Presence Of Small Bowel Obstruction Research Articles

Ileal leiomyosarcoma as a cause of small bowel obstruction

Introduction. Ileal leiomyosarcoma is unusual form of malignant gastrointestinal tumor. Often insidious in clinical presentation, it frequently presents a diagnostic challenge. Occasionally, a correct diagnosis is finally established due to an emergency situation. The aim of this study was to present the role of magnetic enterography in determining the precise cause of small bowel dilation. Case outline. A 59-year-old female patient presented with small bowel obstruction. Erect abdominal radiograph identified the presence of small bowel obstruction and excluded pneumoperitoneum. A non-contrast computed tomography of the abdomen and pelvis noted transitional zone in the region of terminal ileum with collapsed bowel lumen distal to the transitional point, without determined underlying cause. Magnetic resonance enterography observed obstructive intraluminal soft-tissue mass with fatty component sized up to 4 cm in the terminal ileum, with mesenteric involvement. The abdominal surgeon revealed ileal intraluminal tumor which affected the locoregional mesentery and serosa of the adjacent bowel. Histological and immunohistochemical analysis confirmed the diagnosis of ileal leiomyosarcoma with involvement of wall serosa and mesenteric fat tissue. Conclusion. Magnetic resonance enterography is a reliable diagnostic tool for detection and diagnosis of malignant small bowel tumors. Sometimes, tumors manifest clinically as bowel obstruction. Surgical treatment is necessary, while histology and immunohistochemistry are crucial to confirm the diagnosis of small bowel leiomyosarcoma.

Point-of Care Ultrasound in Stratifying Clinically Evolving Inguinal and Femoral Hernias

BackgroundPoint-of-care ultrasound (POCUS) is an optimal imaging modality for the risk stratification of patients presenting to the emergency department (ED) with inguinal and femoral hernias, allowing for better evaluation of clinical presentations and guiding appropriate treatment. The lack of ultrasound classification for inguinal and femoral hernias has led to inconsistent use and often underuse of POCUS in this patient population. Several groin hernia classifications are available, but most are complex and often targeted toward surgical management. ObjectivesThe objective of this study is to review the use of POCUS in the diagnosis of inguinal and femoral hernias, providing a synopsis of critical ultrasound findings in determining signs of incarceration, strangulation, and small bowel obstruction, and suggesting a simple and educative sonographic classification for inguinal or femoral hernias. DiscussionPOCUS can reliably confirm the presence of groin hernias and can uniquely identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls. POCUS can also aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site. ConclusionsIn the ED, POCUS can confirm the presence of a hernia sac and identify and predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias.

Nonoperative management of periappendiceal abscess in children: A comparison of antibiotics alone versus antibiotics plus percutaneous drainage

PurposeTo determine the optimal nonoperative management of periappendiceal abscess in a pediatric population, we compared the therapeutic efficacy and cost-effectiveness of antibiotics alone versus antibiotics plus percutaneous drainage (PD). MethodsWe conducted a 10-year retrospective chart review of pediatric patients less than 18 years of age who had acute perforated appendicitis complicated by periappendiceal abscess. Group 1 consisted of patients (N = 35) who received nonoperative management with antibiotics only.Group 2 consisted of patients (N = 11) who underwent PD and also received antibiotics. Group 1 was subdivided into groups 1A and 1B. Group 1A consisted of patients (N = 25) who responded to antibiotics treatment. Group 1B consisted of patients (N = 10) who were initially treated with antibiotics but subsequently required PD. Patients' demographics, initial clinical presentation, abscess size and location, length of hospital stay, outcome, and complications were compared among these groups. ResultsMedian hospital stay of group 1A and group 2 was identical at 6 days. Group 1B had a significantly longer median hospital stay of 13 days. There were no deaths and no significant long-term complications in any group. One patient in group 1A returned to the emergency room (ER) for abdominal pain and was readmitted for observation. Four patients in group 1B returned to the ER shortly after discharge and required readmission. One of these 4 patients developed acute pancreatitis in addition to enlarging abscess and underwent surgical drainage. There were no documented failures or complications of treatment in group 2 prior to interval appendectomy with the exception of 1 patient lost to follow-up. The presence of small bowel obstruction at the time of admission was an independent predictor of increased length of stay. ConclusionsAntibiotic therapy alone can be effective in a majority of patients and is recommended as initial management. To prevent potential complications and increased cost, PD should not be delayed if clinical symptoms persist or the abscess remains unchanged. Reimaging 6 days after initiation of antibiotic therapy with ultrasound or MRI is recommended to identify patients who would progress on antibiotics alone or who need to receive drainage without delay. Level of evidenceLevel III.

Small bowel obstruction with gallstone. Case report

Clinical case study of a cholelithiasis rare complication — gallstone small bowel obstruction with cholecystoduodenal fistula has been presented. According to several studies, the frequency of gallstone small bowel obstruction is approximately 0.3 to 4 % of all cases of small bowel obstruction, and 0.2 to 0.6 % of patients with cholelithiasis. A patient at the age of 69 years, was admitted to the surgical department in urgently 07.11.2017 with the diagnosis of acute gallstone small bowel obstruction. The diagnosis was based on complaints, anamnesis, clinical signs, additional imaging methods (radiography and ultrasound examination of the abdominal cavity organs). The patient was operated urgently. In the lumen of the small intestine at a distance of 120 cm from the Treitz ligament a concrement up to 33 × 26 mm was found, proximal to the concrement the loops of the small intestine were expanded to 42 mm, filled with intestinal contents and gas, distal to the concrement, the small intestine collapsed. The dense infiltrate up to 6 × 4 cm, involving the gallbladder and duodenum was visualized during operation in the subhepatic space. There was no bile and intestinal content leakage in the infiltration area. Enterotomy, lithoextraction, enterorrhaphia were performed. Dissociation of the cholecystoduodenal fistula was not performed due to the severity of the patient’s condition and the presence of small bowel obstruction. The postoperative period was without complications. The patient was discharged in a satisfactory condition. An ultrasound examination of the abdominal cavity organs allowed to diagnose this pathology before the operation, demonstrating high sensitivity and specificity of the method.

Factors associated with failure of nonoperative treatment of complicated appendicitis in children

Appendicitis remains the most common cause for emergency abdominal surgery in children. Immediate appendectomy in complicated, perforated appendicitis can be hazardous and nonoperative therapy has been gaining use as an initial therapy in children. Previous studies have reported failure rates in nonoperative therapy in such cases ranging from 10% to 41%. Factors leading to treatment failures have been studied with various and disparate results. We reviewed our institutional experience in treated complicated appendicitis, with focus on those initially managed nonoperatively. MethodsRecords of all children admitted with the diagnosis of perforated appendicitis to NYU Langone Medical Center and Bellevue Hospital Center from January 1, 2003 to December 31, 2013 were reviewed. The diagnosis was made with ultrasound and/or computed tomography scan. Those with abscesses amenable to drainage underwent aspiration and drain placement by an interventional radiologist. Broad spectrum intravenous (IV) antibiotics were given until the patient became afebrile, pain free and tolerating a regular diet. Oral antibiotics were continued for an additional week and interval appendectomy was done eight weeks later. The primary outcome measure was treatment response with failure defined as those who did not improve or required readmission for additional IV antibiotics and/or early appendectomy. Multiple patient and treatment related variables, including those previously reported as predicting failure in nonoperative therapy, were studied. Continuous variables were reported as means ± standard error and compared using 2-tailed unpaired t tests; nonparametric variables were analyzed by Mann–Whitney U tests. Categorical variables were reported as medians ± interquartile ranges and compared using Chi-square testing. Statistical significance was accepted for p<.05. ResultsSixty-four patients were identified as undergoing initial nonoperative therapy. Fifty-two (81%) were categorized as treatment successes being treated nonoperatively and 12 (19%) were failures. Variables showing no significance in predicting treatment failures included duration of symptoms, presence of appendicolith, presence of phlegmon, presence of abscess, initial white blood cell count, and SIRS (Systemic Inflammatory Response Syndrome) positive. The variables that predicted failure of nonoperative therapy vs. successes were presence of bandemia (75% vs. 40%, p=0.052) and small bowel obstruction on imaging (42% vs. 15%, p=0.052) and presence of bandemia ≥15% which was highly predictive of failure (67% vs. 4%, p<0.01). ConclusionsPredicting which patients with complicated perforated appendicitis will respond well to nonoperative therapy may allow us to more effectively treat patients with complicated perforated appendicitis. In our study the presence of small bowel obstruction and bandemia, especially ≥15% correlated with treatment failure; this suggests that these select patients may need a modified treatment strategy.

Obturator hernia: the relationship between anatomical classification and the Howship–Romberg sign

The obturator hernia sac may follow the anterior or posterior branch of the obturator nerve, and thus, it can be classified anatomically. The relationship between the symptoms and the anatomical classification of obturator hernia has not yet been clearly described in the literature. Multidetector-row computed tomography (MDCT) examinations of 35 consecutive cases of new-onset obturator hernia admitted from March 2005 to April 2012 were reviewed retrospectively. Obturator hernia was classified anatomically using MDCT. Patient characteristics and clinical presentations were compared among the anatomical classifications. Fifteen cases were classified as type I (anterior branch type) and 20 cases as type II (posterior branch type). There were no significant differences regarding time from onset of symptoms to diagnosis, presence of small bowel obstruction, and need for bowel resection. The Howship-Romberg sign was seen in 6 cases (30 %) of type II and 10 cases (67 %) of type I (p = 0.044). The Howship-Romberg sign was present significantly more often with the anterior than the posterior branch type of obturator hernia.

Advantages of abandoning abdominal cavity irrigation and drainage in operations performed on children with perforated appendicitis

PurposeThis study evaluates the effect of peritoneal irrigation and drainage on postoperative morbidity when used together for perforated appendicitis. Material and methodsThis study was conducted on children undergoing open appendectomy for perforated appendicitis. Sixty-one children with perforated appendicitis operated on with irrigation and drainage between July 1998 and September 2001 (group DI) and 173 children with perforated appendicitis who underwent surgery without irrigation and drainage (group NDI) between October 2001 and November 2011 were retrospectively evaluated (a total of 234 patients). All patients were treated and followed up by the same pediatric surgeon using the same protocol. Both groups were compared in respect to postoperative complications, including wound infection, wound dehiscence, intraabdominal abscess, prolonged ileus, the presence of small bowel obstruction requiring surgery, operative time, and length of postoperative hospital stay. ResultsOf the total 234 patients, 151 were male and 83 were female with a mean age of 8.9 ± 3.7 years (range, 1.5-15 years). The wound infection rates were 4.9% in group DI and 1.7% in group NDI (P = .184). Wound dehiscence was seen in 1.6% vs 0%, prolonged ileus in 8% vs 2.3%, intraabdominal abscess in 4.9% vs 1.7%, and small bowel obstruction requiring surgery in 1.6% vs 0.6% of the patients (P = .261, P = .054, P = .184, and P = .454, respectively). No statistically significant difference in postoperative infectious complications was found between both groups. The length of postoperative hospital stay was 9.9 ± 4.1 days in group DI vs 6.3 ± 2.4 days in group NDI (P < .001). The operation times were 39 ± 8 and 31 ± 11 minutes, respectively (P < .001). ConclusionThis study demonstrates that peritoneal irrigation and drainage in children with perforated appendicitis is not required, and in fact, these procedures cause an increase in operative time.

Spigelian hernia mimicking appendicular mass

Case report A 44-year-old woman with a virgin abdomen presented to the Emergency Department with a 2-day history of nausea, constipation and right iliac fossa abdominal pain. Physical examination revealed tenderness maximum at McBurney’s point associated with an ill defined palpable intra-abdominal mass. The patient’s haemoglobin and white blood cell count were within normal limits. Abdominal plain film radiograph (PFR) showed faecal loading of the colon, but no other cause for the patient’s symptoms (Fig. 1). Given the equivocal blood tests and PFR results, computed tomography (CT scan) of the abdomen and pelvis was performed. The CT scan revealed an incarcerated loop of small bowel within a right sided Spigelian hernia, dilated proximal small bowel loops, and a radiologically normal retro-caecal appendix (Figs. 2, 3). Because of the presence of small bowel obstruction and possible need for bowel resection, the patient underwent open surgery through a right iliac fossa incision where a knuckle of dusky but viable terminal ileum was reduced, and the defect closed with non-absorbable sutures. Incidental appendicectomy was not performed as this would have required extension of the incision and mobilisation of the caecum, and because the appendix was not responsible for the patient’s symptoms. The patient recovered uneventfully, and was discharged on the fourth post-operative day. Discussion

Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery

To evaluate the sensitivity and specificity of eight previously reported computed tomography (CT) signs in diagnosing internal mesenteric hernia following Roux-en-Y gastric bypass surgery. Preoperative CT images of nine patients with surgically proven internal mesenteric hernia as a complication of gastric bypass surgery and 10 matched control patients were reviewed in a blinded fashion by three radiologists. The presence of eight previously reported signs of internal mesenteric hernia was assessed: mesenteric swirl sign, hurricane eye sign, mushroom sign, small bowel obstruction, clustered small bowel loops, small bowel other than duodenum located behind the superior mesenteric artery (SMA), presence of the jejunal anastomosis to the right of the midline, and engorged mesenteric lymph nodes. The sensitivity and specificity were calculated for each sign, as well as inter-observer reliability in recognizing these signs. Mesenteric swirl was the most predictive sign of internal hernia (sensitivity 78-100%, specificity 80-90%). Other CT signs showed good specificity (70-100%), but sensitivities were low (0-44%). The presence of a small-bowel obstruction and engorged mesenteric nodes was found to be 100% specific in predicting the presence of an underlying hernia. There was substantial inter-observer agreement in detecting mesenteric swirl sign (kappa=0.48-0.79), but agreement was relatively poor for all other signs. Mesenteric swirl is an easily recognized CT sign, and is the best indicator of internal hernia following Roux-en-Y gastric bypass surgery. Other reported CT signs are diagnostically insensitive. The presence of small-bowel obstruction with engorged mesenteric nodes is highly specific in diagnosing internal mesenteric hernia.

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

Introduction The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure. Methods Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval. Results Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001). Conclusion Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.

Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images?

Feasibility of diagnosing small bowel obstruction on multidetector-row computed tomography (MDCT) using coronal reformations alone is evaluated. Three radiologists with subspecialty training in abdominal imaging reviewed abdominopelvic CT of 67 patients in consensus. Thirty-four patients had surgically proven small bowel obstruction. The remaining 33 patients had CT for other reasons and had no intestinal obstruction. The images were displayed in either axial or coronal planes and were reviewed on separate days . Each CT was evaluated for the presence of small bowel obstruction and its etiology when applicable. Thirty-three (100%) of 33 patients were correctly diagnosed not to have intestinal obstruction on coronal images. Thirty-four (100%) of 34 patients were correctly diagnosed to have small bowel obstruction on both forms of image display. There were five patients where the final surgical diagnosis for the etiology of small bowel obstruction did not agree with the interpretation of either the coronal or axial images; however, in all five patients, the interpretations of axial and coronal images were similar. In only one patient, the etiology of small bowel obstruction based on the coronal images did not agree with that of axial images and the surgical result; however, the site of small bowel obstruction was correctly diagnosed. There were approximately 20% fewer images in the coronal reformation data set, and the radiologists found review of these images to be easier for localizing the zone of transition in small bowel obstruction. Very high diagnostic accuracy can be achieved based on coronal reformations alone, and this form of image display may potentially be substituted for the conventional axial images. Since there are fewer images to review when the studies are displayed in coronal plane, this may positively impact radiologist workflow.

Jejunal diverticula in the presence of small-bowel obstruction.

Journal Article Jejunal diverticula in the presence of small-bowel obstruction Get access D J Pinto D J Pinto Ipswich and East Suffolk Hospital Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 55, Issue 4, April 1968, Pages 264–265, https://doi.org/10.1002/bjs.1800550407 Published: 06 December 2005

CT of Internal Hernias

Computed tomography (CT) plays an important role in diagnosis of acute intestinal obstruction and planning of surgical treatment. Although internal hernias are uncommon, they may be included in the differential diagnosis in cases of intestinal obstruction, especially in the absence of a history of abdominal surgery or trauma. CT findings of internal hernias include evidence of small bowel obstruction (SBO); the most common manifestation of internal hernias is strangulating SBO, which occurs after closed-loop obstruction. Therefore, in patients suspected to have internal hernias, early surgical intervention may be indicated to reduce the high morbidity and mortality rates. In a study of 13 cases of internal hernias, nine different types of internal hernias were found and the surgical and radiologic findings were correlated. The following factors may be helpful in preoperative diagnosis of internal hernias with CT: (a) knowledge of the normal anatomy of the peritoneal cavity and the characteristic anatomic location of each type of internal hernia; (b) observation of a saclike mass or cluster of dilated small bowel loops at an abnormal anatomic location in the presence of SBO; and (c) observation of an engorged, stretched, and displaced mesenteric vascular pedicle and of converging vessels at the hernial orifice.

Role of CT in the Management of Recurrent Ovarian Cancer

The purpose of this study was to evaluate the potential role of preoperative CT in patients with recurrent ovarian cancer who undergo secondary cytoreductive surgery. Preoperative CT examinations of 36 consecutive patients (age range, 30-75 years; mean age, 55 years) were reviewed retrospectively. Patients had recurrent ovarian cancer and secondary cytoreduction within a mean CT-surgery interval of 22 days (range, 2-69 days). The CT findings recorded were upper abdominal metastases (e.g., peritoneal carcinomatosis; perihepatic, perisplenic, gastrohepatic or gastrosplenic ligaments; gallbladder fossa; falciform ligament; lesser sac), lymphadenopathy (above or below the renal hilum), liver metastasis, large- and small-bowel obstruction, hydronephrosis, ascites, and the presence of a pelvic mass. CT findings and cancer antigen-125 (CA-125) levels were correlated with surgical resectability. At surgery, tumors in 27 patients were optimally debulked (residual disease of <or= 1 cm) and in nine patients were nonresectable. Using multivariate analysis, hydronephrosis (odds ratio = 19.4, p = 0.03) and invasion of pelvic sidewall (odds ratio = 35.6, p = 0.006) were found to be most indicative of tumor nonresectability. The presence of small-bowel obstruction; nodal or perihepatic liver metastasis; ascites; peritoneal carcinomatosis; bladder, rectum, sigmoid colon, or vaginal involvement; or infrarenal paraaortic adenopathy; and the level of CA-125 were not strong indicators of tumor nonresectability. In patients with recurrent ovarian carcinoma considered for secondary cytoreductive surgery, preoperative CT can be helpful in identifying the extent of the disease and can be used as an adjunct to treatment planning and management decisions.

Differentiation of obstructive from non-obstructive small bowel dilatation on CT

Purpose: to find a useful decision procedure for the differentiation of obstructive from non-obstructive small bowel (SB) dilatation on the computed tomography (CT). Materials and methods: four criteria were divided into different degrees and evaluated. These include: (A): continuity (non-continuous, continuous); (B): transition zone (absent, gradual, abrupt); (C): prestenotic SB fluid (minimal, about one-fourth, one-half, and three-fourths, nearly complete); and (D): colonic contents (minimal, moderate, considerable). One hundred fifty-three examinations, 86 obstructive and 67 non-obstructive, were analyzed using χ 2-square tests to determine the relationship of each criterion to the presence of small bowel obstruction (SBO), whether the proportions of various degrees of these criteria differed significantly among the obstructive and non-obstructive subgroups, and to classify the criteria with a tree-based model (calculated by the computer) for the development of a useful decision procedure. Results: in each of the four criteria, the trend of probability of obstruction was statistically significant ( P=0.0000). The proportions of most, except two, of the various degrees of different criteria in the obstructive and non-obstructive subgroups differed significantly ( P<0.01). The obstruction tends to have a continuou dilatation, an abrupt transition, more prestenotic SB fluids, and less colonic contents. The results of classification by a tree-based model were 76 true–positive, ten false–negative, six false–positive, and 61 true–negative. The sensitivity was 88%; specificity was 91%; positive predictive value was 93%; negative predictive value was 86%; and the overall accuracy was 90%. Conclusion: by analyzing the above four criteria together, a useful tree-based model can be developed and utilized as a supplemental decision procedure for the differentiation of obstructive from non-obstructive SB dilatation. The accuracy can be further promoted if the factor of a recognized pathologic condition is taken into consideration.

The role of computed tomography with contrast and small bowel follow-through in management of small bowel obstruction

Background: In a significant percentage of patients, radiologic evaluation other than plain abdominal films are required to confirm or exclude the presence of small bowel obstruction. Methods: Over a 1-year period, 55 patients had both computed tomography and small bowel follow-through studies. Patients were classified as having (1) paralytic ileus, (2) low-grade obstruction, (3) high-grade obstruction, or (4) complete mechanical obstruction. The gold standard for diagnosis was celiotomy in 42 patients and clinical follow-up in 13 patients. Results: Thirty-six out of 42 patients had proven intestinal obstruction at the time of celiotomy. Computed tomography identified 32 out of the 36 high-grade and complete mechanical obstructions. Computed tomography was superior to small bowel follow-through in identifying masses, malignancies, and features of strangulation. Small bowel follow-through correctly identified “insignificant obstructions” when contrast reached the cecum within 4 hours in 18 of 19 patients. Conclusions: In patients with equivocal findings of small bowel obstruction, computed tomography should be used initially and then small bowel follow-through if computed tomography is not diagnostic. Computed tomography was superior in this study for detecting the cause of the intestinal obstruction and presence of strangulation.

A CASE OF INTUSSUSCEPTION DUE TO METASTASIS OF LUNG CANCER

We experienced a case of small cell cancer of the lung proceded by onset of intussusception due to its metastasis to small intestine. A 70-year-old male was admitted to the hospital because of an abdominal pain and distension. Abdominal X-ray findings showed niveau and dilated small intestine. A chest X-ray film showed an old lung tuberculosis. Ultrasound examination, abdominal CT and contrast X-ray examination suggested the presence of small bowel obstruction. Emergency laparotomy was performed, and enteroenteric intussusception caused by a tumor was found in the ileum 80cm proximal to the terminal ileum. Partial resection of the small intestine was carried out. Histological and immunohistochemical examination of the resected specimen revealed a metastatic small cell carcinoma, intermediate type, probably originated from the lung. Bronchoscopy carried out in 6 months after the operation showed a polypoid lesion at the trachea, and revealed small cell carcinoma confirmed by biopsy specimen, consistent with the histology of the small intestine. He received chemotherapy and radiotherapy. Bilateral pleural effusion and pericardial effusion due to metastasis were observed one year after the operation. He died of cachexia. Metastasis of the small intestine should be considered whenever a patient with lung cancer developes abdominal symptoms. Postoperative prognosis is very poor in the cases of lung cancer with metastasis to the small intestine, but surgical treatment should be undertaken as a first aid.

Effectiveness of pneumatic reduction of ileocolic intussusception in children.

A total of 158 consecutive therapeutic air enemas were performed upon 133 patients during a 2-year period. Perforation and/or an impairment of the general condition of the children were the only main contraindications for the reduction attempt (five patients). Successful reductions were achieved in 89% of cases with no complications. Operation was performed in all 17 cases of unsuccessful reduction: resection in four cases, easy manual reduction in nine, difficult manual reduction in two, and spontaneous reduction in two. There were 16 (12%) patients with one or more recurrent episodes. In 23 (16%) cases, following pneumatic reduction, a swollen ileocecal valve showing a multiple appearance was observed. This fact sometimes results in a differential diagnosis with incomplete reduction; in all these cases, small bowel aeration was always a sign of complete reduction. No significant difference was noted between a swollen ileocecal valve and patient age, duration of symptoms, presence of small bowel obstruction, and further recurrences. Air enema has improved our previous success obtained with hydrostatic reduction (79%), as well as being a simpler, cleaner, and faster technique for intussusception reduction in children.

Hepatic encephalopathy induced by small bowel obstruction in a noncirrhotic child with portal vein thrombosis

A case of hepatic encephalopathy in a noncirrhotic child, who has undergone a previous mesocaval shunt for extrahepatic portal vein thrombosis, is presented. Hepatic encephalopathy developed 5 years after the operation and is believed to have been precipitated by the presence of small bowel obstruction. Exploratory laparotomy and lysis of an adhesion relieved the obstruction and led to the resolution of the encephalopathy.

Significance of age, duration, obstruction and the dissection sign in intussusception

A retrospective study of sixty consecutive cases of proven intussusception with attempt at contrast enema reduction was performed to evaluate currently proposed contraindications to such reduction. When patient age, duration of symptoms, presence of small bowel obstruction and presence of a dissection sign were considered alone, none of the findings indicated irreducibility. Our overall reduction rate was 72% with a complication rate of 3%. This is similar to previously reported series and we concur with more recent publications that the only contraindications to non-surgical reduction of intussusception are free intraperitoneal air, peritonitis or evidence of infarcted bowel. Only when we encountered a combination of symptoms being present for greater than 48 hours and the presence of both small bowel obstruction and a dissection sign was reduction likely to be unsuccessful. However, the presence of a prognostic indicator occurring alone should not be considered a contraindication.