy was performed, during which the stomach, duodenum, and proximal jejunum were dilated. The trichobezoar, measuring 35 cm in length, extended from the body of the stomach to the proximal jejunum and caused jejunal perforation due to pressure necrosis. The trichobezoar was removed and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunostomy was done. There were no postoperative complications. The patient followed up with psychiatry in the clinic after discharge, she was diagnosed with trichotillomania and started on fluoxetine, with improvement in her behavioral symptoms. In young female patients with nonspecific chronic abdomen pain and a palpable mass, trichobezoar should be considered in the differential diagnosis. Contrast-enhanced abdomen CT is the preferred imaging modality and removal of the trichobezoar with an appropriate endoscopic or surgical procedure is the treatment of choice. It is essential to diagnose and treat the underlying behavioral condition to prevent recurrent episodes.

Utilization of Point-of-Care Ultrasound in a Specialist Palliative Care Team Across Multiple Care Settings: A Retrospective Chart Review.

Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study was to examine the use of POCUS in a specialist palliative care setting. A retrospective chart review was conducted from January 2018 to June 2019 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS, and, if applicable, volume of fluid drained. We identified 126 uses of POCUS in 89 unique patients. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia, and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance. We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.

A febrile occlusion revealing a biliary ileus.

Biliary ileus is a consequence of the migration of a gallstone from the gallbladder to the digestive tract, most often via a biliodigestive fistula that causes a bowel obstruction.The clinic is atypical and capricious, including bowel obstruction and signs of cholecystitis, causing a delay in diagnosis.The therapeutic objective is to remove the intestinal obstacle by an enterotomy with stone extraction, with or without treatment of the biliary pathology (cholecystectomy and biliary fistula cure).The surgery remains the treatment of choice; laparoscopy and endoscopy present a less invasive alternative and are beginning to prove their effectiveness.The morbi-mortality remains high for biliary ileus, this is principally caused by the delay in diagnosis.

Extracolonic findings at CT colonography in an oncological hospital setting and why they matter

PurposeTo evaluate the frequency and clinical outcome of unknown extracolonic findings in patients with cancer who underwent CT colonography (CTC). MethodsConsecutive patients who underwent CTC from February 2000–April 2016 for any indication were retrospectively included. One radiologist blinded to clinical data determined C-RADS classification for all extracolonic findings on CTC reports as follows: E1: normal examination or anatomic variant, E2: clinically unimportant, E3: likely unimportant, incompletely characterized, and E4: potentially important. Another radiologist performed an unblinded review of medical records and determined if E4 findings were previously known or new, and classified new E4 findings as clinically important or unimportant on follow-up. ResultsOf 855 patients, 686/855 (80.2%) had a normal examination or clinically unimportant extracolonic findings (E1 and E2) and 169/855 (19.8%) had E3–E4 extracolonic findings [99/855 (11.6%) patients had known E4 findings and 102/855 (11.9%) patients had new E4 findings]. On follow-up, among new E4 findings, 71/855 (8.3%) patients had clinically important findings, 66/855 (7.7%) had a malignant outcome previously unknown by the referring physician, and 5/855 (0.6%) had other complications, including bowel obstruction and cirrhosis. Regarding new oncological findings, new extracolonic primary tumors were detected in 13/855 (1.5%) patients, corresponding to 12.7% (13/102) of the new E4 findings. The proportion of new E4 findings on CTC with and without intravenous contrast was not significantly different [41/320 (12.8%) vs 61/535 (11.4%), p = 0.612]. ConclusionAmong oncological patients, detection of new significant E4 extracolonic findings at CTC occurred in 8.3% of all cases, including unknown cancers in 1.5%.

Colo-enteric fistula associated with diffuse large B cell lymphoma that resulted in gastrointestinal bleeding: A case report and literature review

Introduction and importanceThe most common symptoms of primary gastrointestinal (GI) lymphoma are non-specific, such as nausea, vomiting, diarrhea, weight loss, and abdominal pain. The rare acute symptoms include bowel obstruction, intussusception, and perforation. Primary small bowel lymphoma accounts for the smallest proportion of all GI malignancies. We report a case of intestinal lymphoma presenting with bloody stools and anemia.Case presentationThe patient initially underwent both duodenoscopy and colonoscopy with negative findings. Isotopic red blood cell (RBC) scan was then performed due to persistent bleeding along with computed tomography angiography (CTA) because of suspected bleeding in the left abdomen. Successful embolization over the arcade of the sigmoid and left colic arteries was performed. However, the bleeding did not stop, and ischemic colitis was diagnosed by repeat colonoscopy. A coloenteric fistula was finally discovered during emergent laparotomy.Clinical discussionGI lymphomas are a rare disease entity among the all GI malignancies. Despite acute abdominal symptoms including obstruction, perforation, bleeding and intussusception, enteral fistula is also one of the complications. It was seen to be a long-term complication after treatment or disease process in most of cases, however it could occur as the initial manifestation. GI bleeding is a life-threatening condition and commonly needs prompt decision making. There were no standard managements for these patients, it depends on clinical judgements from physician individually.ConclusionThis is a rare condition that has not been previously described in Taiwan. Early diagnosis and timely management will decrease morbidity and mortality in the GI lymphoma population.

Inoperable de novo metastatic colorectal cancer with primary tumour in situ: Evaluating discordant responses to upfront systemic therapy of the primary tumours and metastatic sites and complications arising from primary tumours (experiences from an Irish Cancer Centre).

Systemic therapy is the mainstay of treatment for de novo metastatic colorectal cancer (mCRC). Heterogeneity between primary tumours and metastases may lead to discordant responses to systemic therapy at these sites. The aim of the present study was to examine these discrepancies and to evaluate the rates of complications arising from the primary tumour and the strategies employed to manage these complications. Electronic medical records were screened for patients eligible for data analysis between January 1st, 2014 and December 31st, 2019. All patients diagnosed with de novo mCRC with primary tumour in situ at the time of initial systemic therapy were included in data analysis. Responses in primary tumour and metastatic sites (according to the Response Evaluation Criteria In Solid Tumours v1.1), discrepancies in these responses and rates of complications arising from primary tumours were assessed along with patient, pathological or molecular factors that may be associated with these discrepant responses or primary tumour complications. A total of 50 patients were identified (median age, 62 years). Right-colon, left-colon and rectal primary tumours comprised 34, 44 and 22% of CRC cases, respectively. All patients received 5-fluorouracil-based chemotherapy (either alone or in combination with oxaliplatin or irinotecan). Disease response (DR), stable disease (SD) and progressive disease (PD) were observed as the first response to systemic therapy in 24, 62 and 12% of primary tumours and in 36, 18 and 44% of metastatic sites, respectively. Only 36% of patients demonstrated concordant responses between the primary tumours and metastases, while the remaining 62% demonstrated discordant responses between the primary tumour and distant metastases (22% had DR with SD; 36% had DR or SD with PD; and 4% had PD with SD in the primary tumour and metastases, respectively). Restaging images were not available for 2% of the patients. Approximately 30% of patients developed complications from primary tumours, including bowel obstruction (6.12%), perforation (6%), rectal pain (6%) and rectal bleeding (10%). Approximately 10% of patients underwent palliative stoma creation. Additionally, 12% required palliative radiotherapy to the primary tumour (due to localized complications arising from the tumour). Discordant responses to systemic therapy between primary tumours and metastases occurred in 60% of patients with de novo mCRC (with primary tumour in situ at the time of first systemic therapy). The observations of the present study have potential implications for molecular tissue analysis to help guide systemic therapy. Tissue from metastatic sites may be preferable to confirm biomarker status in mCRC based on this study.

629 Small Bowel Entrapment Secondary to An Acetabular Fracture: A Case Report

Abstract Bowel entrapment within a pelvic fracture is a rare clinical occurrence. The first reported case was documented in 1907, with only 24 further cases reported in the literature since. Entrapment usually involves mobile segments of bowel and various fracture sites within the pelvis have been implicated. We report a case of a 31-year-old ‘trauma alert’, who sustained pelvic fractures following a pedestrian vs car ‘RTC’. The patient was initially taken to theatre for an examination under anaesthesia, where an immobile acetabular fragment was identified, but the hip joint was felt to be stable. A Denham pin was placed in the distal femur and traction applied. Two days post admission they developed abdominal pain and vomiting. A subsequent CT scan demonstrated small bowel entrapment within the acetabular fracture causing a mechanical obstruction. Emergency laparotomy confirmed an intra-acetabular hernia which was released via an extra-peritoneal route. A section of necrotic bowel was resected, and a primary anastomosis performed. Bowel entrapment poses a difficult diagnostic challenge and there is often a delay in diagnosis. Despite advances in imaging, initial radiographic features can be subtle, and it can be difficult to distinguish clinically between mechanical bowel obstruction and adynamic ileus. This case highlights that bowel entrapment is an important consideration in patients with pelvic fractures following high energy trauma. Awareness of this rare complication and a high index of suspicion are key to early diagnosis and timely surgical intervention, which has the potential to prevent significant complications including bowel obstruction, acute peritonitis and death.

Neuroleptiques Causing a Giant Abdominal Mass

A 39 years old patient was admitted to our hospital, never operated before, with a history of mental illness. The patient was treated for schyzophrenia since the age of 15, under a long term treatment of neurolyptics and antidepressants, with complaints of chronic constipation. The patient reported abdominal pains and cessation of stool and gas, no defectation in 15 days, along with continuous vomitting.The patient was concious, instable TA : 80/40mmHG FC: 120B/m FR : 22 c/m. On initial evaluation we could detect an important abdominal distention as well as an apparent venous collateral circulation accompagnied with tenderness to palpation [Figure A]. Rectal examination revealed the presence of a very hard fecaloma. The initial biological assessment showed functional renal insufficiency, Hyperleukocytosis at 11000 /mm3, hyponatremia at 125 mmol/L. Abdominal tomography revealed a giant fecaloma at the rectum, the sigmoid and the left side of the transverse colon, and a mega colon with a diametre reaching 22 cm wide, the lining of the colon was improperly enhanced after the injection of the contrast agent [Figure B]. The patient was then admitted to the trauma room, he was prepared with a rehydration and hydro-electrolytic compensation. Repeated enemas and laxatives were used to stimulate defectation, but they were all unsuccessful, the hard mass of stool could not be removed. It was decided that the patient required abdominal surgery. Under general anesthesia, patient in supine position, a midline laparotomy was performed. During the exploration, we discovered a colon filled with a giant ficaloma, along with ischemic parietal lesions on the sigmoid [Figure C].&#x0D; Resection of the descending and sigmoid colons, manual extraction of the remainder of the fecalomas from the rectum, and terminal colostomy were performed following Hartmann's technique. The patient remained instable even after being treated in intensive care, the patient unfortunately passed away 48 h post operation.&#x0D; Constipation is a common problem that can cause fecal impaction and even development of a fecaloma, a mass of inspissated stool. Fecalomas occur more frequently in the left colon and rectum as stool hardens and the colon narrows. Fecalomas can manifest in various ways including bowel obstruction, urinary retention, and toxic megacolon.&#x0D; Medica­tions that were significantly associated with constipation were opioids, diuretics, antidepressants, antihistamines, antispasmod­ics, anticonvulsants, and aluminum antacids. The use of acetaminophen (&gt;7 tablets weekly), aspirin, and other NSAIDs was also found to be associated with an increased risk of constipation. Fecalomas can often be treated conservatively with laxatives, enemas, and/or digital disimpaction. However, when these methods are unsuccessful, surgical intervention is required to prevent bowel perforation.&#x0D; In patients with history of constipation, new or worsening of abdominal pain, and are under antidepressants and neurolyptic treatment, fecalomas should be considered in the differential diagnosis, and constipation should be aggressively investigated to avoid complications.

Cecal Volvulus a rare cause of Intestinal obstruction: Our experience and literature review

Cecal volvulus represents 25-40% of all colonic volvulus. Symptoms include abdominal distension, constipation, nausea and vomiting where it may be intermittent. Abdominal X-rays and computed tomography (CT) may help with diagnosis and recommended treatment is resection of mobile caecum. Although rarely identified as a source of abdominal pain, cecal volvulus has clinical significance as it can lead to a number of serious complications including bowel obstruction, perforation and ischemia. We report here on our experience and also examine the relevant literature to differentiate cecal volvulus from other forms of bowel obstruction. General surgeons should be aware of this disease and consider it in the differential diagnosis of acute abdomen.

Management of Chilaiditi syndrome: Our Experience and Literature Review

Chilaiditi syndrome is a rare condition defined by the presence of gastrointestinal symptoms associated with the radiological finding of segmental interposition of the intestine between the liver and diaphragm. Although rarely identified as a source of abdominal pain, Chilaiditi syndrome has clinical significance as it can lead to a number of serious complications including bowel obstruction, perforation and ischemia. We report here on our experience and also examine the relevant literature and discuss measures to overcome this diagnostic dilemma. General surgeons should be aware of this disease and consider it in the differential diagnosis of acute abdomen.

The laparoscopic repair of giant diaphragmatic hernia with synthetic mesh: A report of three cases

Three cases of giant diaphragmatic hernia were reported in our study. Computed tomography (CT) scan showed multiple organ migration into the chest. The clinical presentation included bowel obstruction, dyspnea, or chest pain. The operations were performed initially by laparoscopy to reduce the hernia content. The defect was closed with a nonabsorbable suture and was reinforced with a synthetic mesh. All patients recovered well without any serious complications. The symptom improved significantly after surgery. Postoperative CT scan showed normal anatomy. There was no evidence of recurrence within 6 months after the operation.

UNILATERAL EXUDATIVE PLEURAL EFFUSION AS THE SOLE PRESENTING FEATURE OF A CLEAR CELL OVARIAN CARCINOMA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pleural effusions are usually a manifestation of a pleuropulmonary or systemic disease. Pleural fluid analysis often provides insight into the underlying etiology, however, a thorough extrathoracic evaluation is needed in some cases for a definitive diagnosis. CASE PRESENTATION: We present the case of a 48-year-old female with a multinodular goiter who presented with exertional shortness of breath and cough over a 8-week duration. Chest radiograph showed complete opacification of the right hemithorax. Computed tomography of the chest revealed a large right-sided pleural effusion with complete collapse of the right lower and middle lobes, partial collapse of the right upper lobe and mediastinal shift to the left. Also noted was a heterogeneous enlargement of the left thyroid gland, with significant retrosternal extension into the superior mediastinum. A small-bore chest tube was inserted and 3 liters of serosanguinous pleural fluid was drained. Pleural fluid studies were consistent with an exudative effusion with lymphocytic predominance. Infectious workup including tuberculosis was negative. Fluid cytology was negative for malignant cells. Given the significant retrosternal extension of her goiter, the possibility of chylothorax was raised, which was rebutted by the pleural fluid appearance and normal triglycerides levels. Thyroid function tests and autoimmune markers were negative. An abdomino-pelvic ultrasound was performed, with the clinical possibility of an occult malignancy, as a possible etiology. This showed a left adnexal lesion, which prompted further characterization, by magnetic resonance imaging. The findings were compatible with epithelial ovarian/fallopian tube neoplasm. Laparoscopic left salpingo-oophorectomy was performed and pathology confirmed clear cell ovarian carcinoma. DISCUSSION: Clear cell ovarian carcinoma is a subtype of epithelial ovarian carcinoma, the most common type of malignant ovarian neoplasms. It often presents in perimenopausal women in their fifth or sixth decade of life. Epithelial ovarian cancer frequently presents with subacute pelvic or abdominal symptoms; however, it may present acutely with nonpelvic manifestations including bowel obstruction, venous thromboembolism, or malignant pleural effusion. Given the absence of abdominal and pelvic symptoms on clinical presentation, this case would have been missed if pelvic ultrasound was not performed. CONCLUSIONS: In conclusion, an unexplained exudative pleural effusion in a young female should warrant a high degree of clinical suspicion and further evaluation to rule out an abdominal or gynecological malignancy. Reference #1: Stéphane Beaudoin and Anne V. Gonzalez. Evaluation of the patient with pleural effusion. CMAJ March 12, 2018 190 (10) E291-E295 Reference #2: Rubins JB, Colice GL. Evaluating pleural effusions. How should you go about finding the cause? Postgrad Med. 1999 May 1;105(5):39-42, 45-8 Reference #3: Xavier Matias-Guiu and Colin J R Stewart. Endometriosis-associated Ovarian Neoplasia. Pathology, 2018-02-01, Volume 50, Issue 2, Pages 190-204 DISCLOSURES: No relevant relationships by Abdulaziz Alonazi, source=Web Response No relevant relationships by Shine Raju, source=Web Response No relevant relationships by Nadine Zahar, source=Web Response

Magnet ingestion by children: A retrospective study in a medical center in Taiwan

The ingestion of multiple magnets may lead to severe complications including bowel obstruction, perforation, fistula, peritonitis, short bowel syndrome, life-threatening injuries, and even death. The annual case number of high-powered neodymium magnets ingestion has been increasing in the western world and the dearth of available data demonstrates that this issue has been neglected in Taiwan. We searched the electronic medical records of our institution for patients younger than 18 years old who were diagnosed with, who had ever visited our emergency department, or been hospitalized for magnetic foreign body ingestion between January 2009 and March 2018. Demographic data including the number, shape, and size of magnets ingested, the clinical presentation, type of intervention, and complications were reviewed. Thirteen patients who met the enrollment criteria were analyzed. One patient was documented between 2009 and 2013, and twelve were documented between January 2014 and March 2018. Five of the cases documented between 2014 and 2018 had ingested Buckyballs. The median age of the patients was 5 years. All of the patients with clinical symptoms had ingested more than one magnet and required endoscopic or surgical intervention. Bowel perforation or deep ulcer with impending perforation was found in three patients during surgery. The number of children who visited our emergency department or were hospitalized due to the ingestion of magnets has increased recently. The presence of high power of neodymium magnets in many products increases the risk of ingesting multiple magnets resulting in serious complications. Therefore, stricter policies are needed to prevent children from obtaining products that contain magnets.

P132 OUTCOMES AND REASONS FOR ADMISSION IN CROHN’S DISEASE. AN ANALYSIS OF NATIONWIDE INPATIENT SAMPLE 2016

Abstract Objective Recent research suggests increasing nationwide admission for Crohn’s disease (CD), but the most common reasons for admission are not well known. We sought to enumerate the most common presentations of Crohn’s disease requiring admission in Nationwide Inpatient Sample (NIS) 2016 using ICD-10 codes. Methods We identified all adults aged greater than or equal to 18 years with a primary diagnosis of CD, using ICD 10 in Nationwide inpatient database. We analyzed inpatient demographics via chi-square. Inpatient mortality,Length of stay (LOS) and Total Charge (TOTCHG) was calculated using univariate and multivariable linear models. Results 60,244 patients with CD required inpatient admission. Majority of patients were females (53%), white (69%), with private insurance (46%) admitted to large bed sized (53.3%) teaching hospitals (68%). The common reasons for admission in CD patients included bowel obstruction at 24.6% (14,850) of which 57.8% (8,590) presented with small bowel obstruction (SBO). 42.1% (6260) were admitted with both SBO and LBO. Other reasons for admission were GI bleeding (6.5%) and fistulizing CD (2.4%). The inpatient mortality was 0.5%. Age was an independent predictor of mortality in these patients. (aOR 1.08, 95% CI 1.04–1.12; p=0.000). Protein energy malnutrition (PEM) (aOR 2.45, p=0.348), patients requiring pressor support (aOR 4.2, p=1.06) and those with bowel obstruction (aOR 1.1.9 p=0.84) had higher odds of mortality on multivariate analysis model, but couldn’t reach statistical significance. The mean LOS was 4.9 days and patients admitted over weekend had a longer LOS (coeff 0.22, 95% CI 0.08–0.37, p=0.002) as compared to weekdays on multivariate linear regression. The total cost attributable to Crohn’s disease was 706$ million. Independent predictors of increased total charge were Large bed sized hospitals, African-American, protein energy malnutrition, patients requiring pressor support and bowel obstruction in multivariate linear analysis. Conclusions The common reasons for inpatient admission in patients with CD include bowel obstruction, GI bleeding and fistulizing CD. Age was an independent predictor of mortality. The economic burden was highest amongst African-Americans, malnourished, patients requiring pressor support and those with bowel obstruction.