Proximal Small Bowel Obstruction Research Articles

Small-bowel plication prevents ileostomy prolapse in young children with inflammatory bowel disease.

Young children with medically refractory very early-onset inflammatory bowel disease (VEO-IBD) sometimes benefit from ileostomy diversion alone or may be offered subtotal colectomy with ileostomy. Though generally well-tolerated, ileostomy complications are frequent. Prolapse is particularly frustrating as it can be difficult and painful to reduce, becomes a recurring problem is some patients, and often requires ostomy revision or bowel resection. Over the course of the past 6months, eight consecutive children with VEO-IBD underwent 10 creation or revision of a diverting ileostomy (two underwent subsequent colectomy with ileostomy revision). In each of these 10 cases, we plicated the ileum just proximal to the ileostomy for a distance of approximately 3cm using a running permanent monofilament suture. No patient who underwent plication of bowel has developed ileostomy prolapse. There were no cases of ileostomy retraction, parastomal hernia or ostomy-level obstruction. One patient required a lysis of a single band adhesion for a more proximal small bowel obstruction. The stomas have functioned well and there have been no complications. Simple bowel plication appears to be a quick and effective way to prevent ileostomy prolapse in young children with VEO-IBD with an ileostomy who are at high risk for prolapse.

Simultaneous Winslow and Petersen’s Hernias after a Roux-en-Y Gastric Bypass Causing Bowel Obstruction: Laparoscopic Management and Review of the Literature

AbstractInternal hernias after Roux-en-Y gastric bypass are one of the most common complications in bariatric surgery leading to hospital readmissions with or without surgery. Due to the insidious and non-specific clinical presentation combined with difficult radiological identification, internal hernias remain a diagnostic and therapeutic challenge. Delay in diagnosis and treatment can lead to severe morbidity and mortality. We report the case of a patient presenting an unusual intestinal obstruction due to two simultaneous and distinct internals hernias affecting the Petersen’s defect and the foramen of Winslow 4 years after a laparoscopic gastric bypass. A 41-year-old female patient with a history of robotic laparoscopic Roux-en-Y gastric bypass presented with proximal small bowel obstruction symptoms and epigastric pain. Computed tomography showed two simultaneous internal hernias, one affecting the Petersen’s defect and the other affecting the foramen of Winslow with an incarcerated transverse colon. We performed an explorative laparoscopy to reduce both hernias and, after an assessment of bowel viability by indocyanine green angiography, we closed both defects with interrupted non-absorbable sutures to prevent recurrence. The follow-up of more than 1 year has been uneventful. In the cases of obstruction and hospital admission after gastric bypass, we suggest that patients undergo a computed tomography directly after the initial examination. Internal hernia diagnosis is often delicate and requires surgical exploration since bowel strangulation can lead to dramatic outcomes. The operation can be safely done laparoscopically, and all internal hernia defects should be repaired with non-absorbable sutures.

TH7.6 Recurrent Gallstone Ileus: A Case Report

Abstract Introduction Gallstone Ileus (GSI) is a rare cause of mechanical bowel obstruction secondary to impaction of an ectopic gallstone within the bowel lumen. Recurrent GSI is rare, accounting for less than 3% of SBO. The main risk factors for recurrence include a large choleduodenal fistula, an active fistula or faceted gallstones. There is currently no mainstay approach to managing GSI, with “single-stage” and “two-stage” options advocated. Case A 73-year-old lady presented with epigastric pain and vomiting, and was shown to have an obstructing gallstone in the distal ileum. She underwent a laparotomy and enterolithotomy and initially made a good recovery. However, she represented three months later with similar symptoms and was found to have a jejunal gallstone causing proximal small bowel obstruction. She underwent a second enterolithotomy, and is planned for an interval cholecystectomy. Discussion The management of recurrent GSI include one of three options: enterolithotomy alone, “single-stage” (enterolithotomy, cholecystectomy and fistula repair) or “two-stage” approach (enterolithotomy and interval cholecystectomy). The optimal approach in management is still debated. The traditionally taught two-stage approach demonstrates a lower mortality and recurrence rate and shorter index procedure in the unstable patient, requiring a skillset common to most general surgeons. However, with increasing reports of recurrent GSI, a single-stage approach during the index procedure has been advocated, citing decreased risk of cholecystitis, cholangitis and repeat laparotomy in the event of recurrence. Our patient underwent emergency enterolithotomy on both presentations, however there may support for a “single-step” approach in certain patient cohorts.

EP.TU.193Omental band - A unusual cause of mechanical small bowel obstruction in a virgin abdomen

Abstract Introduction The small bowel obstruction in a non-operated abdomen is rare, and the most common causes are hernia and neoplasm. The complete mechanical small bowel obstruction due to an omental band in a patient with no previous abdominal surgery is rare, and less than five cases have been reported in the literature. Case presentation We report a 65 year old male patient presented to the emergency department with complaints of abdominal pain, distension, vomiting and obstipation for four days. On clinical examination, his abdomen was distended, diffusely tender, guarding. The blood investigations showed elevated White blood cells and neutrophils with normal CRP and the Serum lactate. The Abdominal X-ray was suggestive of SBO. The Computed tomography of the abdomen and pelvis showed marked dilatation of the jejunum, the ileum is entirely collapsed, the impression of a double beak sign in the mid-abdomen which would suggest closed-loop obstruction due to a possible internal hernia. We proceeded with emergency diagnostic laparoscopy converted to laparotomy, which showed omental band causing closed-loop proximal small bowel obstruction. The bowel loops appeared congested with the constriction band due to omental band. The omental band was divided, and the obstruction was relieved. Postoperatively patient recovered well and was discharged on day three post-op. Discussion The timely diagnosis and intervention could prevent complications like strangulation, ischemia and gangrene. Though the omental band is rare, it should still be suspected as an aetiology in patients without prior abdominal surgery.

Well-Differentiated Malignant Neuroendocrine Cell Tumor Originating From the Jejunum With Excessive Insulin Secretion

Background: Insulinomas are rare, well-differentiated insulin-secreting neuroendocrine tumors of the pancreas. Insulin-secreting, extra-pancreatic tumors have rarely been reported in the literature. We present a case of a well-differentiated neuroendocrine tumor with clinical, laboratory, and immunohistochemical tumor findings supportive of ectopic insulin production in a non-pancreatic neuroendocrine tumor of the small bowel. Clinical Case: A 70 year-old female with past medical history of end stage renal disease, Type II diabetes mellitus, and hypertension presented to our facility with multiple episodes of dizziness and syncope due to hypoglycemia. She had initially managed her diabetes with metformin but stopped taking the medication due to increasingly frequent episodes of hypoglycemia. Significant labs during the hospitalization include blood glucose <20 mg/dL, insulin 75.9 IU/mL (2.6-21.9 IU/mL) and C-peptide 57.7 ng/mL (1.1-4.4 ng/mL). Her symptoms persisted despite dextrose supplementation. Abdominal and Pelvic CT showed proximal small bowel obstruction and sclerosing mesenteritis with a calcified lymph node but no pancreatic mass. A diagnostic laparoscopy was performed, showing 18 inches of small bowel with malignant appearing masses that were adherent to the mesentery. A 21.0 cm segment of jejunum was resected. There were at least 30, variably sized masses throughout the bowel, involving the mucosa, submucosa, muscularis propria and subserosal fat; along with lymphatic, venous, and perineural space tumor permeation, and metastases involving multiple regional lymph nodes. The tumors ranged in size from 0.5 up to 1.5 cm. They showed well-differentiated nuclear morphology, a mitotic count of 0 per 80 high power fields, and a Ki-67 proliferation index of 1%, indicative of a G1 NET. Immunohistochemical stains confirmed neuroendocrine differentiation with positive staining for chromogranin, synaptophysin, and INSM1 (insulinoma-associated protein 1) transcription factor, while insulin staining was negative. The patient was diagnosed with a pT3N1, G1, ectopic insulin-secreting neuroendocrine tumor of small bowel origin. She was started on diazoxide with significant improvement in her hypoglycemia. Conclusion: Insulin production by non-pancreatic tumors is extremely rare. Clinical, laboratory, and immunohistochemical tumor findings in this case support ectopic insulin production by a well-differentiated neuroendocrine tumor of small bowel origin.

SMALL BOWEL OBSTRUCTION SECONDARY TO OBTURATOR HERNIA: A PRE-OPERATIVE DIAGNOSIS AT COMPUTED TOMOGRAPHY

Obturator hernia is rare, but it must be considered in elderly patients who present with small bowel obstruction. The diagnosis is challenging unless there is a high index of suspicion as the presenting symptoms and signs are usually non-specific. Presence of positive Howship-Romberg sign is considered pathognomonic. Early diagnosis and rapid surgical intervention will reduce the high morbidity and mortality associated with undiagnosed obturator hernia. We report a case of a 93-year-old female patient who was admitted to our surgical department with symptoms of intestinal obstruction of 3-days duration. Howship-Romberg sign was negative. Computed tomography (CT) demonstrated the presence of left obturator hernia with proximal small bowel obstruction and no sign of strangulation. The patient had emergency laparotomy post-CT where the incarcerated bowel loop was released and the obstructed bowel was decompressed without any complication. The hernial defect was close with a mesh and the patient had an uneventful recovery post-surgery. In this case, we highlight that diagnosis of obturator hernia must always be considered in elderly patients who present with intestinal obstruction. Urgent CT could establish a rapid pre-operative diagnosis and aids inappropriate surgical intervention planning which is crucial in optimising the outcome.

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 of proximal small bowel obstruction: is it the motility or the chewing?

An otherwise healthy 80‐year‐old gentleman presents with 1‐day history of generalized abdominal pain and vomiting associated with abdominal distention and bowels not opening for 3 days. He has not had any previous abdominal surgery apart from an elective laparoscopic total extraperitoneal repair of bilateral inguinal hernia. On examination, he was haemodynamically stable with a distended abdomen but without any peritonism. Computed tomography of the abdomen/pelvis demonstrated evidence of small bowel obstruction (SBO) at the mid‐jejunum with a transition point in the left upper abdomen (Fig. 1). He was initially managed conservatively with nasogastric tube decompression, intravenous fluids and a trial of gastrografin. Unfortunately, he failed to improve and underwent exploratory laparoscopy. Intraoperatively, the small bowel was followed from the terminal ileum proximally, finding a hard luminal mass in the mid‐jejunum. The duodeno‐jejunal junction was identified and the small bowel was again followed distally and the luminal mass was again identified. With this single transition point identified, the segment of jejunum was eviscerated and examined. A limited small bowel resection was performed to deliver this mobile hard pigmented intraluminal mass measuring 3 × 4 cm (Fig. 2). Histopathology confirmed normal small bowel with ghosted plant cell walls throughout the firm mass consistent with food bezoar (Fig. 3). The patient made an uneventful recovery and was discharged on day 6

1852 Acute Gastroparesis Syndrome After Percutaneous Atrial Fibrillation Ablation

INTRODUCTION: Percutaneous radiofrequency ablation (RFA) is now a common minimally invasive procedure for the maintenance of sinus rhythm in drug-resistant atrial fibrillation. We present a rare case of acute delayed gastric emptying after an RFA procedure. CASE DESCRIPTION/METHODS: 57-year-old male with a history significant only for paroxysmal atrial fibrillation, who presented for a planned RFA procedure. He has no other medical or surgical history. The patient tolerated the procedure well and was discharged the same day. That evening, 1-2 hours after he ate dinner, he experienced severe nausea, vomiting, and abdominal pain. He was hemodynamically stable on presentation to the emergency department with labs significant only for a mild leukocytosis. Computed tomography showed a severely dilated stomach and proximal duodenum, with a transition point identified at the third portion of the duodenum. The patient was managed conservatively as a case of proximal small bowel obstruction. As he had mild improvement in symptoms after five days, the decision was made for an exploratory laparotomy. An intra-operative push enteroscopy demonstrated large amounts of retained food in the stomach, but no gastroduodenal outlet obstruction. A diagnosis of acute gastroparesis syndrome was made, and surgical exploration was not done. The patient was discharged, managed conservatively, and on follow-up 4 weeks later his symptoms had significantly improved. DISCUSSION: Acute gastroparesis syndrome is a rare complication of RFA for atrial fibrillation, that occurs due to thermal injury to the peri-esophageal vagal nerves during ablation. Symptoms of nausea, bloating, vomiting, gastric pain occur within 72 hours after the procedure. Most patients fully recover within 1-2 months after the procedure with conservative management. However, a few reported cases with persistent symptoms required eventual esophagojejunal anastomosis or intra-pyloric botulinum injection. Due to wide variation in vagal plexus anatomy around the lower esophagus, and lack of visualization of the nervous system, nerve injury is hard to avoid. Higher BMI was noted to be a protective. Minimizing RF ablative power around the esophagus and/or esophageal temperature monitoring may be a strategy to lower the risk. As RFA ablation for atrial fibrillation becomes more common, gastroenterologists should be aware of this complication.

Proximal small bowel obstruction in a patient with cystic fibrosis: a case report

BackgroundAs advancements are made in the management of cystic fibrosis (CF), survival of the CF patient into adulthood has increased, leading to the discovery of previously unknown CF complications. Though gastrointestinal complications of CF, such as distal intestinal obstruction syndrome, are common, this case demonstrates a variant presentation of small bowel obstruction in this population.Case presentationWe describe a 42-year-old male with CF who presented with 2 days of worsening upper abdominal pain, emesis, and loss of bowel function. The patient had no history of any prior abdominal surgeries; however, imaging was concerning for high-grade mechanical small bowel obstruction possibly related to internal hernia. Given leukocytosis and diffusely tender abdomen found on further workup, the decision was made to proceed with diagnostic laparoscopy after a brief period of intravenous fluid resuscitation. Intraoperatively, the transition point was found in the mid-jejunum and was noted to be due to kinking of the bowel causing vascular congestion in the proximal portion. Surgical manipulation of the bowel was required for return of normal perfusion and patency.ConclusionThough the exact mechanism cannot be definitively delineated, we speculate that the increased viscosity and prolonged intestinal transit time, characteristic of CF, resulted in inspissated fecal content in the proximal small bowel, which then acted as a lead point for obstruction. Thus, though small bowel obstruction in patients with CF is often attributed to distal intestinal obstruction syndrome, a broader differential must be considered. Early surgical intervention may be necessary to prevent bowel ischemia and subsequent small bowel resection in a patient presenting with concerning clinical and image findings, as was seen in this patient.

Superior mesenteric artery syndrome in a child with acute gastric dilatation with refractory Guillain–Barré syndrome

Superior Mesenteric Artery Syndrome (SMAS) resulting from proximal partial small bowel obstruction is one of possible causes of acute gastric dilatation (AGD). A child with refractory demyelinating Guillain-Barré syndrome which received 5 times IVIG and consequently 5 times plasmapheresis intubated until 59th day of admission. Because of complicated treatment and cardiopulmonary resuscitation (CPR) nutrition was completely neglected which lead to severe SMAS because of weight loss. Gradual advancements of continuous enteral and parenteral nutrition improved patient's symptoms significantly. Hypophosphatemia complicated the weaning from ventilator which after nutrition therapy resolved and patient extubated. Present case is the first report of pediatric demyelinating GBS suspected to SMAS.

Acute massive gastric dilatation causing ischaemic necrosis and perforation of the stomach

Acute massive gastric dilatation (AMGD) is a rare distinctive condition but associates with high morbidity and mortality. Though usually seen in patients with eating disorders, many aetiologies of AMGD have...

Wilkie syndrome. Case report

Abstract Background Wilkie syndrome, also referred as superior mesenteric artery syndrome, is an unusual cause of a proximal small bowel obstruction. It is characterised by the compression of the duodenum in its third portion due to a narrowing of the space between the superior mesenteric artery and the aorta. Its presentation symptoms are consistent and include the obstruction of the proximal small bowel. However, the physical and laboratory findings are non-specific. Nevertheless, many imaging methods are useful for its diagnosis. The management of this condition varies between observation and surgery, depending on each particular case. Clinical case The case is presented of a 19-year-old male who began with acute, intense abdominal pain, nausea, vomiting, and diarrhoea. On examination, he had abdominal wall rigidity and hyperesthesia. Imaging studies were requested, revealing a decreased superior mesenteric artery angle, a shortening of the aortic mesenteric distance, and a decrease in the calibre of the third duodenal portion, all findings concomitant with Wilkie syndrome. Conservative treatment was applied and the patient was discharged without complications. Conclusions Wilkie syndrome continues to be an unknown condition to the general practitioner, and the underdiagnosis of this condition may put a patient at risk of serious complications. A high index of suspicion is required to reach a diagnosis. Early treatment should give a good outcome most of the time.

Superior Mesentric Artery Syndrome in a Patient with Subacute Intestinal Obstruction: A Case Repor t

Superior Mesenteric Artery (SMA) syndrome is one of the rare cause of proximal small bowel obstruction wherein, the third part of the duodenum is compressed between the SMA at its origin and abdominal aorta due to decreased angulations in these two vessels. This decreased angulation exerts a compression effect on third part of the duodenum, resulting in duodenal obstruction which may be complete or partial. There are number of causes which can lead to this entity and will be discussed briefly. Here we report imaging findings of such a rare cause of proximal small bowel obstruction in a young male patient who presented to the emergency surgical department with non specific symptoms of pain abdomen and abdominal fullness. Patient was evaluated under the standard protocol in management of abdominal pain. General physical examination, erect and supine radiograph were taken. On barium meal follow-through examination, there was paucity of contrast agent distal to the second part of duodenum with proximal dilation of stomach, first and second part of duodenum which raised us the possibility of SMA syndrome. Reconstructed CECT abdomen confirmed the decreased angulation between SMA and abdominal aorta and diagnosed it as SMA syndrome. Findings were correlated on duodenojejunostomy anastomotic surgical procedure. Diagnosing and reporting such a case of SMA syndrome is of utmost importance because the clinical presentation being non-specific pertaining to small bowel obstruction which may pose a diagnostic difficulty to the surgeon and with the further delay in diagnosis, patients may end up with chronic symptoms and complications of the disease, repeated hospital visits and electrolyte abnormalities.

Proximal small bowel obstruction and strongyloides

Proximal small bowel obstruction and strongyloides

Acute Superior Mesenteric Artery Syndrome: Value of Early Diagnosis

Superior mesenteric artery (SMA) syndrome is a rare cause of proximal small bowel obstruction characterized by compression of the third portion of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. This is primarily attributed to loss of the intervening mesenteric fat pad. A 42 year old African American woman with uncontrolled type 1 Diabetes Mellitus presented with shortness of breath, abdominal pain associated with nausea and vomiting of 5 days duration, and recent 40 lb weight loss. EGD and colonoscopy at an outside hospital was negative. BMI was 16.5, and epigastrum was tender without guarding or rebound. Labs: remarkable for glucose 795, anion gap 34 and positive serum ketones. DKA was treated and resolved. However, vomiting persisted despite antiemetic and prokinetic agents. Amylase was 197 and lipase 1068. CT abdomen revealed an unremarkable pancreas, markedly dilated stomach and 2nd duodenum with air fluid levels, wall enhancement, and copious intraabdominal fluid. This was concerning for gastric outlet obstruction. EGD revealed LA class C esophagitis in the distal third of the esophagus and hiatus hernia. Stasis ulcers were seen in the cardia and fundus. Duodenum was dilated and hyperemic but passable to an area of normal jejunum. Abdominal MRI showed dilatation of the stomach extending to the mid third portion of the duodenum where it became collapsed at the level of the SMA. Aortomesenteric angle was 80. Impression: SMA syndrome. The patient was transferred to the surgical service but managed conservatively with hydration, high caloric diet, and her symptoms improved. On follow up, she was noted to have a 2.7kg weight gain and reported complete resolution of her symptoms. Our patient had several risk factors for SMA syndrome including age, asthenic habitus and 40lb weight loss, which may have been due to diabetes. Clinical presentation with symptoms of nausea, vomiting and abdominal pain was typical but nonspecific. Prolonged SMA syndrome may result in a patulous duodenum that must be decompressed by surgical duodenojejunostomy. Patients with acute SMA syndrome, such as our patient, often respond to conservative treatment such as nasogastric decompression, hydration, electrolyte correction, left lateral decubitus positioning and nutritional support to facilitate weight gain. High index of suspicion and early diagnosis are needed to prevent permanent disability due to this rare condition.

Creating a New Path: EUS-Guided Gastrojejunostomy With Lumen-Apposing Stent

Malignant small bowel obstruction is a frequent complication in advanced cancer patients, especially in those with abdominal tumors. A small bowel obstruction occurs when there is blockage of the forward flow of gastric and intestinal contents through the gastrointestinal tract. This results in a delay or inability of gas and fluid to move through the tract. Surgery should be considered for patients in with a single level of occlusion. Less invasive approaches such as duodenal or colonic stenting should be considered when the patient is a poor surgical candidate, or if there are multiple levels of obstruction. However small bowel decompression through lumen opposing stent technology is rare and has yet to be fully described. We present a case of an elderly male with a small bowel obstruction secondary to metastatic colon cancer that was relived with a lumen-apposing stent (Axxios). An 84-year-old male with a metastatic colon cancer, with deposits to the proximal small bowel presented with nausea, vomiting and abdominal distension. The patient noted not having bowel movements or passing gas for several days prior to presentation. The vomit was non-bloody and non-bilious and at times was dry heaving. He stated the nausea was not relieved by anti-emetics including high dose ondansetron. The gastroscope was inserted into the esophagus, which was unremarkable. The gastroscope was exchanged for a linear scope, which was advanced to the gastric antrum. A dilated loop of small intestine was seen adjacent the gastric wall. A cystotome was used to puncture the gastric and small intestinal walls to gain access to the dilate loop of bowel. A guide-wire was advanced into the loop of bowel. The Axxios stent was deployed over the wire, securing the tract between the stomach and dilated loop of bowel. About 2 liters of fluid drained into the stomach from the dilated loop of bowel and was suctioned. Contrast injected into the Axxios stent was seen entering loops of bowel on fluoroscopy. The patient subsequently felt better after the procedure. Treatment options for malignant bowel obstruction must be carefully explored with the patient and family. This diagnosis is often an indication of disease progression, further highlighting the noncurable nature of the underlying disease. EUS Guided gastrojejunostomy with an Axxios stent for a malignant proximal small bowel obstruction should be considered in patients who require decompression. The system allows for a bypass of the small bowel in patients who are poor surgical candidates due to multiple comorbidities or for palliative purposes.

Postmortem Diagnosis of Primary Small Bowel Volvulus in an Adult

Small bowel volvulus is a rare cause of intestinal obstruction. It is defined as the twisting of a segment of the bowel around the axis of its mesentery. Based on the cause, small bowel volvulus is divided into primary and secondary types. The primary type occurs in an otherwise normal abdominal cavity. The secondary type occurs in the presence of predisposing lesions, either congenital or acquired. This is a case report of a primary jejunal volvulus in an 82-year-old man who died suddenly. The autopsy findings included proximal small bowel obstruction and perforation with florid peritonitis secondary to jejunal volvulus. Histology confirmed infarction of the small bowel at the level of the jejunum. We concluded that the cause of death was peritonitis due to small bowel perforation caused by small bowel obstruction secondary to volvulus. No predisposing anatomical abnormality was identified at the site of the volvulus so, by definition, this is a primary type. Jejunal location is usually associated with primary volvulus, and these correlate with a higher incidence of necrotic loops requiring intestinal resection. Primary volvulus is more common in the jejunum than other parts of the small bowel, and these cases are more likely to result in necrosis requiring resection.

An Unusual Cause of Partial Small Bowel Obstruction in a Young Male With HTLV-1

Introduction: There are several causes of small bowel obstruction; in developed countries, these include adhesions, malignancy, and Crohn’s disease. Here, we present an unusual etiology of partial small bowel obstruction and weight loss in a young male. A 45-year-old male who had emigrated from Ghana presented with one year of post-prandial nausea, vomiting, associated 50-pound weight loss, and a diffusely tender abdomen. Laboratory tests revealed 6% eosinophils without leukocytosis and positive HTLV-1 antibodies. Abdominal x-ray revealed a 3.5-cm dilated jejunum in the upper abdomen and multiple air-fluid levels, suggestive of partial proximal small bowel obstruction. The patient was treated with conservative management with IV fluids and nasogastric tube drainage. Given his history of persistent nausea, vomiting, and weight loss, an EGD was performed, which revealed inflammation of the antral and duodenal mucosa with some ulcerations. Gastric and duodenal biopsy results were positive for Strongyloides stercoralis (Figure 1). A diagnosis of S. stercoralis infection with partial small bowel obstruction was established. He was treated with albendazole 400 mg twice daily for 3 days and Ivermectin 200 mcg/kg daily for a total of 6 weeks. The patient was relieved of his symptoms and was noted to gain weight with conservative management. Strongyloides stercoralis is a nematode that burrows in the mucosa of the small intestine. Duodenal obstruction is a rare complication of strongyloidiasis, with only few cases reported in the medical literature. It can occur in severe infection with the parasite due to mucosal edema and inflammation. Widespread strongyloidiasis can also cause paralytic ileus. HTLV-1 affects cell-mediated immunity and increases the risk of severe infection. Parenteral therapy is not available for strongyloidiasis, which makes conservative management of duodenal obstruction and paralytic ileus in this setting challenging. Although surgical management of duodenal obstruction has been reported in the literature, if an early diagnosis is made, then conservative treatment may be used with favorable outcomes, as seen in this patient.Figure 1: Duodenal biopsy.

Unusual cause of bowel obstruction after laparoscopic sleeve gastrectomy

As obesity continues to become an epidemic in the United States, bariatric surgery is becoming more common. The advancement of laparoscopic bariatric surgery has caused general surgeons to face different complications in patients after bariatric surgery. These complications can be very specific to the operation performed. To the authors’ knowledge, they are presenting the first report of acute small bowel obstruction related to laparoscopic sleeve gastrectomy 1 year before presentation. Proximal small bowel obstruction in patients who had laparoscopic sleeve gastrectomy is likely to be related to thick adhesions to the actual sleeve or staple line.