Mid Small Bowel Research Articles

Surgical Exploration for Intestinal Perforation in Extreme Preterm Neonates

Gastrointestinal perforation and peritonitis in preterm infants are most often due to necrotizing enterocolitis. These neonates are usually critically ill with multiorgan involvement and pose a challenge with regard to timing for definitive surgery. Peritoneal drainage is only a temporizing measure. Meticulous pre- and intra-op stabilization is mandatory for timely surgery. We describe a sick 710 g neonate where the perforation was the aftermath of intestinal obstruction from a mid-small bowel intussusception. This lays emphasis on considering other differentials for hollow viscus perforation even in extreme preterm neonates; these require surgical exploration and correction. The baby recovered well after primary resection anastomosis and several weeks of intensive care.

Case report of rare cause of small bowel obstruction: distal migration of metal biliary stent requiring enterotomy

Endoscopic biliary stent placement is a mainstay in the management of biliary strictures both malignant and benign. Distal stent migration is a known complication of metal biliary stents, however small bowel obstruction or perforation are rare. In this report from a tertiary referral centre, we detail a mid-small bowel obstruction caused by covered metal stent migration requiring a laparotomy and enterotomy for definitive management. A 69-year-old male was admitted to the Sunshine Coast University Hospital with obstructive jaundice on a background of previous metal biliary stent placement. On day 3 of his admission, he developed worsening abdominal pain. Cross-sectional imaging demonstrated distal migration of his stent to his mid-jejunum, causing a high-grade small bowel obstruction. He underwent laparotomy to retrieve the stent. He recovered well and underwent a percutaneous transhepatic cholangiogram with stent replacement. In this case, distal biliary stent migration causes a small bowel obstruction. Whilst uncommon, risk factors including previous intra-abdominal operation can be used to identify patients unlikely to achieve successful expectant management of distal migration.

A rare case of infected urachal cyst leading to intestinal obstruction in a 3-month-old boy with febrile urinary tract infection: Case report.

Urachal anomalies are rare and can present with various clinical manifestations. Urachal remnants, in particular, can be difficult to diagnose because of atypical symptoms at presentation. This study reports a case of intestinal obstruction in an infant secondary to an infected urachal cyst. A 3-month-old boy with a known febrile urinary tract infection developed acute abdominal distension. Abdominal ultrasound (US) and computed tomography (CT) revealed a nonspecific, ill-defined soft tissue density at the mid-abdomen, associated with intestinal obstruction. Emergency exploratory laparotomy was performed. The site of the obstruction was found to be at the mid-small bowel; the proximal small bowel was markedly distended, and the small bowel and sigmoid colon were adherent to urachal remnant. The urachal remnant was excised, and the peritoneal adhesions were lysed. The day after surgery, the patient was discharged without any complications. Intestinal obstruction is an exceedingly rare presentation of urachal remnants. This case highlights that urachal anomalies should be considered in the differential diagnosis in patients with intestinal obstruction and a concurrent febrile urinary tract infection.

Sennoside A+B Is as Effective as Polyethylene Glycol in Preparation for Small Intestine Capsule Endoscopy.

We aimed to compare the effectiveness of the polyethylene glycol (PEG) and sennoside A+B regimens after clear fluid diet and fasting in bowel preperation of capsule endoscopy. In this retrospective single-center study, patients who were consecutively examined with small bowel capsule endoscopy (SBCE) between May 2010 and March 2023 were evaluated. Patients who underwent PEG 4 L and sennoside A+B calcium 250 mL for small bowel preparation were assigned. The quality of the small bowel cleaning and the diagnostic yield in detecting of small bowel lesions were compared. Two hundred forty-two patients who underwent SBCE for various indications (PEG 74.4%, sennoside A+B 25.6%) were included in the study. The mean proximal small bowel cleaning scores was 1.97 ± 0.77 for PEG and 1.98 ± 0.04 (P = .83) for sennoside A+B; the mid small bowel cleaning scores was 1.76 ± 0.84 for PEG and 1.59 ± 0.05 (P = .108) for sennoside A+B; the mean distal small bowel cleaning scores was 1.27 ± 0.08 for PEG and 1.3 ± 0.54 (P = .805) for sennoside A+B; and the total small bowel cleaning scores was 1.66 ± 0.06 and 1.62 ± 0.04 (P = .622) for PEG and sennoside A+B, respectively. There were no significant differences regarding small bowel cleaning scores both segmentally and totally. At the same time, the diagnostic value of SBCE was similar in both groups. The effectiveness of sennoside A+B in SBCE preparation is similar to that of PEG and can be used in intestinal cleansing.

Secondary extramedullary plasmacytoma in the absence of active multiple myeloma: a rare cause of small bowel obstruction

A 75-year-old woman with a history of multiple myeloma in remission presented with signs, symptoms and imaging findings consistent with a small bowel obstruction secondary to an intussusception. She underwent operative management, and intraoperative findings were consistent with an intussusception of mid small bowel as the cause of the small bowel obstruction. The offending portion of small bowel was resected, and histopathology confirmed a plasmacytoma deposit in the small bowel at the lead point of the intussusception. Secondary extramedullary plasmacytomas in the gastrointestinal system are rare but can have significant consequences like small bowel obstruction requiring operative management. We present a rare case that emphasizes the need to be highly suspicious for uncommon sequelae of multiple myeloma like secondary extramedullary plasmacytomas when managing patients with history of multiple myeloma in remission with concerning abdominal symptoms.

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.

An unusual case of gastrointestinal immunoglobulin light chain amyloidosis causing small bowel intussusception

Intussusception is a rare complication of gastrointestinal (GI) immunoglobulin light chain amyloidosis. We report a unique case of systemic light chain (AL) amyloidosis with small bowel involvement which presented with GI haemorrhage and mechanical obstruction caused by intussusception. A 78-year-old female with a known history of kappa multiple myeloma presented with a two day history of coffee ground emesis and severe generalised abdominal pain. Abdominal CT imaging confirmed a mid-small bowel obstruction with intussusception and the patient proceeded to surgical resection.

P-B03 Gastric Band Tubing Causing Small Bowel Obstruction

Abstract Background Laparoscopically adjustable gastric bands (LAGB) have been widely employed as a means of weight loss in bariatric surgery over the past two decades. Although now largely superseded by other bariatric surgical techniques, complications from gastric bands continue to be encountered in surgical practice. We report an unusual case of small bowel obstruction due to an internal hernia caused by gastric band tubing resulting in closed loop small bowel obstruction. This is not commonly encountered and emergency general surgeons need to have a high index of suspicion for this condition as a possible cause for small bowel obstruction. Methods A 40 year old male presented with abdominal pain, vomiting and failure to open bowels or pass flatus for nine days. Twelve years previously (2008) he had had Roux n Y gastric bypass (RYGB), followed by by laparoscopic gastric banding of the RYGB about two years later (2010) also in the private sector. He had a soft but distended abdomen, and empty rectum on rectal examination. CT scan abdomen reported as: Multiple loops of distended small bowel demonstrated. No air seen in rectum, indicative of small bowel obstruction. No pneumoperitoneum. There is dilatation of the mid and distal small bowel seen to an apparent transition point in the mid abdomen where a loop is noted associated with the tubing for the inflation device for the gastric band. This appears to be centred on the cause of obstruction and appears tied around the base of mesentery and may be creating a closed loop obstruction, by having created an internal hernia. This patient had an internal hernia around loop of the gastric band tubing with resultant closed loop small bowel obstruction. The patient underwent diagnostic laparoscopy with ileo-caecal resection and primary anastomosis. He made successful recovery. Deflated gastric band remains in-situ. Results While small bowel obstruction is most commonly due to adhesions in individuals who have had previous laparotomy, it is important to bear in mind other causes such as internal hernias particularly in cases of those with history of previous gastric banding or Roux n Y gastric bypass. Early intervention may be necessary to reduce the likelihood of bowel ischaemia and bowel resection. Laparoscopy is a useful tool in the management of small bowel obstruction. Keywords: gastric band, small bowel obstruction, closed loop, emergency surgery, laparoscopy Conclusions Connection tubing causing small bowel obstruction and colonic erosion as a rare complication after laparoscopic gastric banding: a case report. Liza BK Tan, Jimmy BY So, and Asim Shabbir - J Med Case Reports. 2012; 6: 9. Acute small bowel obstruction due to the connecting tube of a gastric band. Federico Oppliger, M.D. Gonzalo Wiedmaier, M.D. Juan. Published April 07 2017. https://doi.org/10.1016/j.soard.2014.03.021 An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. M A Zappa, E Lattuada, E Mozzi, M Francese, I Antonini, S Radaelli, G Roviaro. Obes Surg . 2006 Jul;16(7):939-41. doi: 10.1381/096089206777822250 Total small bowel herniation through the space between the connecting tube of gastric band and abdominal wall: A case report of a surgical emergency. Tarek Hashem, Soliman M Soliman, Sherif Wagih 2. Int J Surg Case Rep. 2017;30:66-68. doi: 10.1016/j.ijscr.2016.11.021. Epub 2016 Nov 17

S2941 Fecal Microbiota Transplant in Recurrent Clostridium difficile Enteritis Following Colectomy

Introduction: Fecal microbiota transplant (FMT) is well-known as treatment for recurrent Clostridium difficile infection (CDI). It is curative in 80% of severe or fulminant CDI cases. In this case, we explore the utility of FMT in a patient with recurrent C. diff enteritis (CDE) after colectomy with ileorectal anastomosis. Case Description/Methods: A 46 yr old woman underwent abdominal colectomy with ileostomy 05/2020 with ileorectal anastomosis 07/2020 for severe colonic inertia and h/o ligament release for Median Arcuate Ligament Syndrome in 2/2021. She initially presented with RUQ abdominal pain, nausea, vomiting and diarrhea during the 1st episode of CDI in 10/2020 which was treated with Vancomycin 125mg PO QID for 10 days. Symptoms recurred a month later, C. diff toxin (CDT)+, and this 2nd episode was treated with 3 weeks of Vancomycin 125mg PO QID. Symptoms resolved but recurred 5 months later with hospital admission, again CDT+. CBC and renal function were normal. CT abdomen/pelvis showed nonspecific prominent fluid-filled loops of proximal and mid small bowel consistent with focal ileus or enteritis. Patient was treated for the 3rd time on a prolonged Vancomycin taper (125mg QID x 10 days, 125mg TID x 7 days, 125mg BID x 7 days, 125mg QD x 7 days, 125mg QOD x 14 days) with plans for FMT. She was readmitted 2 months later for pain, nausea, vomiting and diarrhea, CDT-, and underwent planned FMT. FMT was performed via flexible sigmoidoscopy reaching 70cm proximal to the anus with 250cc of donor fecal material mixed with saline (Open Biome). Since FMT, patient has reported resolution of symptoms. Discussion: FMT for recurrent CDI in patients s/p colectomy is not well-documented. A small series of patients s/p colectomy over 20 years showed recurrent CDE does occur after colectomy, and results in severe disease in half of patients, requiring hospitalization in 81%. Risk factors for CDE were colectomy for IBD, colectomy for fulminant CDI, β-lactam use with enteral feeds, and acid suppression after colectomy. Cases of fulminant CDE with multiorgan failure and death have been reported (diagnosed post-mortem). A young man with UC s/p colectomy with IPAA with recurrent CDE was effectively treated with FMT. While rare, recurrent CDE is potentially fatal and warrants consideration of FMT as a treatment modality. Though our patient did not have IBD, was not immunosuppressed and underwent colectomy for reasons unrelated to IBD, the recurrent CDE was effectively treated with FMT.

S790 Clinical Presentation and Outcomes of Patients With Mid-Small Bowel Crohn’s Disease From a Large Referral Center Cohort

S790 Clinical Presentation and Outcomes of Patients With Mid-Small Bowel Crohn’s Disease From a Large Referral Center Cohort

Double Barrel Stenting for Endovascular Repair of a Superior Mesenteric Artery Dissecting Aneurysm

Abstract The patient was a 58-year-old man with a history of hypertension who had incidentally been found to have a 2.7-cm dissecting fusiform superior mesenteric artery aneurysm involving a long segment of a proximal to distal superior mesenteric artery. Double-lumen anatomy was present, with the true lumen perfusing the proximal and mid-small bowel and the false lumen perfusing the distal small bowel and the ileocolic artery. The patient elected to undergo endovascular repair using double-barrel stenting with self-expanding and balloon-expandable covered stents, as described. Computed tomography angiography after 1 year demonstrated patent stents.

Gastrointestinal Stromal Tumour

A 70 year old female underwent a computed tomography angiogram to investigate chest pain (A). This reported a vascular malformation adjacent to the small bowel, fed via a branch of the superior mesenteric artery. At laparotomy there was a lesion arising from the antimesenteric border of the mid small bowel (B). This was removed by a limited small bowel resection. Histology reported a gastrointestinal stromal tumour (GIST). GISTs are mesenchymal neoplasms that arise in the gastrointestinal tract with variable malignant potential. Alternative pathologies should be considered when reviewing medical imaging reports of unusual vascular lesions.Image 1

S2916 When the Well Runs You Dry: A Case of Entamoeba histolytica Enteritis

INTRODUCTION: Amoebiasis is the second leading cause of death from parasitic disease worldwide with approximately 40,000-100,000 yearly deaths. Entamoeba histolytica is a health risk when there is an insufficient barrier between human feces and water source. Most individuals are infected by ingestion of E. histolytica cysts in contaminated food or drinking water. In the United States, most cases arise in immigrants from endemic areas or those with lower socioeconomic status. We present a case of amoebic enteritis in a patient without history of travel but exposure to well water. CASE DESCRIPTION/METHODS: 44-year-old male with history of chronic pancreatitis attributed to familial hypertriglyceridemia, pancreatic pseudocyst status post CT-guided drainage and failure to thrive status post PEG-J placement presented with progressive intolerance of J-tube feeds. CT Scan of the abdomen and pelvis revealed no structural reason for the patient to be intolerant of his feedings but did reveal new mild thickening of the mid small bowel indicative of enteritis. A GI pathogen panel with PCR was sent to rule out infectious causes. His GJ tube was exchanged, and though he had ongoing pain, he was tolerating tube feeds and was subsequently discharged. The patient was readmitted 2 weeks later with worsening left lower quadrant abdominal pain and up to 10 episodes of watery bowel movements a day. GI Pathogen panel was noted to be positive for E. Histolytica. On detailed history, patient admitted to bathing, drinking, and flushing his GJ tube with well water. He was treated with Metronidazole 500mg every 8 hours for 10 days followed by paromomycin dosed 25-30mg/kg divided into 3 doses daily for 7 days. His diarrhea and left lower quadrant pain resolved. It was recommended that the patient have his well water tested for other infectious agents or parasites. DISCUSSION: Most Entamoeba infections are asymptomatic. Risk factors for severe disease and increased mortality include young age, pregnancy, immunosuppression, malignancy, and malnutrition. Our patient was at increased risk due to malnutrition and flushing of the J arm which allowed the parasitic trophozoites to bypass the gastric acid unharmed. Misdiagnosis for ulcerative colitis and subsequent treatment with steroids has been shown to precipitate severe and fulminant forms of amebic colitis. Careful history taking and testing of stool with PCR when feasible should be conducted before initiating immunosuppression for inflammatory bowel disease.Figure 1Figure 2

Successful treatment of gallstone ileus with double-balloon enteroscopy-assisted electrohydraulic lithotripsy

A 79-year-old male presented with a two-day history of obstipation and vomiting. An abdominal computed tomography (CT) demonstrated a small bowel obstruction with a 3.5 cm gallstone impacted in the mid-small bowel (Fig. 1A, arrow). The small bowel obstruction did not improve after three days of nasogastric tube decompression, therefore we performed double-balloon enteroscopy (DBE)-assisted electrohydraulic lithotripsy (EHL) for removal of the impacted stone.

The Comb Sign

A 20-year-old woman with no significant past medical history presented with a 3-year history of intermittent cramping lower abdominal pain, worse post-prandial, with no change in bowel habit, nausea, or vomiting. Physical examination revealed a soft abdomen with tenderness to deep palpation across the periumbilical area. C-reactive-protein was mildly elevated at 31 mg/L and normal erythrocyte sedimentation rate of 5 mm/h. Gastroscopy and colonoscopy were normal. Computed tomography scan of the abdomen revealed a long segment of abnormality, approximately 60 cm, involving the mid small bowel and Comb sign was present (Figures A and B, arrows). A further magnetic resonance enterography revealed circumferential bowel wall thickening (Figure C, arrow). Subsequent deep intubation retrograde endoscopy revealed several scattered ulcers. Small bowel and colon biopsies revealed noncaseating granulomas (Figure D, arrow) consistent with Crohn’s disease. Comb sign is the engorgement of the mesenteric vessels with vascular dilatation, tortuosity with spacing of the vasa recta, and prominence of surrounding mesenteric fat resembling a comb and is associated with Crohn’s disease. However, it is not pathognomonic of Crohn’s disease and can also be associated with other inflammatory diseases of the bowel or vasculitis. Comb sign can be used to differentiate active inflammatory bowel disease from lymphoma, which is more likely to be hypovascular.

Evaluation and diagnosis of gallstone ileus using point of care ultrasound in the Emergency Department

A 75-year-old female presented to the Emergency Department (ED) with nausea, feculent emesis and abdominal distension. On previous visit the patient was diagnosed with a 2.2x1.9x1.1 cm ectopic gallstone in the mid small bowel without evidence of ileus or bowel obstruction and was subsequently discharged home. She returned 2 days later, abdominal plain radiographs revealed mildly dilated small bowel with air-fluid levels and a calcified mass in the right hemipelvis. Bedside ultrasound was performed and an air filled gallbladder with a fistulous tract was visualized. Dilated loops of bowel were visualized with an abnormal back and forth movement of intestinal contents, consistent with a small bowel obstruction. Patient went on to have an uncomplicated surgical extraction of the gallstone with resolution of her ileus. We would propose using point-of-care ultrasonography with abdominal plain films as an adjunct for evaluation and diagnosis of gallstone ileus in elderly patients.

2688 Blame It on the Migrating Stent: A Case Report

INTRODUCTION: Endoscopic implantation of plastic or metal stents is widely used to manage gastric and biliary disorders. However, complications from stent migration have also been well-documented. Biliary stents usually pass through the intestine without complications. In the case where invasive intervention is necessary, endoscopic retrieval is preferred to prevent surgical intervention. We report an acute abdominal pain case presumably from stent migration. CASE DESCRIPTION/METHODS: A 56 yo woman with past medical history of SMA chronic mesenteric ischemia status post revascularization and choledocholithiasis status post stent placement presented to the hospital for acute abdominal pain with nausea and vomiting. One month ago, she had a metal common bile duct stent placed for choledocholithiasis with biliary obstruction. Imaging showed showed the dislodged stent and mild mid-small bowel loop thickening with mid-small bowel stent. Initially, gastroenterology recommended watchful waiting and she was discharged home in stable condition. She returned to the hospital for persistent abdominal pain. Repeat imaging showed the dislodged common bile duct stent within the distal loop of small bowel, now appearing abnormally thickened and hyperemic but no evidence for bowel obstruction. After review with the surgery team, she was taken for combined mesenteric angiogram and exploratory laparotomy as the stent was inaccessible by endoscopy due to its location. On angiogram, all GI vasculature was patent, however a stricture was found adjacent to the stent. The strictured bowel was surgically resected and the stent was removed. The stricture was related to the ischemic changes that she previously suffered from prior revascularization. Abdominal pain improved and she was discharged home after tolerating a regular diet. DISCUSSION: This case illustrates that when abdominal pain is out of proportion to the physical exam, a broader differential would provide a different perspective. Initially, the diagnosis was homed in on the stent migration as the etiology of acute abdominal pain. Unfortunately, histories of previous abdominal surgeries and SMA revascularization were not explored until later. The stricture was only discovered after exploratory laparotomy. This case demonstrates premature diagnosis can be detrimental to patient care. It is imperative to understand the entirety of the patient’s history in order to make not only the correct diagnosis but to intervene in a timely manner to prevent morbidity and mortality.

2009 Bleeding Intestinal Lymphangiectasia Diagnosed and Treated by Using Double Balloon Enteroscopy in a 41-Year-Old Female: Case Report and Review of Literature

INTRODUCTION: Intestinal lymphangiectasia (IL) is a rare disease characterized by dilated lymphatic vessels in the intestinal wall and small bowel mesentery, which induce loss of protein and lymphocytes into the bowel lumen. Gastrointestinal bleeding (GIB) rarely has been described as the only symptom of IL. We describe a case of obscure GIB in a young female caused by lymphangiectasia localized to the distal jejunum by antegrade double balloon enteroscopy. CASE DESCRIPTION/METHODS: A 41-year-old African American female who initially presented to her PCP with chronic fatigue and intermittent episodes of melena. The patient was subsequently placed on iron supplementation and referred to gastroenterology for further work up. Physical examination finding were largely unremarkable. On laboratory tests, her hemoglobin declined to 5.8 g/dL (from a baseline of 10 g/dL). Initial Esophagogastroduodenoscopy (EGD) showed 2 cm hiatal hernia but was otherwise unremarkable. A subsequent colonoscopy showed mild internal hemorrhoids and a 3 mm solitary ulcer in the distal rectum but no other obvious sources of GI bleeding. Magnetic resonance enterography (MRE) was unremarkable. Next, a video capsule endoscopy was done which showed a site of active bleeding from the mid-small bowel and was associated with nodular mucosa and prominent lacteals. A subsequent double balloon enteroscopy (DBE) showed an oozing fold in the distal jejunum with white speckled appearance consistent with a bleeding lymphangiectasia. A total of seven clips were placed on the lesion and during application of clips, a white milky substance was noted coming from the lesion suggesting the diagnosis of lymphangiectasia. DISCUSSION: IL is most commonly found in the small bowel, making its diagnosis difficult by EGD or colonoscopy. DBE and video capsule endoscopy (VCE) are the two most important diagnostic modalities available to evaluate the entire small intestine.The noninvasive nature of VCE and its capability to visualize the entire small bowel has made it a first-line tool in many centers. However, DBE is preferred over video capsule endoscopy because of higher sensitivity from better endoscopic visualization and ability to perform biopsies for pathologic diagnosis. In this report, we present an extremely rare case of primary intestinal lymphangiectasia in causing obscure GIB and successful intervention using DBE. We believe this is the second case to report small bowel bleeding from jejunal lymphangiectasia, which was successfully treated using DBE.

2539 Case of a Young Man With Small Bowel Obstruction After Trauma

INTRODUCTION: In few reports, trauma has been associated with small bowel obstruction. These cases typically happen in children; however, in adults this is a rare phenomenon. We present a case in a young male with a history of MVA 5 years prior, who presented for small bowel obstruction related to his prior trauma. CASE DESCRIPTION/METHODS: A 27 yo male presented with recurrent abdominal pain for six months. He had intermittent diarrhea, abdominal bloating, and a 15 lb weight loss over that time. Physical examination was normal. Basic laboratory studies were significant for T bili of 1.4 mg/dl (normal 0.1 - 1.0). Diagnostic EGD, colonoscopy, and CT scan of the abdomen/pelvis were normal. Due to concern for a potential diagnosis of small bowel Crohn's disease, a video capsule study was performed, which showed a hold-up in the mid small bowel for over 2 hours, without any other abnormalities. Due to this, an upper double balloon enteroscopy was performed, which was revealing for a stenosis in the distal jejunum. The stenosis was marked with submucosal india ink injection. Biopsies of the stenosis were unrevealing. Previous medical history was negative with the exception of a motor vehicle accident complicated by intra-peritoneal bleeding five years ago, which was managed conservatively without surgery. Review of this patient's medications was negative for any NSAID use. He had no history of radiation exposure or abdominal surgery. He had never experienced any symptoms of abdominal pain or bloating prior to the onset of symptoms 6 months ago. Family history is negative for celiac disease or inflammatory bowel disease. Surgical resection of the stenotic segment was performed. The patient recovered from surgery without complication. Histopathology from the resected segment was consistent with benign small bowel without inflammation or other pathologic features. The conclusion of the medical providers was that this patient developed a symptomatic stricture as the result of previous MVA with hematoma. DISCUSSION: Small bowel obstruction from trauma has been highlighted in few cases in children; however, trauma-causing small bowel obstruction (SBO) in adults is more rare. Throughout the cases we reviewed, the timeline of this trauma causing SBO ranged from thirteen weeks to eight years after the initial event.2,3,4 In this case, the man presented five years after his MVA with symptoms of bowel obstruction, with a prior hematoma being the cause of this obstruction. This case highlights MVA as a cause of SBO in adults.

2599 Retained Video Capsule Due to Stricturing Crohn's Disease Safely Diagnosed With Use of Magnetic Resonance Imaging (MRI) in a Pregnant Patient

INTRODUCTION: Videocapsule endoscopy (VCE) is a noninvasive technology that provides diagnostic imaging of the small intestine. We present a case where MRI was safely utilized to diagnose a retained VCE in a pregnant patient. There is a lack of literature on the use of VCE in pregnancy as well as the use of MRI to diagnose retained VCE. Our case highlights the use of MRI to diagnose a retained VCE during pregnancy without any harmful effects to the patient or fetus. CASE DESCRIPTION/METHODS: A 16-year-old woman with a 4-year history of Crohn's disease presented at 24 weeks gestation with six months of achy, left upper quadrant (LUQ) abdominal pain associated with a 20-pound weight loss. On presentation, the patient was depressed, withdrawn and provided limited history. Exam demonstrated a thin young female with gravid uterus and LUQ tenderness. Labs were notable for ESR >100 mm/h and CRP 4.1 mg/L. An MRI was performed to aid diagnosis and minimize risk of radiation to the fetus. This revealed artifact at the anterolateral aspect of the left mid-abdomen (Figure 1). CT enterography confirmed foreign body in the left mid small bowel, likely jejunum, compatible with retained videocapsule (Figure 2). There was an adjacent segment of small bowel with suspected stricture (Figure 3). Additional history was then revealed by the patient's mother. She had undergone VCE six months prior. Shortly after, pregnancy testing was positive and imaging to confirm passage of the VCE was deferred. Subsequently, her pain worsened. Antegrade double balloon enteroscopy was attempted but could not reach the videocapsule. She underwent exploratory laparotomy revealing an intra-abdominal phlegmon and a loop ileostomy was performed. Patient delivered a healthy infant at 34 weeks. Resection of phlegmon and retrieval of foreign body were performed post-partum. DISCUSSION: Capsule retention is a potential complication of VCE, with a rate of 2.6% in patients with known or suspected Crohn's disease compared to an overall retention rate of 1.4%. Pregnancy is a relative contraindication to VCE due to a lack of safety data on whether the electromagnetic field of the capsule-recorder-system could harm the fetus. There is also feared theoretical complication of performing MRI while a capsule is within the gastrointestinal tract due to migration of the capsule and the potential for bowel injury or perforation. Our case reinforces the theory that 1.5 Tesla MRI can be safely performed in pregnancy with retained VCE without harm to patient or fetus.