Rectal Tube Research Articles

Kolostomi Kapatılması Sonrası Erken Dönem Rektal Tüp Uygulamanın Barsak Peristaltizmine Etkisi

Objective: All surgeons performing colostomy closure strive to achieve early postoperative intestinal peristalsis in their patients. Early peristalsis following abdominal surgery leads to a shorter time to flatulence/defecation, thereby allowing early transition to oral feeding and early hospital discharge. The aim of this study was to investigate the effect of rectal tube applied after colostomy on intestinal peristalsis, time to first flatulence/defecation, and time to hospital discharge.
 Material and Methods: This retrospective study included 40 patients that underwent colostomy closure between September 2013 and October 2020. Age, gender, and indications for colostomy were reviewed for each patient. Patients were divided into two groups as patients who underwent and those who did not
 undergo rectal tube application. In both groups, time to first flatulence/defecation, time to oral feeding, and hospitalization period were recorded.
 Results: The 40 patients comprised 26 boys and 14 girls with a mean age of 3.46±2.11 years. Time to first flatulence/defecation and hospitalization periods were significantly shorter in patients that underwent rectal tube placement than in patients that did not undergo rectal tube placement (p=0.001).
 Conclusion: Rectal tube application following colostomy leads to early onset of intestinal peristalsis and a shorter time to flatulence/defecation, thereby allowing early transition to oral feeding and early hospital discharge.

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis.

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

Successful Treatment with Rectal tube Placement and Barium Enema in Uncomplicated Acute Sigmoid Volvulus: A Case Report

Sigmoid volvulus is a condition in which sigmoid colon wraps around itself and its own mesentery, which then causes a closed-loop obstruction. This condition accounts for 50-90% cases of twisted large intestine and often affects adults and are commonly found in males. The classic triad signs and symptoms are abdominal pain, distention, and constipation. Although the emergency resection seems to be the right procedure in treating acute sigmoid volvulus, there is still non-surgical treatment often done in several conditions. We reported a 52-years-old male with uncomplicated acute sigmoid volvulus who underwent non-surgical treatment due to his refusal of surgical therapy. Non-surgical treatment was successfully done and no recurrence found within one year. The aim of this report was to emphasize that non-surgical therapy only could be successfully done without surgical treatment.

Effect of colonic distension on small bowel motility measured by jejunal high-resolution manometry.

BackgroundAbnormal motility patterns in the jejunum can be detected in patients with prominent colonic content, and these abnormalities may be due to either a primary jejunal dysfunction or a reflex distortion. The objective of the present study was to determine the effect of colonic distension on small bowel postprandial motility using high‐resolution manometry.MethodsSingle center, controlled, parallel, randomized, single blind study in healthy subjects testing the effect of colonic filling vs sham infusion on the responses to a meal in 16 healthy subjects. Nutrients were continuously infused in the proximal jejunum (2 Kcal/min) during the 2‐h study period to induce a steady‐state postprandial motor pattern. Jejunal motility was measured by water‐perfused, high‐resolution manometry. After 1 h postprandial recording (basal period), gas was infused during 7.5 min via a rectal tube (720 mL or sham infusion), and jejunal motility was recorded for another hour.Key ResultsJejunal postprandial motility during the basal period was characterized by two overlapping components: a) continuous segmental activity (non‐propagated or shortly propagated) and b) intercurrent propagated fronts (3.8 ± 1.1 fronts of 2‐5 clustered contractions/h >10 cm propagation). As compared to sham infusion, colonic gas filling: a) inhibited continuous segmental contractile activity (by 17 ± 4%; p = 0.044 vs control group) and b) stimulated intermittent propagated fronts (up to 9.0 ± 2.2 fronts/h; p = 0.017 vs control group).Conclusions and InferencesLong retrograde reflexes induced by colonic distension distort the balance between segmental and propagated activity, and may affect the normal response of the jejunum to food ingestion. Jejunal manometry in patients may be artifacted by colonic overload.

Multi-Donor Fecal Microbial Transplantation for Critically Ill Patients: Rationale and Standard Operating Procedure

Patients in the intensive care unit often lose a considerable fraction of their gut microbiome due to exposure to broad-spectrum antibiotics and other reasons. Dysbiosis often results in prolonged diarrhea and increase occurrence of multi-drug resistant pathogens in the colon with clinical consequences not yet well understood. Restoring the microbiome by fecal microbial transplantation (FMT) is a plausible therapeutic possibility, so far only documented in case reports and case series using very heterogeneous methodologies. Before FMT with critically ill patients can be tested in randomized controlled trials, there is a burning need to describe a standardized operating procedure (SOP) of the whole process, respecting the specifics of the critically ill population, such as the risk of the disrupted intestinal barrier and time-critical nature of the procedure. We describe the SOP that has been developed for experimental use in critically ill patients by a multidisciplinary team of intensivists, gastroenterologists, and microbiologists based on feedback from regulatory authority (State Institute for Drug Control of the Czech Republic). The hallmarks of these SOPs are multi-donor freshly frozen transplants guaranteed for 2 months consisting of seven aliquots from seven unrelated healthy donors and administered by a rectal tube. In this paper we discuss the rationale for this SOP and the process of its development in detail and release the full proposed SOP is in the form of an online appendix.

Outcome and Complications of Rectal Tube Placement in Intestinal Obstruction Due to Sigmoid Volvulus

Background: The most common site of colon volvulus is in the sigmoid colon and then in the cecum and transverse colon. The aim of this study was to evaluate the results of the rectal tube placement as an initial treatment for devaluation of sigmoid volvulus. Materials and Methods: In this cross-sectional study, 60 patients with sigmoid volvulus admitted to the emergency department of Imam Reza and Sina Teaching Hospitals due to intestinal obstruction were undergone blind rectal tube placement. After discharge, patients were followed up in two 1 month and 6 months intervals, so the rate of recovery, relapse, or mortality of the patient (in case of the patient’s death) were investigated. Results: Of the 60 patients reported, 41 patients (68.3%) were male, 54 patients (90%) the operation was successful and the patient was devaluated, but in the remaining 6 patients (10%) the operation was not successful and the patient immediately underwent an operation. The number of attempts to devaluation of patients with the rectal tube was once in 50 patients (83.3%), twice in 2 cases (3.3%) and three times in 8 cases (13.3%). The rate of hospitalization after surgery (in patients who had undergone surgery) was 6.44 ± 0.9 days. The overall rate of hospitalization in patients with sigmoid volvulus with initial treatment by rectal tube placement to devaluation was 5.78 ± 0.96 day. Conclusion: We suggested that rectal tube placement is less costly and available procedure in the treatment of patients with sigmoid volvulus.

Drain fluid amylase as a biomarker for the detection of anastomotic leakage after rectal resection without a diverting ileostomy.

Anastomotic leak (AL) is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary diverting ileostomy (TDI) does not prevent an AL and presents inherent complications of its own. Numerous drain fluid biomarkers (BM) have been studied in colorectal surgery and extravasated intraluminal substances (EILS) such as amylase have shown promise. The aim of this study was to assess drain fluid amylase (DFA) as a BM of AL after minimally invasive rectal resection without a TDI. A single centre prospective cohort study performed from 2018 to 2021. The primary outcome was DFA measured daily whilst the drain was in situ. Rectal tube amylase was also measured for the first two post-operative days to quantitate the intra-luminal levels of the enzyme. DFA was compared between patients who experienced AL and those who did not. Of the 62 patients studied, six (9.7%) experienced AL. There was a statistically significant difference in DFA between patients who experienced AL (Median:1373.5U/L; IQR: 306-7953) and patients who did not experience an AL (Median: 27.0U/L; IQR: 16-38); p< 0.0001. The measurement of drain fluid amylase is a highly sensitive BM of early clinical anastomotic leak in patients undergoing a rectal resection with an extraperitoneal anastomosis and when a TDI is not incorporated. This simple, inexpensive and non-invasive test should be considered in all patients as an adjunct to the clinical diagnosis and differentiation of AL from other postoperative complications.

Sigmoid volvulus in a child with Autism Spectrum Disorder

Sigmoid volvulus is an uncommon cause of abdominal pain and obstruction in the pediatric population, with most physicians not considering it in the differential diagnosis. History of Autism Spectrum Disorder (ASD) with concomitant volvulus of the sigmoid colon is a rare occurrence that presents with communication challenges that can impair diagnosis and treatment. This is the case of a 10-year-old male patient with ASD who presented with abdominal pain, obstipation, and vomiting. Plain abdominal radiograph showed an intestinal obstructive pattern subjective for sigmoid volvulus. The patient was successfully decompressed with a nasogastric and rectal tube and underwent an open sigmoidectomy with end-to-end coloproctostomy during the same admission. Communication impairment made it difficult to assess subjective parameters such as pain, and nausea. On post-operative day #8 extensive pneumoperitoneum was observed on a chest radiograph and the patient was taken for emergency laparotomy that resulted in a partial colectomy with end colostomy. Sigmoid volvulus is an exceptionally rare occurrence in the pediatric population. High suspicion should be kept for prompt diagnosis and treatment in patients with ASD. Particular attention to objective information such as physical examination, vital signs, laboratories, and imaging studies should be maintained since communication is usually impaired.

Bloodstream infections in hospitalized patients before and during the COVID-19 surge in a community hospital in the South Bronx

Bloodstream infections in hospitalized patients before and during the COVID-19 surge in a community hospital in the South Bronx

201. Comparison of Bloodstream Infections Between Hospitalized Patients with and without COVID-19 Infection During the First Wave of the COVID-19 Pandemic in a Community Hospital in South Bronx: An Observational Study

BackgroundComparative data on bloodstream infections (BSI) in hospitalized patients with and without SARS-CoV2 positive test is lacking.MethodsA retrospective observational study comparing (BSI) with and without COVID-19 infection was performed was performed from Jan1- May 1, 2020. Patient demographics, clinical microbiological characteristics of infections, therapeutic interventions and outcomes was compared between the two groups. ResultsOf 155 patients with BSI, 104 were SARS-CoV2 PCR negative (N) while 51 were positive (Table 1). Majority of SARS-CoV2 positives (P) had ARDS (58.8%), required mechanical ventilation (73%), inotropic support (55%), therapeutic anticoagulation (28%), proning (35%), Rectal tube (43%), Tocilizumab (18%), and steroids (43%) (Table 2). BSI was higher in N with HIV (16.3% vs 3.9% p=0.027). Duration of antibiotic therapy (DOT) prior to BSI was significantly longer in P (15 days vs. 5 days, p < 0.0001) (table 2). In-hospital mortality was significantly higher among P with BSI (49% vs. 21% p < 0.0001). 185 BSI events were observed during the study period with 117 in N patients and 68 in P. Primary BSI was predominant (76%) in N while secondary BSI (65%) was common in P of which 50% were CLABSI. Median time from admission to positive culture was 0.86 days in N compared to 12.4 in P (p = 0.001). Majority of BSI in P were monomicrobial (88%) and hospital acquired (71%) when compared to N (p< 0.001). Enterococcus spp (28%), Candida spp(12%), MRSA (10%) and E.coli (10%) were predominant microbes in P compared to Streptococcus grp (16%), MSSA (14%), MRSA (13%) and E.coli (12%) in N (figure 1). Mortality from BSI was associated with COVID-19 infection (OR 2.403, p = 0.038), DM (OR 2.335, p = 0.032), Charlson comorbidity index >3 (OR 1.236, p = 0.004), and mechanical ventilation (OR 11.398, p < 0.001) on multivariate analysis. Comparison of Microorganisms isolated in the BSI X-axis represents the number of BSI events whereas the number at the end of each bar represents the percentage ConclusionIncreased events of hospital acquired, secondary BSI (CLABSI) due to Enterococcus was observed in adult P compared to N. These patients were critically ill, developed BSI in the second week of hospitalization, had longer DOT prior to positive cultures and worse outcomes. Breakdown of infection control measures and inappropriate antimicrobial use during the surge could be contributory. Disclosures All Authors: No reported disclosures

208. Comparison of Bloodstream Infections in Hospitalized Patients Before and During the COVID-19 Surge in a Community Hospital in the South Bronx: An Observational Study

BackgroundThere is a paucity of data of bloodstream infections (BSI) before and during the COVID-19 pandemic. The aim of our study was to compare the incidence and characteristics of blood stream infections (BSI) in hospitalized patients before and during the surge of COVID-19 pandemic in a community hospital in South Bronx. MethodsThis is a retrospective observational comparative study of adult hospitalized patients with BSI admitted before (Jan 1-Feb 28, 2020) and during COVID-19 surge (Mar 1- May 1,2020). The incidence of BSI, patient demographics, clinical and microbiological characteristics of infections including treatment and outcomes were compared. ResultsOf the 155 patients with BSI, 64 were before COVID and 91 were during the COVID surge (Table 1). Incidence of BSI was 5.84 before COVID and 6.57 during surge (p = 0.004). Majority of patients during COVID period had ARDS (39.6%), required mechanical ventilation (57%), inotropic support (46.2%), therapeutic anticoagulation (24.2%), proning (22%), rectal tube (28.6%), Tocilizumab (9.9%), and steroids (30.8%) in comparison to pre-COVID (Table 2). Days of antibiotic therapy prior to BSI was 5 days before COVID and 7 during COVID. Mortality was higher among patients with BSI admitted during COVID surge (41.8% vs. 14.1% p < 0.0001). Of 185 BSI events, 71 were Pre-COVID and 114 during surge. Primary BSI were predominant (72%) before COVID contrary to secondary BSI (46%) (CLABSI) during COVID. Time from admission to positive culture was 2.5 days during COVID compared to 0.9 pre-COVID. Majority of BSI during COVID period were monomicrobial (93%) and hospital acquired (50%) (p=0.001). Enterococcus (20.2%), E.coli (13.2%), and MSSA (12.3%) were predominant microbes causing BSI during COVID vs. MRSA (15.5%), Streptococci (15.5%), and S. pneumoniae (14.1%) before COVID (Figure 1). In multivariate logistic regression, Enterococcal coinfection was associated with COVID positivity (OR 2.685, p = 0.038), mechanical ventilation (OR 8.739, p = 0.002), and presence of COPD/Asthma (OR 2.823, p = 0.035). Comparison of Microorganisms Isolated in the BSI X-axis represents the total number of BSI events whereas the number at the end of each bar represents the percentage ConclusionHigher incidence of secondary BSI (CLABSI) due to Enterococcus spp. was observed during the surge of COVID-19 infection in the South Bronx. Breakdown of infection control measures during the COVID-19 pandemic could have been contributory. Disclosures All Authors: No reported disclosures

Successful Treatment with Rectal tube Placement and Barium Enema in Uncomplicated Acute Sigmoid Volvulus: A Case Report

Sigmoid volvulus is a condition in which sigmoid colon wraps around itself and its own mesentery, which then causes a closed-loop obstruction. This condition accounts for 50-90% cases of twisted large intestine and often affects adults and are commonly found in males. The classic triad signs and symptoms are abdominal pain, distention, and constipation. Although the emergency resection seems to be the right procedure in treating acute sigmoid volvulus, there is still non-surgical treatment often done in several conditions. We reported a 52-years-old male with uncomplicated acute sigmoid volvulus who underwent non-surgical treatment due to his refusal of surgical therapy. Non-surgical treatment was successfully done and no recurrence found within one year. The aim of this report was to emphasize that non-surgical therapy only could be successfully done without surgical treatment.

TP9.2.30Sigmoid Volvulus: Is a More Aggressive Approach Justified? Results of a Retrospective Cohort Study

Abstract Aims Sigmoid volvulus is a common cause of emergency surgical admission. It often affects older males who are institutionalised and are less suitable surgical candidates. Definitive treatment is surgical but first line treatment is via endoscopic devolution with or without placement of a rectal tube. After non-operative management recurrence is likely and carries a high mortality, therefore an early surgical approach may be considered in patients who are fit for surgery. We have retrospectively analysed a cohort of patients with sigmoid volvulus in order to clarify if and when a more aggressive management is indicated. Methods We have reviewed data on admitted patients diagnosed with sigmoid volvulus over a 2-year period. Demographic, clinical data, morbidity and mortality were recorded in a database. Analysis was carried out with statistical programs. The primary endpoint was patient survival. Secondary endpoint was the estimation of the factors that condition surgical choice. Results We analysed 78 cases. 74.4% had multiple admissions and recurrences. 39.7% of patients underwent surgical resection. The average survival was 54.9±8.8 months from the first hospitalisation, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low “social score”, a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival. Conclusions In conclusion, we believe that early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient's social and functional condition.

Effects of Bladder Filling and Rectal Gas on Number of CBCT Scans and Treatment Time for Prostate Cancer Patients Undergoing EBRT

Prostate cancer patients undergoing EBRT may be treated with a full bladder and empty rectum to maintain a consistent prostate position. To optimize setup for hypofractionated regimens, cone beam CT (CBCT) scans may be performed to assess the level of bladder filling and the amount of rectal gas before each treatment. However, achieving a precise bladder volume and minimizing rectal gas prior to radiation treatment can be difficult and time-consuming. This process often leads to repeated CBCT scans, treatment delays, and an unpleasant patient experience. We prospectively evaluated the interplay between bladder filling, rectal gas, number of CBCT scans, and the total in-department time. We evaluated whether there was sufficient clinical evidence to justify the use of an alternative imaging technique to reduce the number of CBCT scans and improve treatment efficiency.For bladder and bowel preparation, patients drank 8 oz of water 45-60 mins prior to CBCT scans and took simethicone twice daily and psyllium supplementation daily throughout the treatment course in addition to a saline enema 2-3 hours before CBCT. Inadequate bladder filling prompted oral administration of 8 oz of water and a 20-30-minute delay. Excess rectal gas was passed either voluntarily or via a rectal tube. Relevant data, such as patient arrival time, the number of CBCT scans, and total in-department time, were recorded.We evaluated 475 individual treatments among 194 patients. A total of 34.3% of treatments had bladder filling events, 17.7% had rectal gas events, and 10.5% had both events. The number of CBCT scans had a right-skewed Poisson distribution, with mean 1.43 ± 0.88 (range 0-5). 47.4% of treatments had 1 CBCT scan, 31.8% had 2 CBCT scans, 7.8% had 3 CBCT scans, 1.7% had 4 CBCT scans, and 0.4% had 5 CBCT scans. The distribution of the number of retries (taken off the table) heavily clustered in 0 and 1. 66% of treatments had 0 retries, 19% had 1 retries, 13% had 2 retries, and 2% had 3 retries. The mean and median actual in-department times were 68.9 ± 41.9 and 60.0 mins, while the mean and median scheduled appointment times were 30.1 ± 16.6 and 20 mins. The actual in-department time had a range of 18-245 mins. The median actual in-department time was significantly different from the median scheduled appointment time (P = 2.2e-16). The difference between the two was 40.0 mins.Our findings demonstrate that the level of bladder filling affected the number of CBCT scans, number of retries, and ultimately the total in-department time. There was sufficient clinical evident to support the use of an alternative imaging technique, such as bladder ultrasound, to reduce the number of repeat CBCT scans and improve the overall treatment efficiency of prostate cancer.

S2195 Thoroughly Investigating HIV Late Presenters With Wasting Syndrome

Introduction: HIV late presenters with advanced AIDS are known to have multiple opportunistic infections (OI). Late presentation has been exacerbated by the COVID19 pandemic. Treatment is complicated by many unidentified OIs exhibiting similar symptoms and clinical progress is delayed. The following case presents a newly diagnosed HIV patient with chronic diarrhea. The patient was ultimately diagnosed with GI OIs of Shigella, Microsporidia, Cryptococcus, CMV enteritis/colitis, Candida esophagitis, and Kaposi sarcoma of the stomach. These are all contributors to HIV wasting syndrome. The patient required bacterial, fungal, protozoal, and viral therapy, while antiretroviral therapy was delayed to avoid IRIS. Case Description/Methods: A 47-year-old male with recently diagnosed HIV with AIDS was admitted for cryptococcal meningitis treatment. He showed symptoms of sore throat and diarrhea, and he reported unintentional weight loss of 100lb over eight months with no prior workup. On admission, the patient weighed 85lb and had a BMI of 12.2. He exhibited bitemporal wasting on exam, as well as sacral ulceration. Labs: CD4# 10;WBC 9.9;Hgb 11.1;Hct 26.3;Albumin 2.5;LDH 334 Stool PCR was positive for Shigella and ova and parasite (O&P) testing was positive for Microsporidia. However, he did not respond to Bactrim and albendazole therapy. Diarrhea complicated ulcer healing, requiring rectal tube placement. EGD with biopsies identified Kaposi sarcoma in the stomach body, candida in the esophagus, and cryptococcus in the duodenum. Colonoscopy with biopsies showed ulcerations throughout the terminal ileum and the ascending, descending, and sigmoid colon, which confirmed CMV enteritis/colitis. The patient was receiving amphotericin and flucytosine on admission for cryptococcal meningitis and was started on valganciclovir for CMV. His diarrhea improved and the rectal tube was removed once his incontinence resolved. He experienced weight gain of 3lb over the hospital course. Discussion: Typically noninvasive treatment and further investigation if symptoms don't resolve is standard practice. Patients such as this warrant aggressive evaluation because multiple OIs may occur concurrently, contributing to a common symptom. Quality of life suffers when diarrhea is prolonged. Hospitalization provided the means for monitoring therapy and rapidly advancing evaluative measures. Endoscopy, O&P testing, and stool PCR were necessary to identify the contributors to this patient's wasting. (Figure Presented).

S2458 Can SARS-CoV-2 Enterocolitis Trigger New Onset Inflammatory Bowel Disease ?

Introduction: Prevalence of gastrointestinal symptoms in patients infected with SARS-CoV-2 virus is 6.8% - 61.3%. Most common symptoms include diarrhea (8.1% - 33.7%), nausea/vomiting (1.5% - 26.4%), anorexia (12.1% - 26.4%), and abdominal pain (0 – 14.5%). Management involves treating respiratory manifestation of COVID-19, treating co-existing infections, and supportive care. We present a case of severe hemorrhagic enterocolitis managed with a biologic. Case Description/Methods: 47-year-old woman with COVID-19 pneumonia was admitted for extracorporeal membrane oxygenation. She developed copious amounts of watery diarrhea followed by bloody diarrhea. Stool work-up was negative for infectious causes of diarrhea. Colonoscopy revealed diffusely erythematous and friable mucosa with epithelial loss involving the entire colon and distal ileum. She was managed with rectal tube, blood transfusions, parenteral nutrition. Despite escalating doses of numerous anti-diarrheals, topical as well as systemic steroids, copious volumes of bloody diarrhea continued. Repeat colonoscopic biopsies demonstrated CMV-like inclusions with borderline elevated serologic titers. Despite successful eradication of CMV with prolonged courses of ganciclovir and foscarnet, hemorrhagic diarrhea continued. Several upper and lower endoscopies suggested worsening mucosal erythema and friability, predominantly involving small bowel and colon. Given COVID enterocolitis refractory to all the above treatments, induction therapy with a biologic was considered to treat possible de novo inflammatory bowel disease (IBD) versus immune mediated effects of COVID-19 enterocolitis. After induction doses of Ustekinumab, an IL-12 and IL-23 inhibitor, volume of diarrhea reduced and bloody diarrhea resolved, facilitating removal of rectal tube, resumption of oral nutrition, discontinuation of anti-diarrheals. Patient was discharged on maintenance Ustekinumab. Follow-up endoscopic evaluation demonstrated mucosal healing, with epithelial regeneration and chronic inflammatory changes of crypt distortion. Discussion: SARS-CoV-2 infection triggered an inflammatory cascade in the intestinal tract leading to altered or increased immune response, probably on a background of genetic predisposition, in our patient. Initiation of Ustekinumab, IL-23/IL-12 inhibitor, likely resulted in suppression of the severe systemic inflammatory response, resulting in clinical, endoscopic and pathological response.Figure 1.: (a) demonstrates endoscopic appearance of transverse colon with erythema, friability and hemorrhages prior to treatment with biologic (b) demonstrates epithelial denudation with minimal acute inflammation in colonic mucosa prior to treatment with biologic (c) demonstrates endoscopic appearance of transverse colon with resolving erythema after treatment with biologic (d) demonstrates chronic inflammatory changes with crypt architectural distortion and pyloric gland metaplasia after induction of remission with biologic, many months after initial presentation.

S1942 Microscopic Hematuria Leading to the Diagnosis of Appendiceal Mucinous Carcinoma

Introduction: Appendiceal mucinous neoplasms (AMNs) are an exceedingly rare gastrointestinal malignancy with in incidence of 2.8 cases per million, accounting for less than 1% of all GI cancers, and approximately 1,500 new cases in the US annually. AMNs typically present as acute appendicitis, given the predilection for appendiceal perforation, however as many as 23% are incidentally diagnosed. They are generally thought to be indolent compared to their colorectal counterparts and rarely metastasize outside of the peritoneum. Case description/methods: A 71-year-old female with a 6 pack-year smoking history and long-term methotrexate use for lichen planus presented to her PCP’s office for her annual evaluation. Routine urinalysis at that time showed microscopic RBCs so CT abdomen/pelvis was ordered and showed a 7.9 × 4.8 × 5.1 cm complex right adnexal cyst with adjacent free fluid. Subsequent pelvic ultrasound re-demonstrated the same plus a thickened 6 mm endometrial strip. MRI pelvis was pursued and showed this large adnexal cystic mass to be contiguous with the tip of the appendix, in addition to multiple uterine fibroids. After an unremarkable cystoscopy, suspicions were raised for an exophytic ovarian neoplasm, so the patient proceeded with laparoscopic bilateral salpingo-oophorectomy, appendectomy, collection of pelvic ascites, peritoneal biopsies and liver serosa biopsy, hysteroscopy and endometrial polypectomy. Intraoperatively, the patient had a mucinous fluid covering her pelvic and abdominal cavity with normal appearing uterus, and a ruptured 6 cm complex mass encompassing the appendix. Pathology revealed low grade primary appendiceal mucinous carcinoma with rupture and mucin extravasation, without gynecologic dysplasia. Colonoscopy was then done and only a 3 mm sessile polyp with benign morphology was found in the descending colon. PET CT showed no evidence of metastatic disease. The hospital course was complication by septic shock with polymicrobial bacteremia requiring prolonged mechanical ventilation and tracheostomy. She was discharged to an acute rehab hospital around 8 weeks later, and at 6-month follow-up had no disease recurrence. Discussion: Demonstrated is of the many potential red herrings observed in the evaluation of invasive GI cancers, emphasizing the importance of maintaining broad differentials and an interdisciplinary approach. Also unique was the lack of substantial symptoms despite rupture of said AMN and peritoneal spread - often an acutely clinically significant and painful event.Figure 1.: Figure A: Whirl sign on CT, with a dilated descending colon. Figure B-C: Benign-appearing, intrinsic twisted stenosis in the descending colon. Markedly dilated descending colon after a gentle advance of the colonoscope. The rectal tube was navigated proximal to the volvulus area. Figure D: Abdominal x-ray showing resolution of massive colonic distension after detorsion and rectal tube placement.

The Outcome of Emergency Surgery among Patients with Large Bowel Volvulus (LBV)

Introduction: volvulus is a twisting or axial rotation of a portion of bowel about its mesentery. Large Bowel Volvulus (LBV) accounts for (5%) of all organic large bowel obstructions and are most common between 50 and 60 years of ages .The reported incidence of the various forms of LBV, (59%) for sigmoid volvulus (SV), (39%) for caecal volvulus (CV) and (2%) for transverse colon volvulus. The diagnosis of acute LBV can be challenging because its clinical presentation has low specificity compared with other non-traumatic abdominal pain. Emergency surgery is the appropriate treatment for those who present with diffuse peritonitis, intestinal perforation or ischemic necrosis. Aim of the study: To review the comparison and benefits of emergency operative procedures in the treatment of patients with acute large bowel volvulus in the emergency setting. Place and Duration: Department of General Surgery at Azadi-teaching hospital in Kirkuk city from December 2008 to December 2013. Patients and Methods: Total 48 patients; 31 male (64.6%) and 17 female (35.4%) (95.8%) patients were over 55 years of age. were included in the study of which 41 (85.4%) diagnosed preoperatively with acute sigmoid volvulus on emergency laparotomy. The remaining 7 patients (14.6%) with caecal volvulus. The choice of surgical procedure depended on the; large bowel viability, time of presentation following onset of obstructive features, extent of proximal colonic dilatation, co morbid diseases and surgeon’s preference. For acute sigmoid volvulus; 11 patient (27.2%) patients underwent sigmoid resection with primary anastomosis (RPA), 18 patient (43.9%) underwent Hartmann’s procedure and 12 patients (29.3%) operated by sigmoid resection with Paul-Mikulicz. For caecal volvulus; Right hemicolectomy performed for three patients (42.9%), caecopexy in two (28.6%) and caecostomy in other two patients (28.6%). Results: Abdominal distension and constipation occurs in all patients (100%), while (95.8%) presented with abdominal pain and peritonitis in (79.2%) (41.5%) has a previous history of bowel decompression either by endoscopic instruments or deflation by rectal tube with a recurrence rate of (76.0%). Chronic medical illnesses are found in most of the patients. LBV is presented in two forms sigmoid (85.4%) of cases, the rest (14.6%) with caecal volvulus. (33.4%) of cases presented with gangrenous colon while bowel perforation (fecal peritonitis) in (4.2%). The operative procedures ;- one stage Resection with Primary Anastomosis in (26.8%) of patients , two stage operative procedures resection of the volvulus sigmoid with (Hartmann and Paul-Mikulicz done in (73.2%), in caecal volvulus right hemicolectomy (with ileo-transverse Anastomosis done for (42.9%), caecopexy (28.6%) and Caecostomy for 2 patients(28.6%) patients. Postoperative complications; Wound infection in (31.3%) of cases. Anastomotic leak (12.5%). Total mortality occurs in 10 cases (20.8%). Conclusion: In acute LBV emergency surgery is indicated, Hartmann’s procedure is the procedure of choice. The presence of cardiac, renal, or respiratory diseases has a significant impact on the complications, morbidity and mortality of patients undergoing surgery for large bowel volvulus.

A rare case of persistent fetal intestinal hyperechogenicity – Question

A 24-year-old pregnant woman with an in vitro fertilization (IVF)-assisted pregnancy was examined at 12 weeks of gestation with a fetal ultrasound showing intestinal hyperechogenicity. The maternal anamnesis revealed 3 previous miscarriages, 2 due to ectopic pregnancies. Fetal karyotype and screening for cystic fibrosis performed on both parents were normal. Another ultrasound examination at 27 weeks showed fetal intestinal and gastric dilation and moderate polyhydramnios. The day before delivery, an ascitic effusion was found, not associated with pleural or pericardial effusion. At 29 weeks and 6 days of gestation, an emergency cesarean section was performed for absent variability of the cardiotocographic tracing. The female newborn birth weight was 1,390 g. Apgar scores were 5 at 1 minute and 7 at 5 minutes. The patient was intubated in the Delivery Room and remained on mechanical ventilation until she was transferred to the Neonatal Intensive Care Unit (NICU), then she was ventilated in high-frequency oscillatory ventilation (HFOV). At the time of admission to the NICU, in addition to severe respiratory insufficiency (the saturation was at the lower limits, with FiO2 = 1), at the clinical examination she had moderate pale skin and globose abdomen with generalized tenderness. The nasogastric tube was positioned correctly, and 6 ml of gastric fluid mixed with blood were aspirated. It was possible to insert the rectal tube only for 1.5 cm. To better understand the case, anteroposterior (AP) and translateral chest-abdomen X-rays were performed. 1. What do you see in these X-rays? 2. Which further investigations would you suggest? 3. What is your diagnosis?

Colonic Volvulus

Colonic volvulus accounts for 3 to 5% of bowel obstructions in the United States. Current data reveal sigmoid volvulus as the most common colonic volvulus, followed by volvulus of the cecum, transverse colon, and splenic fixture. Despite a low incidence in the United States, diagnosis, management, and patient outcome depend on an appropriate index of suspicion and adherence to the proposed algorithm highlighting the approach to the patient with colonic volvulus. This review outlines the definition, pathogenesis, and epidemiology of colonic volvulus, as well as its clinical evaluation and treatment. Tables review the demographics of colonic volvulus in the United States, the differential diagnosis of and risk factors for colonic volvulus, important radiographic findings in colonic volvulus, and nonoperative management of sigmoid volvulus. Figures show the types of ileosigmoid knot; plain radiographs of cecal, sigmoid, transverse, and splenic flexure volvulus; contrast enema of cecal, transverse, splenic flexure, and sigmoid volvulus; cross-sectional abdominal imaging of cecal, sigmoid, and transverse colon volvulus and ileosigmoid knot; endoscopic evaluation in sigmoid volvulus; use of an esophageal overtube for placement of a rectal tube; necrotic cecum and transverse colon volvulus in the operating suite; and sigmoid volvulus in an elderly gentleman. This review contains 14 figures, 13 tables, and 165 references Keywords: Colonic volvulus, colonic obstruction, endoscopy, surgical intervention, ileosigmoid knot, splenic flexure volvulus, sigmoid volvulus, transverse colon volvulus, cecal volvulus