Small Bowel Loops Research Articles

S2895 A Rare Case of Inferior Pancreaticoduodenal Artery Pseudoaneurysm Rupture Following Endoscopic Retrograde Cholangiopancreatography

Introduction: Hemorrhage is a known potential complication of endoscopic retrograde cholangiopancreatography (ERCP), often occurring at the site of sphincterotomy. Less commonly, intra- and retroperitoneal hemorrhage can occur secondary to splenic, hepatic, or vascular injury. Here we present a rare case of inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm (PSA) rupture following ERCP in a patient with a large diaphragmatic hernia. Case Description/Methods: The patient is a 68 year old man with a history of hypertension, chronic kidney disease, and splenectomy. He presented with jaundice, fatigue, and labs notable for hypoglycemia, acidemia, acute kidney injury, normal transaminase levels, alkaline phosphatase (129 IU/L), total bilirubin (4.2 mg/dL), direct bilirubin (2.5 mg/dL), and lipase (157 IU/L). Computed tomography (CT) with contrast revealed choledocholithiasis with a 1.2 cm stone in the head of the pancreas associated with pneumobilia, intra- and extrahepatic ductal dilation, and pancreatic ductal dilation. A large left diaphragmatic hernia with protrusion of nonobstructed loops of large and small bowel into the left hemithorax was also noted. He underwent ERCP with biliary sphincterotomy and removal of one stone. One large stone remained. A plastic stent was placed in the common bile duct with plans to repeat ERCP in 4-6 weeks with cholangioscopy and electrohydrolic lithotripsy. Following ERCP, the patient developed acutely worsening anemia without overt evidence of lumenal gastrointestinal bleeding. CT angiography revealed active extravasation and a PSA within an intra-abdominal hematoma (18.4 x 8.5 cm). The patient then underwent mesenteric angiography which showed one multilobulated (2 x 1.8 cm) and one smaller PSA arising from an IPDA branch. Coil embolization of the dominant PSA was performed, achieving hemostasis. (Figure, Table) Discussion: Visceral artery aneurysm (VAA) rupture is an exceedingly rare complication of ERCP with IPDA pseudoaneurysms accounting for just 2% of VAA. Although there is a known association of VAA with pancreatitis, the mechanism for PSA formation following ERCP is unclear. It is thought to be associated with sphincterotomy with rupture caused by direct mechanical injury related to pancreaticobiliary manipulation. Mortality related to VAA rupture and hemorrhage can be as high as 19%. A high index of suspicion and early detection followed by angioembolization are critical for reducing mortality.Figure 1.: (A) CT with contrast showing choledocholithiasis with a 1.2 cm stone in the head of the pancreas. (B) CT angiography showing active extravasation and a pseudoaneurysm (PSA) within an intra-abdominal hematoma (18.4 x 8.5 cm). (C) Mesenteric angiography which showed one multilobulated (2 x 1.8 cm) and one smaller PSA arising from an inferior pancreaticoduodenal artery branch. Table 1 - Summary of currently available case reports of inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm (PSA) development following endoscopic retrograde cholangiopancreatography (ERCP) Age/Sex Comorbidities ERCP Indication Interventions Symptom Diagnosis Treatment Al-Jeroudi et al 2001 76 F None Palliation of pancreatic carcinoma Precut sphincterotomy, biliary stent Abdominal pain IPDA PSA Embolization Rim et al 2021 27 M Sickle cell disease Choledocholithiasis Sphincterotomy, stone extraction, biliary stent, pancreatic duct stent Abdominal pain, acute anemia IPDA PSA rupture Embolization Current Case 68 M Hypertension, chronic kidney disease, diaphragmatic hernia Choledocholithiasis Sphincterotomy, stone extraction, biliary stent Abdominal pain, acute anemia IPDA PSA rupture Embolization

S3359 Diaphragm Disease: A Crohn's Mimicker?

Introduction: Diaphragm disease of the small bowel is a rare disease typically associated with NSAID use. The disease is characterized by multiple strictures appearing as ‘pinhole’ sized lumens caused by mucosal thickening. Often the condition goes misdiagnosed until the lumen is visualized, with clinical presentations initially consisting of recurrent bowel obstructions, anemia and/or protein loosing enteropathy. Case Description/Methods: A 50-year-old male with a history of hypertension, incarceration, and prior recurrent small bowel obstructions and prior exploratory laparotomy with lysis of adhesions, presented with recurrent abdominal pain, nausea, vomiting and constipation. A year prior to presentation, the patient was hospitalized for similar symptoms, with colonoscopy demonstrating a fibrotic stricture at the ileocecal valve, which was only able to be traversed after balloon dilation. The mucosa appeared endoscopically normal, however, biopsies of the terminal ileum demonstrated chronic active focal ileitis, suggestive of Crohn’s disease. The patient then experienced two more hospitalizations for small bowel obstruction, which resolved with supportive care and steroid administration. During this hospitalization, CT scan demonstrated a small bowel obstruction with several transition points in the mid small bowel. Intravenous corticosteroids were started, and nasogastric tube was placed with improvement. He adamantly denied any current or past prolonged NSAID use. It was decided that patient would benefit from a surgical small bowel exploration. Several strictures were seen in the proximal small bowel, and therefore proximal and distal resection of jejumum with a primary end-to-end enteroenterostomy anastomosis was performed. Histopathological evaluation of the resected specimen showed small bowel with circumferential membranes with submucosal neuromuscular and vascular hyperplasia, displaced mucosal glands, and associated mucosal active and chronic ileitis with ulceration, compatible with a diagnosis of diaphragm disease. (Figure) Discussion: NSAIDs can have deleterious effects on the small bowel including, ulceration, structuring, erosion formation, perforation and/or the formation of fibrous diaphragms that can lead to obstruction. Diaphragm disease is uncommon, especially in the absence of prior NSAID use. Clinically, it is important to recognize this group of patients as obstructive symptoms due to structuring/diaphragm disease are unlikely to resolve without some form of surgical intervention.Figure 1.: a + b) Submucosal fibrosis and neuromuscular and vascular hyperplasia. c) Focal narrowing and proximal dilation of a loop of small bowel with transition point within the mid small bowel.

S2167 Chronic, Massive Pneumoperitoneum in a Patient Without Signs of Peritonitis: A Case Report

Introduction: Pneumoperitoneum is the presence of free air in the abdominal cavity. This alarming symptom can be due to a wide variety of etiologies, including infection, trauma, perforation, and others. However, pneumatosis intestinalis, which is the presence of free air in the extraluminal space, can be due to other pathology unrelated to the GI tract. It can be seen in pulmonary disease, such as COPD and asthma, autoimmune conditions, and drug-induced causes as well. It can present with more benign symptoms. We present a case of chronic pneumatosis intestinalis that was present in the patient for over 2 years and presented with relatively minor, nonspecific symptoms. Case Description/Methods: This patient was a 62-year-old male who presented with concerns of bloating and cramping, ongoing for 2 years. Previous work-ups had not revealed a clear cause for his ongoing symptoms. He had undergone CT of the abdomen, which was significant for massive pneumoperitoneum, as well as fluid-filled prominent loops of small bowel concerning for ileus or obstruction. There was no site of bowel perforation that could be visualized. Upper endoscopy and colonoscopy had been performed, which showed normal mucosa and colonic diverticulosis. After further workup at an additional institution, diagnostic laparotomy was recommended to further evaluate his small bowel. At the lower anterior diaphragm, the peritoneal surface had subperitoneal emphysema, suggesting a potential thoracic source for the pneumoperitoneum. Thoracic surgery were consulted for exploratory right-sided thoracoscopy since he was noted to have peritoneal blebs along the diaphragm most notably, with one also being identified on the liver. It was concluded that the etiology was most likely due to an alveolar-peritoneal fistula through the right hemidiaphragm (Figure). Discussion: Pneumatosis Intestinalis can be a benign presenting symptom. Pneumoperitoneum can be due to primary (idiopathic) or secondary causes. Secondary causes are numerous, and these can be seen in the setting of COPD, immunodeficiency, or acute GI pathology. Increased pressure in the abdomen or the mediastinum can result in gas diffusing across tissues and into the bowel wall. Treatment and management varies depending on the patient's presentation. More serious abdominal pathology requires surgical management, while benign causes in the setting of chronic lung pathology can be asymptomatic, or present with mild symptoms that require only conservative medical management.Figure 1.: Pneumatosis Intestinalis on CT Scan.

S3577 Chronic Intrathoracic Gastric Volvulus Management: Could Less Be More?

Introduction: Chronic intrathoracic gastric volvulus usually presents with mild vague symptoms requiring high suspicion index to diagnose. Treatment can be either endoscopic or surgical. Nevertheless, neither approach is always ideal. Endoscopic management carries a high risk of gastric perforation, while surgical management may not be suitable due to the risk of anesthesia. In the following case report and literature review we evaluate the role of non-interventional conservative management in high-risk surgical patients with chronic intrathoracic gastric volvulus who experience breakthrough clinical symptoms. Case Description/Methods: An 88-year-old woman with history of dementia and hysterectomy presented for abdominal pain and vomiting. Vital signs and laboratory work up were stable. CT scan of the abdomen with contrast showed the stomach to be largely contained within the right hemithorax and rotated along its long axis compatible with an organoaxial volvulus, yet was nondilated nor obstructed, with contrast visualized throughout nondilated loops of small bowel which seem to be chronic in etiology as there were intrathoracic bowel loops on abdominal imaging six months prior (Figure A). Review of prior images noted the presence of the intrathoracic stomach on a CT scan done 12 years prior (Figure B). The patient was deemed high risk for sedation and anesthesia, for either endoscopic or surgical management, given the history of worsening dementia, debilitated medical condition, and diminished PO intake with malnutrition. She was started on TPN then 2 days later was switched to PO as her appetite and oral intake improved with frequent re-orientation and her family attempting to orally feed her. On evaluation one-month later, the patient had no more abdominal symptoms, continued to have maintain oral intake, with considerable improvement of her mental status and physical capabilities. Discussion: In this report, we demonstrated that conservative management is, perhaps, a more appropriate approach in patients with chronic gastric volvulus who are poor endoscopic or surgical candidates. Furthermore, our patient’s mental status and ability to tolerate oral diet has improved with adequate supportive measures (frequent re-orientation; meeting needs for nutrition, fluids, and sleep). Nevertheless, our patient remains at a high-risk form symptom recurrence given the history of abdominal hysterectomy for a leiomyoma, and thus close monitoring is necessary for symptom recurrence of the uncorrected gastric volvulus.Figure 1.: Computed tomography scan of the abdomen (axial view) performed on this admission (on the left (A)) vs 12 years prior (on the right (B)) Figure legend: The arrow points to the intrathoracic gastric volvulus.

S1998 Colonic Merkel Cell Carcinoma of Unknown Primary: Small Cell Carcinoma Outside the Usual

Introduction: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin carcinoma with documented metastases to the liver, lungs, and gastrointestinal (GI) tract. Colonic metastases are rare but seen with recurrent or primary cutaneous lesions. Described is a patient who presented with bowel obstruction with a hepatic flexure MCC of unknown primary (MCCUP). Case Description/Methods: A 69-year-old female with a history of breast, lung, and anal cancer presented to the emergency department with abdominal pain and distension. Computed tomography of her abdomen demonstrated dilated loops of small bowel and a partial obstruction with transition point in the hepatic flexure. Colonoscopy demonstrated a 4 cm mass at the hepatic flexure obstructing the lumen. Biopsy revealed a high-grade neuroendocrine carcinoma. A right colectomy and histopathology confirmed small cell neuroendocrine carcinoma involving the colonic wall into the pericolic adipose tissue with nodal involvement. It was positive on cytokeratin CAM 5.2, synaptophysin, and Merkel cell polyomavirus (MCPvY) and negative on CDX-2 and TTF-1, excluding primary bowel or lung small cell carcinomas, respectively. Dermatologic evaluation did not reveal a primary cutaneous lesion. Genetic testing was unremarkable. Discussion: This is the first case of MCCUP presenting with colonic obstruction; prior described cases of MCC metastatic to the colon were recurrent disease or from primary skin lesions. Because MCC is rare, has non-specific symptoms, and may lack a primary lesion, MCCUP must be distinguished from other small round blue cell malignancies more commonly found in the GI tract. Thus, neuroendocrine, keratin and MCPyV ancillary staining are critical to distinguish MCC from B-cell lymphoma, small cell carcinoma of bowel or lung primary, and other metastatic dermal malignancies. MCPyV testing in the absence of prior diagnosis is uncommon but vital to the workup of neuroendocrine carcinomas when CDX-2 and TTF-1 are negative as MCPyV positive lymph nodes predict worse outcomes such as disease-free survival. In this patient immunosuppression and prior radiation increased the risk of MCC, and even suggest that this might be a colonic primary. Rarely, MCC and MCCUP are root causes of neuroendocrine carcinomas of the GI tract. In immunocompromised patients, biopsy and pathologic staining are necessary to distinguish insidious malignancies. MCPyV analysis is helpful for diagnosing MCCUP and informing its prognosis.

Rapunzel Syndrome: A Case of Trichobezoar with Small Bowel Complications

Introduction Rapunzel syndrome is characterized by a large trichobezoar in the stomach with a tail extending beyond the pylorus into the small bowel, causing mechanical obstruction of the small bowel. A 7-year-old girl presented to the emergency room with severe epigastric pain. Computed tomography suggested trichobezoar causing jejuno-jejunal intussusceptions, bowel wall thickening, and dilated small bowel loops proximal to the obstruction. On laparotomy, two concealed perforations were noted at the duodenojejunal (DJ) junction and 40 cm distal to the DJ junction. An enterotomy incision was given at the antimesenteric border of the distal jejunal perforation site, and the mass was successfully extracted. Primary repair was done at the DJ perforation site, and resection was followed by an end-to-end anastomosis at the distal jejunal perforation site. Surgery confirmed a complex mass of tangled hair within the gastric cavity with a tail extending into the pylorus of the stomach and small intestine, consistent with trichobezoar. Conclusion Computed tomography is superior to other radiological imaging modalities for diagnosing trichobezoars as it helps diagnose and demonstrate mechanical bowel complications.

S2489 Differentiating CMV Colitis From GVHD in Post-Transplant Patients: A Case Study

Introduction: Cytomegalovirus (CMV) infection can complicate the clinical course of immunocompromised patients including allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients, where the infection can be serious. CMV can involve different organs including lungs, brain, eyes, and the GI tract. Signs and symptoms of CMV infection may overlap with other conditions including graft-versus-host disease (GVHD), a multisystem disorder commonly seen in allo-HSCT recipients. Case Description/Methods: A 57-year-old female presented with abdominal pain and diarrhea. Past medical history included relapsed acute myeloid leukemia, treated with azacitidine and venetoclax followed by allo-HSCT. She was recently hospitalized for suspected GVHD with skin, liver, and gastrointestinal involvement. She was also found to have a CMV viral load of 920 IU/mL. Endoscopy showed diffuse inflammation across the GI tract, with biopsies revealing apoptotic bodies consistent with acute GVHD. She was treated with ruxolitinib and prednisone for GVHD, and valganciclovir prophylactically for CMV viremia. At this presentation, labs were notable for lymphocytes of 39 x103/uL and platelets of 22 x 103/uL, and CMV viral load of 1,822,242 IU/mL. CT imaging revealed thickened distal small bowel loops, cecum, and right colon, and edematous gastric walls with submucosal enhancement. Infectious work-up, including stool culture, ova/parasite, and clostridium, was negative. She underwent endoscopic evaluation; EGD showed white discoloration that washed off in the esophagus and diffuse erythematous mucosa in the stomach (Figure). Biopsies from gastric mucosa and right colon mucosa revealed focal nuclear changes. Immunohistochemical stains were positive for CMV. She was diagnosed with refractory CMV colitis and treated with maribavir with improvement of symptoms and reduction of viral load, and prior course of steroids was tapered. Discussion: Immunosuppression for GVHD has been identified as an important risk factor for CMV reactivation. Differentiating CMV colitis and GI-GVHD poses a diagnostic challenge, and endoscopic evaluation is needed to address this. Endoscopy can identify cecal ulcers, a reliable finding for CMV colitis in patients with GVHD after allo-HSCT.1 It is important to timely identify CMV colitis to prevent post-transplant morbidity and mortality. This case also demonstrates effectiveness of maribavir, a novel antiviral, for refractory post-transplant CMV colitis.Figure 1.: EGD images showing white discoloration in the entire esophagus and diffuse erythematous mucosa in the entire examined stomach.

S3344 The Hunt for the Lost Intragastric Balloon and Its Complications

Introduction: Obesity is a global pandemic on the rise, affecting about 40% of adults in the United States. There is a need for minimally invasive methods to aid current standard of care practices. The intragastric balloon (IGB) is a temporary therapy for weight loss, with the FDA approving several devices including the ObalonⓇ in the recent years. In 2021, AGA published clinical practice guidelines on Intragastric Balloons in the management of obesity. Serious adverse events are relatively rare in patients receiving IGB treatment, and include injury to the gastrointestinal (GI) tract, such as perforation (0.3%), esophageal mucosal injury (0.8%), gastric ulcer/bleeding (0.76%), and gastric outlet/bowel obstruction (0.12%). Case Description/Methods: A 47-year-old female with a medical history including two intragastric balloon placements (ObalonⓇ) one year ago, presented with severe acute abdominal pain. Patient’s BMI was 28 kg/m2. Routine labs were unremarkable and vitals were stable. Initial CT Abdomen/pelvis with contrast showed gastric and duodenal thickening; however, imaging failed to comment on a foreign object and location. A gastroscopy was performed subsequently showing one Obalon balloon found in the gastric fundus. The balloon was cut with a needle knife, collapsed and withdrawn with rat tooth forceps. To locate the second balloon, repeat imaging showed dilated bowel loops with a deflated ObalonⓇ lodged in the distal ileum, 7 centimeters proximal to ileocecal valve, resulting in mechanical small bowel obstruction. A colonoscopy was deferred due to concern for risk of perforation given the small bowel obstruction. Subsequently, the patient underwent laparoscopic enterectomy with approximately 5 cm of bowel on either side of the enterotomy with creation of anastomosis and foreign object retrieval. (Figure) Discussion: Intragastric balloons are a minimally invasive therapy for weight loss in conjunction with lifestyle modifications in the war against obesity. We present a rare, yet crucial case report of IGB complication resulting in small bowel obstruction and subsequent need for surgical intervention. IGBs are meant to be a short term, temporary tool for weight loss in obese patients generally BMI ≥ 30. This case highlights the importance of a timely removal, risk of severe complications, and emphasis on the importance of assessing proper indication for placement.Figure 1.: (A) Coronal view of CT scan showing dislodged Intragastric Balloon in the distal ileum (red arrow); (B) XR Abdomen showing radiopaque density overlying the left hemisacrum (red arrow) and dilated small bowel loops; (C) XR Abdomen Complete w/ Decub/Erect showing radiopaque foreign body in the right mid abdomen and second foreign body in the stomach (red arrows).

S2738 Isolated Celiac Artery Vasculitis Presenting as Ileus in a Patient With Ulcerative Colitis

Introduction: Small case series have reported an association between IBD and large vessel vasculitides, ANCA-associated vasculitis, and cutaneous vasculitis. Gastrointestinal (GI) involvement of vasculitis can be a severe complication, resulting in mesenteric ischemia, ileus, or GI bleeding, and often requires aggressive medical or surgical interventions. We report a case of celiac artery vasculitis presenting as abdominal pain and ileus in a patient with ulcerative colitis (UC). Case Description/Methods: A 69 year old male with an 11 year history of UC in remission on infliximab and azathioprine (AZA) presented to the emergency room with abdominal pain and constipation for five days. He had decreased AZA from 200 mg to 100 mg one month prior. Initial CT abdomen and pelvis showed stranding surrounding the celiac artery, fluid-filled small bowel loops, and segmental areas of distal colon collapse with proximal colon distention. He developed progressive small bowel and colonic distention with cecum diameter of 10 cm. A colonoscopy was performed for decompression. He had no evidence of active UC. EGD demonstrated dusky appearing gastroesophageal junction and inflammation with cratered ulcers in the gastric cardia and body. Biopsies confirmed ischemic necrosis. CTA demonstrated perivascular inflammation of a patent celiac artery without evidence for dissection, suggestive of acute vasculitis. ESR and CRP were 50 mm/hr and 7.8 mg/dL respectively. Myeloperoxidase, serine-proteinase 3, rheumatoid factor, ANA, were negative. He was started on methylprednisolone IV with oral prednisone taper at discharge, and AZA was increased to 200 mg daily. A CT one month later showed minimal residual inflammation. ESR and CRP had normalized. (Figure) Discussion: We present the first case of isolated celiac artery vasculitis in a patient with IBD. A diagnosis of IBD often precedes vasculitis, and patients are typically on immunosuppressive therapy at the time of onset. Anti-TNF agents have been implicated as a potential inciting cause. Although it is unclear whether long-term anti-TNF therapy precipitated vasculitis in our patient, the dose reduction in AZA prior to presentation may have unmasked vasculitis. This was supported by his rapid clinical and radiographic improvement with combination of steroids and increased AZA dose despite continuation of infliximab. This case highlights the importance of maintaining a high degree of suspicion for vasculitis in patients with IBD on immunosuppressive therapy presenting with ischemia or ileus.Figure 1.: A 69 year old male underwent EGD for evaluation of abdominal pain and NG tube placement; he was found to have inflammation with a dusky appearing mucosa at the gastroesophageal junction (GEJ) (A). Non-bleeding gastric ulcers with overlying pigment (Forrest Class IIc) were identified (B). H&E stain image shows the GEJ biopsy with extensive ischemic necrosis and hemorrhage (C). Initial CTA abdomen/pelvis shows fat stranding surrounding the celiac artery (D).

CHILAIDITI SYNDROME ABOUT A CASE: THE EXPERIENCE OF THE MEDICAL CLINIC THE STARS OF BAMAKO

The chilaiditi syndrome is a pathology characterized by the interposition of the small or colonic intestines in the space between the lower surface of the diaphragm and the liver. We report the case of a 39-year-old man, worker, operated 3 months ago for acute appendicitis who presented with abdominal pain, acute urinary retention and occlusive syndrome. The CT scan was performed and revealed small bowel obstruction and Chilaïditi syndrome with interposition of distended small bowel loops in the right inter hepato-diaphragmatic area and bilateral basal broncho-pneumopathy. An exploratory laparotomy made it possible to treat this Chilaïditi syndrome and intestinal obstruction with the discovery of a colon tumor of the transverse colon. The purpose of this work is to provide the diagnostic and etiological interest of computed tomography and the complications related to chilaiditi syndrome.

P30 A case of small bowel and leukocytoclastic vasculitis associated with acitretin therapy

Introduction/BackgroundAcitretin is an oral retinoid that is used to treat a number of skin conditions including acne. It is generally well tolerated and common side-effects such as gastrointestinal upset, mucosal and skin reactions are usually mild. However, we present what we believe to be the first reported case of small bowel and leukocytoclastic vasculitis (LCV) caused by acitretin and this required prompt treatment with intravenous glucocorticoids and cyclophosphamide to induce remission.Description/MethodA 53-year-old caucasian male presented to the Emergency Department with severe bilateral foot pain for four days and a purpuric rash which initially affected the soles of his feet and spread to affect all four limbs, both hands and abdomen. He was three weeks into his second course of acitretin 20mg daily for a flare of psoriasis, having ceased treatment three months before due to a suspected iatrogenic rosacea type reaction. He had generalised abdominal pain and recent constipation. Observations demonstrated a sinus tachycardia at 130 beats per minute only and examination revealed widespread patchy non-blanching palpable purpura and deep ulcers over the soles of both feet. There was mild abdominal distension and global tenderness but no peritonism. The remainder of the physical examination was unremarkable. Initial blood tests showed: haemoglobin 156 g/L, white cell count 13 x 109/L (neutrophilia: 10.6 x 109/L), platelets 514 x 109/L, CRP 123 mg/L, ESR 12 mm/hr, normal renal and liver function. Detailed immunology, microbiology and viral screens were negative including anti-neutrophil cytoplasmic antibodies (ANCA) and cryoglobulins. Urine dipstick was unremarkable. Abdominal x-ray showed distended small bowel loops and CT demonstrated significant intestinal wall oedema suggestive of small bowel vasculitis. Skin biopsy demonstrated typical changes of leukocytoclastic vasculitis. After surgical review he was managed conservatively on the high dependency unit with intravenous methylprednisolone 1g daily for three days followed by intravenous hydrocortisone and one dose of cyclophosphamide (15mg/kg). Total parenteral nutrition was initiated, and his bowel symptoms settled after two weeks. His skin significantly improved and he was discharged after four weeks’ inpatient stay. Actretin was stopped indefinitely, and he has remained in remission over three years later. Prednisolone was successfully tapered at a slow rate, and no further cyclophosphamide was required. His psoriasis is currently managed well with oral methotrexate.Discussion/ResultsLCV is a small vessel vasculitis which mostly occurs in the cutaneous form but can be life-threatening with systemic involvement. Around 50% of cases are idiopathic, with infections (15-20%), autoimmune diseases (15-20%) and malignancy (<5%) being well-recognised causes.Drug-induced LCV accounts for nearly 15% of cases and antibiotics, non-steroidal anti-inflammatories, anti-epileptics and TNF-alpha blockers are well-known precipitants. It usually occurs within three weeks after commencement of the medication, and the timing of re-introduction of acitretin in our patient makes it likely to be the cause. Up to 90% of LCV cases resolve within weeks to months after addressing the precipitating cause, with or without oral steroids. However, a 2% mortality is reported, likely due to systemic involvement and given the severity of our patient’s presentation, it was decided to commence immunosuppression in view of the skin biopsy and CT findings. (A biopsy of the small bowel was considered but would have delayed treatment).To our knowledge there are no published case reports linking LCV and small bowel vasculitis to acitretin therapy. However, there have been several case reports of LCV and other vasculitides caused by all-trans-retinoic acid (ATRA) and isotretinoin (first generation retinoids). Yamada et al. (1999) reported a severe case of haemonecrosis of the ileum, as a complication of ATRA treatment for acute promyelocytic leukaemia. Surgical intervention was required and histology demonstrated LCV.Isotretinoin was attributed to cause 5 out of 11 LCV cases reviewed by Dwyer et al. (1989). Turan et al. (2012) reported a case of a Henoch-Schonlein Purpura secondary to isotretinoin that improved with discontinuing treatment and three weeks of fluocortolone 20mg daily. More recently, a case of diffuse alveolar haemorrhage due to isotretinoin-induced granulomatosis with polyangiitis was described by Assuncao et al. (2018), which remitted with intravenous methylprednisolone and cyclophosphamide.Key learning points/ConclusionAlthough very rare, consider retinoids including acitretin in cases of drug-induced LCV and small bowel vasculitis.Symptoms usually improve on cessation of the treatment alone, but immunosuppression might be required for more severe cases.Future case series could help guide treatment choices.

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

An Unusual Cause of a Cecal “Seesaw” and Pneumatosis Intestinalis

Question: A 66-year-old woman with history of stroke, previous hernia surgery with mesh placement, and obstructive cholestasis due to choledocholithiasis presented with 3 days of right-sided abdominal pain, 15-lb weight loss over 1 month, and 3 weeks of constipation with thin stools. Colonoscopy was normal a few months prior. Her prior episode of choledocholithiasis in 2017 led to endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a double pig-tail stent. She was recently admitted 1 month ago for jaundice and right upper quadrant (RUQ) pain at which time magnetic resonance cholangiopancreatography showed severe intrahepatic and extrahepatic biliary duct dilation but no liver or pancreatic lesions. The cecum was nonspecifically distended and fluid filled. Esophagogastroduodenoscopy revealed a benign-appearing intrinsic duodenal stricture felt to be related to scar tissue from the previous hernia mesh surgery. ERCP revealed an occluded biliary stent that had migrated to the major papilla and a severe burden of choledocholithiasis. The occluded stent was removed, and partial removal of stones was achieved via basket extraction. A new biliary stent was placed with a plan to follow up in 4 weeks for repeat ERCP for further stone extraction and stent removal. Before this appointment she was readmitted for worsening RUQ pain. A computed tomography scan revealed dilated loops of distal small bowel and a dilated cecum that had folded anteriorly and superiorly with extensive pneumatosis. The ascending colon was also dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized, suggesting a transition point. No obvious mass or lesion was noted at the hepatic flexure (Figure A). Despite clinical improvement with conservative management, a lower gastrointestinal series performed a few days later showed persistent severe obstruction at the hepatic flexure with bird-beak appearance (Figure B). What is the most likely explanation for these imaging findings and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The patient’s imaging findings are consistent with cecal bascule (type III cecal volvulus). Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement.1Rabinovici R. Simansky D.A. Kaplan O. et al.Cecal volvulus. Dis Colon Rectum. 1990; 33: 765-769Crossref PubMed Scopus (119) Google Scholar Bascule in French means “seesaw,” describing the pathophysiology of the cecal presentation. Surgical management was indicated given the persistent and severe hepatic flexure stricture seen on lower gastrointestinal series. Exploratory laparotomy revealed numerous omental nodules and a mass was discovered in the RUQ involving the gallbladder and liver that was causing extrinsic compression of the hepatic flexure. The largest nodule was excised and confirmed a diagnosis of metastatic cholangiocarcinoma. A distal loop ileostomy was created to decompress the colon and prevent ongoing colonic obstruction. No colonic resection was necessary. The patient began cancer staging and treatment planning, but unfortunately passed 1 month after diagnosis. This is a unique case of an extrinsic malignant obstruction causing cecal bascule. The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus or after abdominal surgery, such as open appendectomies, which require extensive division of peritoneal attachments to the cecum. Clinical presentation varies with abdominal pain, distention, and nausea being the most common symptoms but can progress to an acute abdomen and perforation.2Lung B.E. Yelika S.B. Murthy A.S. et al.Cecal bascule: a systematic review of the literature.Tech Coloproctol. 2018; 22: 75-80Crossref PubMed Scopus (14) Google Scholar Diagnosis of type III cecal volvulus requires computed tomography imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel because colonoscopic detorsion may lead to recurrence.3Le C.K. Nahirniak P. Qaja E. Cecal volvulus. StatPearls Publishing. StatPearls Website, 2021Google Scholar

Spontaneous enterocutaneous fistula secondary to femoral hernia: A case report

Background: Femoral hernias account for 10% of all groin hernias. Females have a 4:1 incidence of abdominal hernias, while males have a 5% incidence. A spontaneous enterocutaneous fistula is rare due to a small bowel loop perforation in an incarcerated femoral hernia. Patients’ ignorance and late presentation cause these fistulas.

MECKELS DIVERTICULUM WITH MESENTERY AS A RARE CAUSE OF CLOSED LOOP OBSTRUCTION-A CASE REPORT

Meckel's Diverticulum is most common congenital anomaly of gastrointestinal tract. It arises from Antimesenteric border of the small bowel [1]. In contradiction, a case encountered at our institution where a 32-y old female presented with complaints of pain abdomen since 3 days, vomiting's since 3 days, obstipation since 3 days and distention since 1 day. On examination abdomen is distended, diffuse tenderness present all over the abdomen with no bowel sounds and collapsed rectum with no fecal staining per rectally. Imaging studies on ultra-sonography shown dilated small bowel loops with max diameter of 3.1cm showing to and fro peristalsis. On CT abdomen multiple dilated small bowel loops with air uid levels with maximum diameter of 4.1cms with collapsed terminal ileum and large bowel. ?Closed Loop Obstruction. Emergency exploratory laparotomy was planned and shown Meckel's diverticulum with mesentery present on anti-mesenteric border with mesentery extending from mesenteric border to tip of Meckel's diverticulum with internal herniation of proximal ileum between the Meckel's and its mesentery causing closed loop obstruction noted at 60cms from IC junction for which herniated bowel loops was released with diverticulectomy followed by anastomoses of proximal and distal ileal loops. Resected Meckel's sent for histopathological examination and cut section showed mucosa, sub-mucosa, muscularis propria and serosa. Mucosa shows chronic nonspecic inammation, sections from the adjacent area's shows hyperplastic mucosa, hypertrophied muscularis layers and serosa with congested blood vessels with feature's consistent with Meckel's diverticulum. Patient was followed for 6 months, and the course was un-eventful.

Ovarian torsion causing bowel obstruction in a premature infant

We report a case of 3-months-old infant with diagnosed complex ovarian cyst admitted to the hospital with acute onset of clinical signs of upper gastrointestinal tract obstruction. Urgent laparotomy was performed. A Treves' field mesenterial defect with herniation of small bowel loops and a complex ovarian cyst with torsion was identified. Unexpectedly, the Fallopian tube as a strangulation band of the herniated bowel loops was discovered within the mesenterial defect. During the operation bowel loops reduction, mesenterial defect closure and left adnexectomy due to presence of necrotic changes was done. Perioperatively, coincidental malrotation with Ladd's bands were found, thus Ladd's procedure was performed. Finally, right small paraovarian simplex cyst was fenestrated. The following postoperative course was uneventful. To the best of our knowledge, it is the first case report described in literature proposing unusual combination of congenital anomalies leading to acute intestinal obstruction.

EP-346 Laparoscopic extraction of a migrated gastric balloon from the terminal ileum causing small bowel obstruction

Abstract Aim Laparoscopic management of small bowel obstruction secondary to a migrated gastric balloon. Method A 57 years old female patient with BMI of 45 presented to ED by central colicky abdominal pain and recurrent attacks of vomiting with absolute constipation since 2 days. The patient had history of insertion of a gastric balloon since a year. On examination: abdomen: lax soft, mild abdominal distension, central abdominal tenderness, no signs of peritonitis. observations: Pulse:122bpm, BP 90/60, RR 25. blood tests: WCC 22.0×10 /L and CRP 129 mg/L. Venous lactate of 4. PMH:DM type 2, Missed appointments for gastric balloon extraction about 6months ago. Admitted under the surgical team resuscitated with IV fluid, IV antibiotics, sepsis 6 protocol activated. AXR: dilated small bowel loops. CT abdomen with I.V and oral contrast revealed impaction of the gastric balloon at the terminal ileum causing high grade small bowel obstruction. Patient had underwent laparoscopic extraction of the migrated gastric balloon from the terminal ileum and primary closure of the ileum by endo-stitch. Patient has smooth recovery postoperatively and discharged home two days after the surgery. This case highlights one of the complication of the gastric balloon which is migration of a gastric balloon into a terminal ileum as a result of missed appointments for its extraction after 6 months time. Conclusion laparoscopic management of SB obstruction in morbid obese patient should be the first choice provided that the surgeon has the required skills and experience.

SMALL BOWEL OBSTRUCTION CAUSED BY A SHIITAKE MUSHROOM: A CASE REPORT

A 77-year-old male farmer sustained severe abdominal cramping pain for one hour. Contrast-enhanced multidetector computed tomography (MDCT) showed a 5.2 cm, oval lesion with interior mottled gas and slightly hyperdense component in the small bowel loop causing distension of the proximal small bowel loop. CT diagnosis of a bezoar in the small bowel causing bowel obstruction was made. Exploratory laparotomy disclosed a foreign body of soft texture in the jejunum located at 150 cm from the ligament of Treitz. A whole, undigested shiitake mushroom was noted after incision of the bowel. The patient had an uneventful course during the 9 days of hospitalization. The patient had recalled that he did not have any teeth and did not use dentures during eating, and accidentally swallowed the shiitake mushroom 2 days before the incident occurred.

Mesenteric panniculitis, a rare entity presenting as (sub)acute intestinal obstruction: a case report

Mesenteric panniculitis (MP) is a rare condition. A few literatures have been published reporting MP. No prior case reports have been published from Nepal. We report 1 such case of MP mimicking an intestinal obstruction at our Center. A 79-year-old lady presented with complaints of diffuse abdominal pain associated with vomiting. X-ray abdomen showed multiple thickened and dilated small bowel loops. Ultrasound of the abdomen revealed prominent small bowel loops with sluggish peristalsis. A provisional diagnosis of intestinal obstruction was made. A contrast-enhanced computerized scan of the abdomen-pelvis showed diffuse, heterogeneous mesenteric fat stranding. She was started on oral prednisolone (40 mg once daily) and discharged on the fourth day. Her follow-up 2 weeks later was uneventful. The steroid was tapered gradually over the next week. With a wide spectrum of clinical manifestations, MP often poses diagnostic challenges to physicians. Lack of awareness of the disease may be associated with an increased disease burden to patients. MP should also be considered as a differential diagnosis when features of bowel obstruction are present.

CASE REPORT ON A NOVEL MANAGEMENT APPROACH FOR A BODY PACKER IN INDIA

Packaging of illicit drugs , concealed within the body by swallowing or insertion into vagina or rectum is called body packing. A 50 year old male patient brought by the customs department with alleged complaints of ingesting 50-60 contraband substance packets 6 days ago ; with no associated vomiting / pain abdomen / fever. General survey including vitals were under normal limits and examination of the abdomen was soft with no palpable mass or tenderness .Preliminary routine blood workup showed no derangements. Imaging studies like CT scan revealed multiple, well dened hyper-dense foreign bodies(drug packets) within small and large bowel loops with no signs of obstruction. A conservative management approach was adopted for this patient with IV uids, antibiotics, analgesics , antiemetics , proton pump inhibitors along with bulk laxatives. Intensive monitoring and frequent physical examination was done. The patient purged out a total of 108 drug packets in 6 days , with an uneventful hospital stay.