Presence Of Bowel Obstruction Research Articles

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice.

Nasogastric tubes (NGT) have been in use for over 100years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.

A predictive model of bowel resection for incarcerated inguinal hernia based on the systemic immune-inflammation index.

Background and PurposeAn inguinal hernia is a common surgical disease. Once incarcerated or strangulated, it may endanger the life of the patient. Therefore, it is essential to study the risk factors of incarcerated inguinal hernia (IIH) and strangulated inguinal hernia (SIH). One of the serious complications of IIH and SIH is intestinal necrosis, which occurs owing to blood supply disorder. The study explores the risk factors of intestinal resection and establishes a simple model to assess the incidence of intestinal resection to provide significant assistance and limited guidance for clinical work.Patients and MethodsOur research team collected and retrospectively analysed the clinical data of 338 patients with IIH who were hospitalized in the First Affiliated Hospital of Wenzhou Medical University between September 2008 and December 2016. According to the surgical plan, we divided the included cases into two groups, non-intestinal and intestinal resection groups, and the clinical case characteristics of these groups were statistically analysed.ResultsBased on multivariable logistic regression analysis, we found that increased risk of bowel resection was highly correlated among the elderly (≥70 years), and for people with high temperature (≥37.3°C), high systemic immune-inflammation index(SII) values (≥1230.13), presence of bowel obstruction, and signs of peritonitis. Further, we processed the five independent risk factors using special software to obtain a simple model called a nomogram. To verify the nomogram’s accuracy and predictive ability, we calculate the C-index: 0.806 and use the calibration curve to evaluate its stability and predictive performance. We constructed the ROC curve nomogram and other sub-variables, and calculated the area under the curve (AUC) corresponding to the nomogram (AUC = 0.808, 95% CI = 0.762 to 0.848), SII (AUC = 0.752, 95% CI = 0.703 to 0.797), age (AUC = 0.641, 95% CI = 0.587 to 0.692), temperature (AUC = 0.579, 95% CI = 0.524 to 0.632), bowel obstruction (AUC = 0.685, 95% CI = 0.633 to 0.734), and signs of peritonitis (AUC = 0.580, 95% CI = 0.525 to 0.633).ConclusionIt can be said that we found for the first time that clinical variables such as SII are independent risk factors for enterectomy for IIH. The nomogram based on SII and other variables can accurately and easily predict the probability of IIH requiring bowel resection.

Nomogram reliability for predicting survival in patients with incurable cancer referred for home parenteral nutrition

In the presence of bowel obstruction, enterocutaneous fistula, short bowel, or severe mucosal disease, patients with incurable cancer are increasingly being referred for consideration of home parenteral nutrition (HPN). The decision to commence such treatment largely relies on expert opinion rather than robust data showing survival outcome. To address this shortcoming, a nomogram to predict median survival length in palliative cancer patients treated with HPN has been developed and validated.1 The nomogram is based on Glasgow prognostic score (CRP & albumin), primary cancer, metastases and Karnofsky performance status.

Haematological inflammatory markers for indicating ischemic bowel in patients with incarcerated abdominal wall hernias

To reveal the clinical significance of preoperative haematological inflammatory markers in the diagnosis of abdominal wall hernias with strangulation. The data of 200 patients who underwent surgery for incarcerated hernia were retrospectively analysed. The patients were grouped into three groups; Group 1; only surgical reduction and hernia repair, Group 2; small bowel resection and Group 3; omentum resection. Age, gender, hernia type, the presence of radiological bowel obstruction and preoperative complete blood count data were obtained. Neutrophil-leukocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), haematological inflammatory index (HII) and systemic immune-inflammation index (SII) values were calculated. The study was consisted of; Group 1: 119 patients (59.5%), Group 2: 46 patients (23%) and Group 3: 35 patients (17.5%). Advanced age (p = 0.001), female gender (p = 0.036), incisional hernias (p = < 0.001) and the presence of bowel obstruction (p = < 0.001) were found to be statistically significant in terms of strangulation. NLR, PLR and SII values were significantly higher in Group 2 compared to Group 1, and PLR values were significantly higher in Group 2 compared with Group 3 (p < 0.05). The preoperative elevated NLR, PLR and SII values may indicate strangulation and possible intestinal resection, in incarcerated abdominal wall hernias.

Role of clinical and CT findings in the identification of adult small-bowel intussusception requiring surgical intervention.

BackgroundIn adults, intussusception has been considered traditionally to have an underlying aetiology. The aim of this study was to determine CT and clinical features of small-bowel intussusceptions that required surgical intervention.MethodsAdult patients were identified in whom small-bowel intussusceptions were noted on CT images. The appearance, number, type (enteroenteric versus enterocolic), length and maximum short-axis diameter of intussusceptions, and presence of bowel obstruction (short-axis diameter of proximal small bowel greater than 3 cm) were analysed. The outcome was defined as surgical (complicated) or self-limiting (uncomplicated). Associations between complicated and uncomplicated intussusceptions and patient characteristics were investigated.ResultsAmong 75 patients (56 male) with a mean age of 45 years, 103 intussusceptions were identified, of which 98 (95 per cent) were enteroenteric and 5 (5 per cent) enterocolic. Only 12 of 103 intussusceptions (12 per cent) in 12 of 75 (16 per cent) patients required surgical therapy and were considered to be complicated, with half of these having a neoplastic lead point. Length (P < 0.001), diameter (P < 0.001) and type (P = 0.002) of intussusception as well as presence of vessels (P = 0.023) within an intussusception on a CT scan, clinical symptoms (P = 0.007) and signs of bowel obstruction (P < 0.001) were associated with a surgical outcome.ConclusionClinical symptoms, signs of bowel obstruction, type and length of intussusception, and a visible tumour within an intussusception on CT scan were critical signs of complicated intussusception, requiring surgical intervention.

69-Year-Old Man With Abdominal Pain and Obstipation

69-Year-Old Man With Abdominal Pain and Obstipation

Analysis of Hospital-Based Emergency Department Visits for Inflammatory Bowel Disease in the USA.

Inflammatory bowel disease (IBD) is a chronic, debilitating condition with high emergency department (ED) utilization. We aimed to investigate the utilization patterns of ED by IBD patients and measure hospitalization and surgical rates following ED visits. We conducted a cross-sectional study of adults with IBD listed as the primary ED diagnosis from the 2009 to 2011 Nationwide Emergency Department Sample. The characteristics of the IBD-related ED visits in relation to following hospitalizations and surgeries were analyzed. Adult IBD patients constitute 0.09 % of the total ED visits. Crohn's disease (CD) contributed to 69 % of the IBD-ED visits. The hospitalization rate from ED was 59.9 % nationally, ranging from 56 % in west to 69 % in northeast. The most significant factors associated with hospitalization were intra-abdominal abscess [odds ratio (OR) 24.22], bowel obstruction (OR 17.77), anemia (OR 7.54), malnutrition (OR 6.29), hypovolemia/electrolyte abnormalities (OR 5.57), and fever/abnormal white cell count (OR 3.18). Patients with CD (OR 0.66), low-income group (OR 0.90), and female gender (OR 0.87) have a lower odds of getting hospitalized. Age above 65 years (OR 1.63), CD (OR 1.89), bowel obstruction (OR 9.24), and intra-abdominal abscess (OR 18.41) were significantly associated with surgical intervention. The IBD-related ED visits have remained relatively stable from 2009 to 2011. The presence of anemia, malnutrition, hypovolemia, electrolyte abnormalities, fever, abnormal white cell count, bowel obstruction, or intra-abdominal abscess during the ED visit was associated with hospitalization. The presence of bowel obstruction and intra-abdominal abscess was strongly associated with surgical intervention.

Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis.

Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues. A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment. Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02). The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.

Outcomes of surgical treatment of primary signet ring cell carcinoma of the colon and rectum: 22 cases reviewed with literature.

Colorectal primary signet ring cell carcinoma (PSRCCR) is a rare entity with a dismal prognosis, mainly because of delayed diagnosis. The objective of this study was to investigate the clinicopathologic features and prognostic factors for PSRCCR. This is a retrospective study including the data of 22 patients with PSRCCR who underwent surgery. Patients were categorized by age, sex, tumor site, and stage. Fifteen patients were male. Median age was 40 years. Sites for metastases were lymph nodes (86.4%), peritoneum (40.9%), and liver (9.1%). Most of the patients (91%) had stage III or IV tumors. The rates of curative and palliative resections performed were equal. Mean overall survival and mean progression-free survival times were found to be 33.3 ± 7.1 months (95% confidence interval, 19.4-47.2 months) and 11.8 ± 3.5 months (95% confidence interval, 4.9-18.7 months), respectively. It was concluded that site of the tumor, presence of bowel obstruction, peritoneum and lung metastases, adjacent organ infiltration, TNM stage, and efficiency of surgery have significant effects on survival. All in all, these aggressive tumors are generally diagnosed at advanced stages. Depending on the situation, survival is shorter. A high degree of vigilance is required for these patients to avoid the negative impact of late diagnosis on survival.

Varying models of intra-abdominal hypertension and their effect on renal function in a porcine model

Intra-abdominal hypertension (IAH) is an independent predictor of renal impairment and mortality [1]. Organ dysfunction caused by the pressure effect of IAH is well understood, but how this is modified in the presence of bowel obstruction is unclear. The aim of this study was to determine how different IAH models cause renal dysfunction in a pig model.

336: Ultrasound derived estimated fetal weight using customized standards: does it improve prediction of adverse pregnancy outcomes?

gestational age at delivery, infant gender, mode of delivery, birthweight, and gestational age at maximal bowel dilation. Infants requiring surgery had statistically significant maximal bowel dilation at 50% and 100% increases over the 90th percentile (p .02, p .004). These infants also had significantly higher maximal bowel diameters (p 0.01), and hospital length of stay (p .007) (Table). CONCLUSION: Prenatal diagnosis of bowel dilation is concerning and may suggest the presence of bowel obstruction requiring surgical intervention. Our data show that the degree of bowel dilation antenatally may be a better predictor in determining those infants most likely to require surgery. Further examination of surgical cases is required to determine the degree to which ultrasound diagnosis of bowel dilation can predict surgical diagnosis.

Impact of bowel obstruction at the time of initial presentation in women with ovarian cancer

To determine whether the presence of bowel obstruction at the time of initial presentation has any prognostic significance in these women. Retrospective cohort study. Dedicated gynaecological oncology service of a large tertiary institution. Women who had a bowel obstruction as part of their initial presentation of ovarian cancer were identified between 1995 and 2007. Each woman was matched with four control women (with disease but no obstruction). Women with disease were compared with controls to determine the impact, if any, of bowel obstruction at presentation. Several prognostic variables including bowel obstruction were also evaluated in a Cox proportional hazard model. Progression-free survival (PFS) and overall survival (OS). Forty-eight women with disease and 192 controls were identified during the study period. The median follow-up period was 19 months among women with disease versus 20 months in controls. No differences were seen in demographics and clinical characteristics of the women. Optimal cytoreduction rate was similar between the two groups (75% versus 78%, P = 0.7). Patients with bowel obstruction had a shorter PFS and OS compared with controls [19 months versus 21 months (P = 0.01) and 22 versus 35 months (P = 0.008)], respectively. Bowel obstruction at presentation was an independent prognostic variable with a hazard ratio of 1.5 (P = 0.009). Other prognostic variables were age, stage and extent of surgical cytoreduction. Bowel obstruction at the time of initial presentation is an adverse prognostic factor in women with ovarian cancer.

The impact of smoking on cancer recurrence and survival in patients with stage III colon cancer: Findings from intergroup trial CALGB 89803

4039 Background: Although tobacco use is linked to the development of colon cancer, little is known about its impact in colon cancer survivors. Methods: We prospectively collected data on prior and current cigarette smoking on 1,045 patients with stage III colon cancer enrolled in a phase III adjuvant chemotherapy trial (bolus 5-FU/leucovorin ± irinotecan). Patients (pts) reported tobacco use in self- report questionnaires during (Q1) & 6 months after completion of adjuvant therapy (Q2). Smoking status was defined as never, current, or past. Lifetime pack years (pyr) were defined as # of packs of cigarettes over pt’s lifetime. Since there was no difference in efficacy between the two treatments, data for all patients were combined. Cox proportional hazards were computed for disease-free survival (DFS, our primary endpoint) and overall survival (OS). DFS and OS were measured from completion of Q1 to event of interest, excluding events within the 1st 90 days to avoid biases of change in behavior due to impending event. Results: Data on smoking history were captured on 1,045 patients of 1,264 in the phase III trial (460 [44%] past smokers; 107 [10%] current smokers; 478 [46%] never smokers). In analyses adjusted for age, N and T stage, grade of differentiation, and presence of bowel obstruction at dx, past smokers had hazard ratio (HR) for DFS of 1.15 (95% CI, 0.92–1.43; p=0.2) and current smokers had HR for DFS of 1.20 (95% CI, 0.85–1.70; p=0.3), compared to never smokers. Consistent with prior analyses, we defined pyr categories as 0, 0–10, 10–20, 20 or more. In unadjusted analyses, HR for DFS were 1.16 (95% CI, 0.89–1.52), 1.24 (95% CI, 0.85–1.83) and 1.33 (95% CI, 1.03–1.73) for lifetime pyr 0–10, 10–20 and 20+, respectively, compared to never smoking (p trend 0.04). In adjusted analyses, HR for 20+ pyr was 1.25 (95% CI, 0.96–1.63) compared to never smoking (p trend 0.15). HRs for OS were similar as DFS for smoking status and lifetime pyr. Conclusions: Lifetime total of tobacco usage may influence outcomes in patients with stage III colon cancer. Further research with larger datasets is warranted. No significant financial relationships to disclose.

Progress in the Management of Gynecologic Cancer

Progress in the Management of Gynecologic Cancer

Does the CT Whirl Sign Really Predict Small Bowel Volvulus?

The objective of this study was to determine the sensitivity of the CT "whirl sign" for the diagnosis of small bowel volvulus in patients who present with a clinical suspicion of intestinal obstruction. Between January 2002 and September 2004, 1,493 CT scans performed in 1,213 patients suspected of having small bowel obstruction were retrospectively reviewed by one attending radiologist with gastrointestinal subspecialization and one senior radiology resident. Multislice helical CT scans were performed after oral and intravenous contrast administration. All CT scans showing a combined vessel and bowel whirl appearance were identified. Other features recorded included the number of degrees of whirl rotation, direction of rotation, presence of bowel obstruction, and signs of ischemia. Diagnoses were determined at either surgery or clinicoradiographic follow-up. Surgical follow-up was available in 174 of the 1,213 patients. There were 460 males and 753 females ranging in age from 1 to 95 years (mean 59 years). A whirl sign was found in 33 of the 1,493 CT scans by reader 1 and in 13 of the 1,493 CT scans by reader 2. In 11 patients, surgery revealed small bowel volvulus (0.9%). Reader 1 detected 7 of the 11 volvuli (sensitivity 64%, specificity 98%, positive predictive value 21%, negative predictive value 99.7%). Reader 2 detected 3 of the 11 volvuli (sensitivity 27%, specificity 99%, positive predictive value 23%, negative predictive value 99.5%). The CT scans of the four remaining patients with volvulus not initially recognized by either reader were re-reviewed and were felt to contain whirl signs. Most patients with small bowel volvulus can be identified on CT through detection of a whirl sign. However, most whirl signs detected on CT will not prove to be indicative of small bowel volvulus.

The abdominal radiographic series in children with suspected bowel obstruction--should the second view be abandoned?

To determine whether the addition of a second (horizontal beam) view to the supine abdominal radiograph improves diagnostic accuracy in the diagnosis of paediatric bowel obstruction. The abdominal radiographs of 72 paediatric patients were retrospectively evaluated for the presence of bowel obstruction by 22 independent observers (radiologists, surgeons and emergency physicians) of varying experience. Evaluation involved initial assessment of the supine radiograph alone, followed by reassessment with the addition of an upright or decubitus radiograph. When observers evaluated supine radiographs alone, their sensitivity was 66%, specificity 72% and accuracy 70%. With the addition of the second view sensitivity was 78%, specificity 75% and accuracy 76%. The mean change in accuracy was 6% with no statistically significant difference between radiologists, surgeons or emergency staff. The value of the routine second radiograph in the accuracy of diagnosis of bowel obstruction is limited, and its use should be restricted to selected cases in which diagnostic uncertainty persists.

DISSEMINATED STRONGYLOIDIASIS ARISING FROM A SINGLE DOSE OF DEXAMETHASONE BEFORE STEREOTACTIC RADIOSURGERY

SUMMARY A fatal case of disseminated strongyloidiasis is described, abruptly following a single high dose of dexamethasone before stereotactic radiosurgery. The mechanism of steroid‐induced dysregulation of Strongyloides infection is unclear. Treatment failure and the use of rectal thiabendazole in the presence of bowel obstruction is discussed. This case reinforces the need to screen selected patients for strongyloidiasis before any high‐dose steroid therapy, particularly in the presence of persistent eosinophilia.

Percutaneous Colostomy for Treatment of Mechanical Bowel Obstruction: Factors Affecting Feasibility

To assess the feasibility of large-bore tube colostomy in the presence of bowel obstruction in a pig model. Porcine spiral colon was isolated, obstructed, pressurized to 18 mm Hg, punctured with 24-F radial dilators or balloon-sheath combinations in randomized sequences, and assessed for leakage. In another experimental set, T tacks were used. The effects of various drainage configurations and systems (open vs closed) on drainage and leakage were assessed during continued gut perfusion. Pressurized colon leaked 0-19.8 mL during radial dilation, 0-210 mL during balloon-sheath dilation, and 7.4-29.8 mL/min at T-tack sites. Leakage increased with minor motion. Leak-free drainage during perfusion could be obtained only with open systems or with closed systems that were inserted at least 10 cm proximal to the obstruction. Percutaneous colostomy should only be attempted in very select cases with extreme attention to detail.

PREDICTION OF OUTCOME AFTER CURATIVE RESECTION FOR LARGE BOWEL CANCER

Prospectively collected information on 2524 patients who had undergone "curative" resection for colorectal cancer was analysed to establish the rank-order of importance of both clinical and pathological factors affecting outcome. The patients were divided into two groups. In the first, a statistical weighting was established for each prognostic factor and those that influenced long-term survival were, in order of importance, lymph node status, tumour mobility, number of lymph nodes positive for tumour, presence of bowel obstruction, and depth of primary tumour penetration. Factors that influenced in-hospital mortality were cardiopulmonary complications, intraabdominal sepsis (without anastomotic leak), presence of bowel obstruction, and age. In the second group these mathematical weightings were applied, and the predicted and observed outcomes were in close agreement. Statistical techniques of this kind will be of value in prognosis and in analysis of the results of new treatment regimens.

Elaboration of Criteria upon which the Early Diagnosis of Acute Intestinal Obstruction may be Made, with Special Consideration of the Value of X-ray Evidence

THE mortality in acute intestinal obstruction continues to be prohibitively high. Recent reports from large municipal hospitals where cases of bowel obstruction are frequently seen indicate that from 35 to 60 per cent of patients operated upon for acute bowel obstruction die (Miller). Despite the fact that marked improvement is manifest in the results of practically all other acute abdominal catastrophes, the mortality of obstruction to-day is almost that of forty years ago. This is due in large measure to late diagnosis, for any number of statistical studies indicate that when cases come to operation early the results compare fairly satisfactorily with the issue attending the surgery of other acute abdominal disorders. Finney reports a mortality of 36 per cent in 217 cases, but within the first 12 hours the mortality was 5 per cent and for the 12-to-24-hour period, 11 per cent. Whereas the mortality in the entire group of 128 cases of acute intestinal obstruction reported by Tuttle was 41.3 per cent, in 13 cases operated upon within 6 hours there were no deaths and in the 25 patients operated upon within 12 hours the mortality was 4 per cent. In 124 cases reported by Brill the mortality for the group was 36.3 per cent, but of the 17 cases operated upon within the first 12 hours there were no deaths, and of 16 cases operated upon between 12 and 24 hours, 12.5 per cent died. Diagnostic Features of Obstruction The criteria upon which the diagnosis of intestinal obstruction is usually made are the following: Pain, nausea and vomiting, obstipation, meteorism, and collapse. All of these symptoms may be observed at some time during the course of obstruction, but usually at not sufficiently early an hour to afford the patient early remedial help. Difficulties in Diagnosis Absence of Local Physical Findings.—There are two factors, I believe, which are largely responsible for the difficulty in making the diagnosis. One of these is the absence of local physical findings in acute bowel obstruction. When obstruction of the strangulating variety is present, local physical findings are usually in evidence; when, however, only the continuity of the bowel is obstructed without vitiation of the blood supply of the intestine, early physical findings are absent. In all other acute abdominal disasters rigidity and tenderness occur early, suggestive of the presence of a serious lesion within. Were acute cases of appendicitis not heralded by the presence of tenderness or rigidity, undoubtedly a larger number would come to operation when peritonitis had already supervened. The very fact, however, that acute intestinal obstruction is the only serious abdominal disorder of an acute nature in which physical findings are absent early is of great importance. When a patient complains of intermittent, crampy, colicky pain, nausea and vomiting, but local physical signs are absent, the presence of bowel obstruction should immediately be accorded serious consideration.