Proximal Small Bowel Loops Research Articles

A Case Report and Literature Review: Grape Seeds Causing Meckel’s Diverticulitis, Perforation and Small Bowel Obstruction in a Young Adult Patient

Background: Meckel’s diverticulum is a true diverticulum consisting of a 3-layered outpouching of the bowel wall along the antimesenteric border. It is a remnant of the omphalomesenteric duct and the most common congenital gastrointestinal disorder. It has a male predilection and remains asymptomatic in the majority of cases. It constitutes a diagnostic challenge to physicians, as it can present with gastrointestinal bleeding in the pediatric population, and as an intestinal obstruction in adults. While the management of an asymptomatic Meckel’s diverticulum is on a case-by-case basis, when symptomatic, prompt surgical intervention is necessary, and a laparoscopic approach allows both in-situ diagnosis and treatment. Case Report: A 23-year-old previously healthy female patient, presented with diffuse abdominal pain, vomiting, and obstipation. Abdominal X-Ray and abdominopelvic Computed Tomography showed an intra-abdominal inflammatory process and evidence of bowel obstruction but were not conclusive. The patient was admitted to the hospital for management, and on the third day of hospitalization physical examination showed abdominal guarding suggestive of peritonitis. An urgent exploratory laparotomy identified a Meckel’s Diverticulum obstructed with phytobezoar grape seeds, and an inflamed and perforated bowel wall, with adhesive bands to proximal small bowel loops, necrosis, and resultant small bowel obstruction. We resected the Meckel’s diverticulum and the necrotic bowel and performed an end-to-end primary anastomosis of the small bowel. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. Conclusion: The diagnosis of Meckel’s diverticulum remains a challenge as it has a myriad of clinical presentation and radiological imaging sometimes fails to provide a definite diagnosis. It must be systematically included in the differential diagnosis of small bowel obstruction in adult patients, as it requires prompt surgical intervention for both diagnosis and treatment.

Case report on Tracheoesophageal Fistula with review of current literature

Major structural anomalies occur in 2-3% of live births all around the World. The reported global incidence of tracheoesophageal fistula (TEF) is roughly 1 in 2,500 live births varying by region. In Pakistan, incidence is reported only by those tertiary care centers that have pediatric surgery facilities available, making it an underreported and often mismanaged condition. We report a case of esophageal atresia (EA), rectovaginal fistula and tracheoesophageal fistula associated with Meconium Aspiration Syndrome (MAS) in an infant. The baby was 2 days old when she arrived at our center, born at 34 weeks, and weighed 2.3 kilograms. There was no significant antenatal history except that the mother was on antihypertensive drugs. The baby had an Apgar score of 3 and 4 at 1 and 5 minutes respectively, severe respiratory distress and cyanosis. Her chest examination revealed subcostal and intercostal recessions, bilateral crepitation and tachycardia at 180/minute. She was immediately put on ventilator and required frequent suctioning due to excessive secretion, developed abdominal distension, and had multiple episodes of desaturation and cyanosis. Complete blood picture showed leukocytosis and arterial blood gases signifying metabolic acidosis. Upon trying to pass to a catheter, baby passed stool through vagina. Contrast esophagogram showed evidence of distended stomach and proximal small bowel loops. No evidence of air was seen in the rectum. On passing the nasogastric tube into the esophagus, it curled on itself at D4 level with evidence of blind-ending proximal esophageal pouch that dilated with contrast medium. On 10th day of life baby’s condition deteriorated despite all efforts. Eventually she stopped breathing, her pupils dilated and all efforts to resuscitate her failed. This report highlights the importance of thorough clinical examination and availability of support facilities in a pediatric unit. TEF/EA should be suspected in any newborn who presents with respiratory distress, drooling, history of polyhydramnios with an inability to pass nasogastric tube. The parents should also be counselled as TEF/EA carries a 1% risk of recurrence.

Intussusception following rotavirus vaccination: a reminder for practitioners.

Intussusception is a paediatric surgical emergency that requires prompt diagnosis and management to prevent significant patient morbidity and mortality. Of the recognised causes, intussusception following rotavirus vaccination is relatively rare and may be overlooked by practitioners. We present the case of a 2-month-old infant found to have intussusception following rotavirus vaccination together with a review of current literature around this important topic. A 2-month-old male infant was admitted under the paediatric team with a 1-day history of non-bilious vomiting, pyrexia, and irritability a day after receiving his first-dose rotavirus vaccination. On examination he was haemodynamically stable and had no focal signs of sepsis. His abdominal examination revealed a soft, non-distended abdomen with no palpable masses. He had passed normal stool within the preceding 24 hours. Following initial assessment, he underwent a full septic screen including lumbar puncture, the results of which were all within normal range. After developing bilious vomiting overnight a paediatric surgical review was obtained and an upper gastrointestinal contrast study was performed. This revealed no evidence of malrotation. An abdominal X-ray was subsequently performed which revealed a soft tissue mass in the right hypochondrium, dilated proximal small bowel loops, and a paucity of distal bowel gas, in keeping with small bowel obstruction (Figure 1). An urgent ultrasound scan was obtained which showed dilated proximal small bowel loops and the characteristic target sign typically seen in intussusception (Figure 2). The child received full resuscitation before an air enema reduction was performed under …

Colonic tuberculosis

A 22-year-old previously healthy Ethiopian woman was admitted with a history of colicky lower-abdominal pain associated with vomiting, diarrhea, fever, night sweats, and unintentional weight loss. CT showed mildly dilated proximal small-bowel loops with air fluid levels, with mesenteric lymphadenopathy and congestion, associated with right iliac fossa fat stranding and bowel wall enhancement. Colonoscopy demonstrated multiple submucosal lesions extending from the splenic flexure to the ascending colon (A and B). The lesions extruded white chylous fluid during biopsy (C and D), which suggested a cystic nature. Multiple biopsy specimens were taken from the cyst wall, and the cyst content was sent for culture and cytology. Histopathologic examination revealed submucosal fibrosis with foci of inflammatory cells and ill-defined granulomas on deeper levels; Ziehl-Neelsen staining showed acid-fast bacilli (AFB). A sputum smear for AFB was negative; however, culture from the cyst aspirate was positive for Mycobacterium tuberculosis. Cytology was unremarkable.

Celiac Crisis: A Rare Manifestation of a Common Disease

Introduction: Celiac crisis is a rare and life threatening manifestation of celiac disease. Case presentation: We present a 46 year old male with a history of DM1 complicated by ESRD on HD and a recent diagnosis of Bell's Palsy who was admitted from a dialysis center with hypotension and voluminous diarrhea. Reported up to 20 watery, nonbloody bowel movements per day x 7 days. The diarrhea was associated with LLQ crampy pain. Denied fevers. +Nocturnal diarrhea. The diarrhea did not improve with fasting. Denied recent weight loss.Figure 1Figure 2Figure 3Vital Signs and PE: Afebrile BP 55/42 Pulse 102. Dry mucous membranes. Mild LLQ tenderness with hyperactive bowel sounds. A rectal tube was in place with voluminous light brown watery stool identified. Inital laboratory results and imaging. 6.8/11\173. 130 | 98 | 98. 4.6 | 19 | 13.4. pH 7.27 Alb 2.9 Ca 7.2 C. Diff PCR negative CT abdomen and pelvis with IV contrast revealed mild thickening of proximal small bowel loops, suspicious for enteritis. Further pertinent labs: Stool 0 + P and culture negative. Lactoferrin: positive. ESR and CRP elevated. TTG IgA 80 (0-19). Gliadin IgA 39 (0-19). Stool Osmolar gap 36 Gastrin and VIP normal 5HIAA excretion normal. Over a 24 hour period, the patient required 13 L's of IVF's to keep up with GI losses and maintain blood pressure. An esophagogastroduodenoscopy revealed scalloping in the duodenal bulb and 2nd part of the duodenum. Biopsies were obtained and revealed villous atrophy, increased intraepithelial lymphocytes, and crypt hyperplasia (Marsh 3C). The diagnosis of celiac crisis was made based on the endoscopic and serologic results in conjuction with the dramatic presentation. After 3 days of gluten withdrawal our patients bowel movement frequency and caliber improved dramatically. Discussion: In this rare manifestation of celiac disease marked metabolic derangements are encountered. It is unclear what triggers this more aggressive disease course, however it has been suggested to be a combination of severe mucosal inflammation and immune activation.1 In our case, we propose that his recent diagnosis of Bell's Palsy precipitated an immune activation leading to the crisis. Celiac disease should be considered in adults presenting with acute voluminous diarrhea and profound electrolyte abnormalities.

Small Bowel Volvulus Following Upper Gastrointestinal Barium Radiography

Introduction: Small bowel volvulus is extremely rare in adults. Barium has been associated with obstructive symptoms related to baroliths, but these take several days to weeks to form. Small bowel volvulus has never been reported immediately following a barium study. Case: The patient is a 49-year-old man who presented with persistent gastroesophageal reflux despite treatment with dexlansoprazole. An upper GI series was performed to evaluate for hiatal hernia. The study revealed mid-esophageal reflux with small hiatal hernia and one area of nonspecific proximal small bowel prominence. One hour after the study, he ate lunch, and fifteen minutes later developed nausea, vomiting and diffuse abdominal pain. The pain progressed and his vomiting persisted requiring hospital admission. His past medical history includes bipolar disorder, hypertension and obstructive sleep apnea. He had no prior abdominal surgeries. His medications include depakote, trileptal, seroquel, lisinopril and dexlansoprazole. Exam revealed hypoactive bowel sounds and tenderness in the epigastrium and bilateral upper quadrants. Laboratories were notable for only mild neutrophilia. Abdominal computed topography (CT) scan showed small bowel volvulus and closed loop obstruction without free air. Contrast from the prior day was present in dilated proximal small bowel loops. Nasogastric tube was placed. Repeat abdominal x-ray showed persistent obstruction without any contrast in the colon. Given lack of improvement, laparoscopy was pursued. It revealed torsion of the jejunal mesentery that was corrected. No ischemic changes were noted. His symptoms resolved and he was discharged home without any further issues. Five months later, CT enterography with gastrograffin showed no evidence of intraluminal lesion or mesenteric pathology. Discussion: Small bowel volvulus is generally described in neonates with embryologic malrotation of the midgut. The etiology in this patient is a mystery. Contributing factors may have been slowing of colonic transit as side effect of bipolar medications as evidenced by excessive stool on CT. A large bolus of barium in setting of mild ileus may have caused the jejunal volvulus.

Right Hemicolectomy for Intestinal Obstruction Due to Yersinia pseudotuberculosis: A Histopathological Surprise

A 56-year-old man was diagnosed to be having enteric fever elsewhere and put on antibiotics. Despite therapy over 3months, this patient had recurrent bouts of fever with chills, tiredness, and lower abdominal pain, distension, and vomiting with which he was admitted to our hospital. CT abdomen and pelvis showed significant wall thickening in the cecum and terminal ileum, with marked luminal narrowing and marked dilatation of proximal small bowel loops. Clinically a diagnosis of intestinal obstruction was made and the patient underwent exploratory laparotomy and right hemicolectomy. Histopathological examination showed necrotizing enteritis with necrotizing mesenteric lymphadenitis consistent with Yersinia pseudotuberculosis. We report a rare and possibly the first case of intestinal obstruction due to Yersinia infection, requiring right hemicolectomy.

Intranodal Schwannoma Mimicking a Gastrointestinal Stromal Tumor of the Stomach: A Case Report

A 66-year-old-woman is presented with intranodal schwannoma of the retroperitoneum. Ultrasonography (US) and computed tomography (CT) results demonstrated a large encapsulated mass with internal cystic or necrotic portions in the gastrosplenic space. The tumor abutted the greater curvature of the gastric body and slightly indented the proximal small bowel loops on a small bowel series. The observations suggested a gastrointestinal stromal tumor. The mass was surgically proven to be a retroperitoneal tumor and histopathologically intranodal ancient schwannoma.

Recurrent ileostomy prolapse: is it a solved problem?

Dear Editor, End ileostomy, introduced by Brooke [1] in 1952, has become a popular procedure in colorectal surgery. Reported postoperative complication rates range from 5 to 100% [2]. The most common complications include prolapse, necrosis, parastomal hernia and peristomal skin erosions. Stomal prolapse, as a long-term complication, occurs in 22% of adults and 38% of children [3]. It is caused by the invagination of proximal redundant bowel through the distal part in patients with ileostomy or colostomy. A loop stoma poses a greater risk of prolapse than an end stoma. Loop colostomy is more prone to prolapse than is ileostomy. Prolapse rates ranging between 3 and 42% have been reported [4, 5]. Immediate postoperative stomal prolapse is very rare. We present a case of small bowel obstruction caused by prolapse and intussusception through end ileostomy in a 36-year-old woman who underwent urgent laparotomy due to Crohn’s disease of the terminal ileum close to the ileocaecal valve. The patient was diagnosed with Crohn’s disease in 2008. She was treated conservatively (Salofalk, Metypred, PPI, Scopolan). Despite increasing symptoms of obstruction, the patient was not treated surgically. She slowly deteriorated and lost weight. At admission in July 2008, the patient’s BMI was 14.5 (body weight 42 kg), and her serum albumin level was 2.28%. The patient presented with signs and symptoms of small bowel obstruction. After a short-term preparation, the patient underwent laparotomy. At laparotomy, a 19-cm-long loop of distal ileum was found to be narrowed, inflamed, edematous, congested, thickened and causing ileal obstruction. The ileum, 11 cm in diameter and 30–40 cm long, was distended and inflamed. Proximal small bowel loops looked normal. The patient underwent partial resection of the diseased ileum. End ileostomy was performed to avoid primary anastomosis, because the patient was considered high-risk, with hypoalbuminemia and malnourishment. It was difficult to perform end ileostomy with eversion due to extensive inflammation. In addition, the everted ileostomy was fixed with through-and-through u-sutures to prevent de-eversion. The free edge of the ileal mesentery was sutured to the lateral parietal peritoneum. On postoperative day 2, a marked prolapse (30 cm) of small bowel through the ileostomy occurred. Manual reduction of the prolapse was unsuccessful. The patient was taken to the operating room (OR), where the prolapse was reduced under general anesthesia. On postoperative day 6, marked prolapse of at least 30 cm in small bowel recurred. The patient underwent laparotomy, and the prolapse and ileal intussusception were reduced. The terminal 40 cm of the ileum was thickened and distended up to 9–11 cm. A modified Reymond’s intestinal plication [6] of 4 ileal loops, each about 15 cm long, was performed. A single row of interrupted 3–0 Vicryl stitches (Ethicon Inc., Cincinnati, USA) was placed on mesentery approximately 1 cm away from its attachment to the bowel. The fixation of the terminal 60–70 cm of ileum prevented a subsequent prolapse and intussusception of the narrowed proximal ileal loops into a wide and stiff terminal ileum. On the day following this procedure, the patient began to tolerate a normal diet, and she was discharged 1 week later. At 2-week follow-up, the patient was in very good condition with an almost normal looking ileostomy. The preventive procedure used in our case of a 36-year-old female patient with 2 episodes of early postoperative ileostomy prolapse resembles the Nobel procedure that has been used in a similar case described by Irving et al. [7] in 1955. As this was the first case of this nature I encountered in my 47-year surgical practice, I have the following 2 questions: Is it better to perform end or lateral ileostomy in a wide, inflamed, stiff ileum? How can the invagination of peristaltic and narrow proximal small bowel into the distended terminal ileum be prevented? Any comments and remarks concerning the aforesaid questions will be greatly appreciated.

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

Visual Vignette

Case Presentation: A 27-year-old woman came to the emergency department because of abdominal pain, food intolerance, and vomiting for 3 days. She had a history of obesity and had initially been examined in our endocrine clinic 2 years previously. At that time, her weight was 103 kg, and her height was 1.68 m (body mass index [BMI] 36 kg/m2). She was prescribed a 1,500-kcal diet but was lost to follow-up. During the next few months, her weight increased to 115 kg (BMI 41 kg/m2), at which point she decided to begin a diet on her own. Her weight declined steadily and was 45 kg (BMI 16 kg/m2) when she was seen in the emergency department. Physical examination revealed a distended and painful abdomen with no peristaltic sounds. A plain film of the abdomen (Fig. 1) showed dilatation of proximal small bowel loops and absence of gas in the distal small bowel. A computed tomographic scan of the abdomen (Fig. 2) disclosed a substantial distention of the stomach (asterisk) as well as the first and second parts of the duodenum (asterisk), in conjunction with collapse of the third part of the duodenum at the level of the aortomesenteric crossing (arrowhead). (The aorta and superior mesenteric artery are denoted by arrows.) What is the diagnosis?

CASE REPORT: Inflammatory Fibroid Polyp of the Small Intestine Causing Intussusception: A Report of Two Cases

Inflammatory fibroid polyp (IFP) is a rare, localized, nonneoplastic lesion originating in the submucosa of the gastrointestinal tract. When localized in the small bowel, the presenting symptoms are colicky abdominal pain and obstruction (1). Intussusception due to IFPs is uncommon; moreover, jejunojejunal intussusception has only rarely been reported (2‐9). We describe two cases of IFPs of the small intestine causing jejunojejunal and ileoileal intussusception, respectively. The literature and radiologic findings are briefly reviewed. CASE 1 A 54-year-old woman presented to our hospital with an 8-month historyof intermittent episodes of abdominal pain, vomiting, and diarrhea. The patient denied any previous surgical operation or systemic disease. Physical examination was normal. Laboratory tests showed only mild hypochromic anemia. Upper and lower gastrointestinal endoscopies were performed and showed no abnormalities. An enteroclysis study revealed a quite typical configuration of ileo-ileal intussusception, causing small bowel obstruction, with pronounced proximal dilatation. The presence of a well-rounded, intraluminal filling defect was suspected at the distal part of the formation (Figure 1). An ultrasound scan that followed showed a hypoechoic, round, 35-mmdiameter soft tissue mass at the end of a dilated, thick-walled ileal loop at the right flank. Abdominal CT scan demonstrated an intussusception formation in the midabdomen, due to a smooth soft tissue mass, with concomitant high-degree dilatation of the proximal small bowel loops. A diagnosis of intraluminal ileal stromaltumor was suggested. Partial enterectomy was performed. The

Relapsing encephalopathy following small bowel transplantation

We report a case of a 40-year-old man presenting with relapsing encephalopathy 4 years post-intestinal transplantation. Each episode was preceded by symptoms suggestive of subacute intestinal obstruction, marked dehydration, and, on one occasion, grade 4 encephalopathy. Physical examination revealed hypertonia, clonus, and hyperreflexia. Biochemistry was consistent with renal impairment, metabolic alkalosis, hyperammonaemia, and normal liver function. Plain radiographs and abdominal computed tomography revealed dilated proximal small bowel loops, and barium radiography demonstrated a strictured distal anastomosis. Hydrogen breath testing indicated bacterial overgrowth. Following rehydration and antibiotic therapy, the patient recovered fully between episodes. Further episodes of encephalopathy did not recur following resection of the distal anastomotic stricture and resolution of bacterial overgrowth. Unfortunately, one year later the patient died of pneumonia. To the best of our knowledge, encephalopathy secondary to intestinal transplant related porto-caval shunt and bacterial overgrowth in strictured bowel has not been previously reported but might have implications for the management of future patients.