Recurrent Small Bowel Obstruction Research Articles

Mesenteric venous thrombosis presenting as recurrent small bowel obstruction – a difficult diagnosis and an unusual aetiology

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Indications for Readmission for Small Bowel Obstruction: A Comparison of Medical vs Surgical Service Admission.

Small bowel obstruction (SBO) impacts the health care system and patient quality of life. Previously, we evaluated differences between medical and surgical admissions in the management of SBO. This study investigates indications for readmission based on original admission to medical (MS) or surgical services (SS). A retrospective chart review was performed for 799 patients aged 18 to 89 admitted between 2012 and 2019 with a diagnosis of SBO. Patient characteristics examined included length of stay (LOS), prior abdominal operations, prior SBO, use of small bowel follow through imaging, operative intervention, mortality, and 30-day readmission. There was no difference in readmission rates in patients originally admitted to MS or SS (13.2% vs 12.7%, P = .86). Patients admitted to SS were more likely to be readmitted for recurrent SBO (39% vs 8.6%, P = .006). Patients admitted to MS were more likely to be readmitted for other reasons (73.9% v. 40.2%, P = .004). In the MS cohort, 30.4% (7 patients) had surgery during their initial admission for SBO, and none of those patients were readmitted for recurrent SBO (rSBO). In the SS cohort, 23% had surgery during their initial admission and 31.6% were readmitted for rSBO (P = .002). Patients admitted to SS were more likely to be readmitted for rSBO and to require surgery. Patients admitted to MS were more likely to be readmitted for other reasons. None of the MS patients who had surgery were readmitted for SBO. 31.6% of SS patients who had surgery were readmitted for SBO.

Assessing risk of recurrent small bowel obstruction after non-operative management in patients with history of intra-abdominal surgery: a population-based comprehensive analysis in Taiwan.

Despite a significant 30% ten-year readmission rate for SBO patients, investigations into recurrent risk factors after non-operative management are scarce. The study aims to generate a risk factor scoring system, the 'Small Bowel Obstruction Recurrence Score' (SBORS), predicting 6-month recurrence of small bowel obstruction (SBO) after successful non-surgical management in patients who have history of intra-abdominal surgery. We analyzed data from patients aged ≥ 18 with a history of intra-abdominal surgery and diagnosed with SBO (ICD-9 code: 560, 568) and were successful treated non-surgically between 2004 and 2008. Participants were divided into model-derivation (80%) and validation (20%) group. We analyzed 23,901 patients and developed the SBORS based on factors including the length of hospital stay > 4 days, previous operations > once, hemiplegia, extra-abdominal and intra-abdominal malignancy, esophagogastric surgery and intestino-colonic surgery. Scores > 2 indicated higher rates and risks of recurrence within 6 months (12.96% vs. 7.27%, OR 1.898, p < 0.001 in model-derivation group, 12.60% vs. 7.05%, OR 1.901, p < 0.001 in validation group) with a significantly increased risk of mortality and operative events for recurrent episodes. The SBORS model demonstrated good calibration and acceptable discrimination, with an area under curve values of 0.607 and 0.599 for the score generation and validation group, respectively. We established the effective 'SBORS' to predict 6-month SBO recurrence risk in patients who have history of intra-abdominal surgery and have been successfully managed non-surgically for the initial obstruction event. Those with scores > 2 face higher recurrence rates and operative risks after successful non-surgical management.

Endo the line: stricturing terminal ileum endometriosis

Endometriosis is the implantation and proliferation of endometrial tissue outside the uterus, and while involvement of the small bowel is rare, it is particularly unusual for it to present with terminal ileum stricture mimicking Crohn’s ileitis. We present the case of a 38-year-old female with recurrent mechanical small bowel obstruction with transition point in the terminal ileum. She was struggling with infertility issues and was not previously known to have endometriosis. The presumptive diagnosis was Crohn’s disease due history of previous anal fissure, high faecal calprotectin level, and imaging findings of terminal ileitis with stricture, despite lacking tissue confirmation from colonoscopy. She underwent laparoscopic ileocolic resection with histology showing endometrial stricture and secondary mucosal inflammation, without any established features of Crohn’s disease. This case demonstrates the potential diversity in presentation of endometriosis, including small bowel manifestations that can mimic Crohn’s ileitis. If endometrioma can be confidently diagnosed based on characteristic imaging features or tissue sample, unnecessary treatment may be avoided, whilst appropriate specialist management improves endometriosis symptoms and fertility outcomes.

Small Bowel Follow-Through: Treatment for Small Bowel Obstruction or Delaying the Inevitable?

Over 400,000 patients are admitted annually for small bowel obstruction (SBO), of which 20-40% require operative intervention, representing more than 2.3 billion dollars in healthcare expenses. Recurrence of SBO increases with a longer duration of follow-up with up to 15-20% recurrence rates within a five-year period. Small bowel follow-through (SBFT) consisting of serial X-rays with oral contrast has been shown to decrease overall length of stay (LOS) in patients with adhesive SBO. The aim of this study is to determine if SBFT administered to patients with SBO decreases 30-day and up to five-year readmission rates secondary to recurrent SBO. The institutional review board (IRB) approved a single institution retrospective study from 2010 to 2020 that included a total of 742 patients. These patients were organized into groups of those who received the SBFT <24 hours after admission (n=40), those who received the SBFT >24 hours (n=198), and the third group of patients who did not receive the SBFT (n=658). Readmission rates <30 days, <one year, one to three years, and three to five years were evaluated using analysis of variance. Risk factors such as age groups of <30, 30-50, 50-70, >70 years along with BMI<25, 25-29.9, 30-34.9, 35-39.9, >40, as well as the number of intraabdominal surgeries, gender, and need for operative intervention during the admission were evaluated to assess for any associations with recurrence. Readmission within 30 days and up to five years were compared. There were no significant differences in recurrence rates between groups with SBFT <24 hours (p=0.338) or SBFT >24 hours (p=0.889) when compared to the no SBFT group. There was nearly a 48% chance of readmission for another episode of an SBO for patients who did not undergo an operative intervention. While patients who underwent operative intervention had around a 29% chance of having a subsequent episode of an SBO. This is consistent with a statistically significant decrease in one-year (p=0.027) recurrences in patients who underwent operative intervention. There was no significant difference in recurrences with gender, most BMI groups, or in groups who underwent an SBFT. Operative intervention is associated with a statistically significant decrease in recurrence rates of SBO within one year of presentation.

A nomogram for predicting the recurrence of small bowel obstruction after gastrectomy in patients with gastric cancer

BackgroundThis study aimed to create a nomogram for predicting the recurrence of small bowel obstruction (SBO) after gastrectomy in patients with gastric cancer (GC) in order to provide better guidance for its diagnosis and treatment.MethodsA total of 173 patients undergone gastrectomy and developed SBO from January 2015 to October 2022 were admitted into this case–control study. The risk factors of postoperative recurrent SBO were analyzed by univariate and multivariate regression, and a nomogram for predicting the recurrent SBO after gastrectomy was developed using R Studio.ResultsThirty-nine cases of postoperative recurrent SBO occurred among the 173 GC patients who underwent radical gastrectomy, and the percentage of recurrent SBO was 22.54% (39/173). Age [odds ratio (OR) = 0.938, p = 0.026], WBC count (OR = 1.547, p < 0.001), tumor size (OR = 1.383, p = 0.024), postoperative metastasis (OR = 11.792, p = 0.030), and the interval from gastrectomy to first SBO (OR = 1.057, p < 0.001) were all identified as independent risk factors for postoperative recurrent SBO by logistic regression analysis. The receiver operating characteristic curve, the calibration curve, the model consistency index, and the decision curve analysis showed that the nomogram had good predictive performance.ConclusionBased on these factors, we created a nomogram to predict the occurrence of postoperative recurrent SBO. This novel nomogram could serve as a crucial early warning indicator that would guide doctors to make informed decisions while managing patients with gastric cancer.

SAT335 Bilateral Pheochromocytomas In Multiple Endocrine Neoplasia Type 2B: A Frozen Abdomen, A Slow Growing Mass, And A Backdoor Solution

Abstract Disclosure: O.A. Shariq: None. T.J. McKenzie: None. W.F. Young: None. Background: Multiple endocrine neoplasia type 2B (MEN2B) is most commonly caused by a germline methionine-to-threonine substitution at codon 918 (M918T) of the RET proto-oncogene. The syndrome is characterized by medullary thyroid carcinoma, pheochromocytoma, and extra-endocrine manifestations (intestinal ganglioneuromas, mucosal neuromas, and skeletal and ophthalmic abnormalities). We describe a patient with MEN2B and bilateral pheochromocytomas, in whom the slow-growing nature of the lesions, and previous history of an extra-endocrine manifestation, precluded the typical approach to surgical resection. Clinical Case: A 58-year-old-male with MEN2B, diagnosed at age 15, presented with a 6-month history of episodic palpitations and labile blood pressures. His past surgical history included a total abdominal colectomy and ileorectal anastomosis at age 7 years for megacolon, secondary to intestinal ganglioneuromatosis. He subsequently required multiple laparotomies and adhesiolysis procedures for recurrent small bowel obstructions. During his most recent laparotomy at age 44, he was noted to have a ‘frozen’ abdomen with dense adhesions involving the small bowel. CT abdomen revealed bilateral adrenal masses, measuring 2.9 cm and 1.5 cm on the right and left, respectively. Review of previous imaging revealed that the right adrenal mass had been present 16 years prior, measuring 1.0 cm at that time, while the left-sided mass was not seen. Biochemical workup was negative previously, but now showed elevated plasma metanephrine (4.1 nmol/L [N&amp;lt;0.5 nmol/L ]) and normetanephrine 2.3 nmol/L [N&amp;lt;0.9 nmol/L ]) levels. In the setting of extensive intra-abdominal adhesions and the slow-growing nature of both masses, the decision was made to perform a unilateral right adrenalectomy through a retroperitoneoscopic, rather than a transabdominal, approach. Pathology confirmed a 4.4 cm pheochromocytoma. The patient was discharged on postoperative day 1 and was symptom free at 1 year follow-up. His most recent plasma metanephrine and normetanephine levels were 0.7 nmol/L and 0.5 nmol/L, respectively. Clinical Lessons: Patients with MEN2B have a 50% lifetime risk of developing pheochromocytoma. Unlike medullary thyroid cancer, which exhibits an aggressive phenotype in this syndrome, MEN2B-associated pheochromocytomas may be slow growing, thereby avoiding the need for an initial bilateral adrenalectomy. Many patients with MEN2B develop gastrointestinal manifestations, including megacolon during infancy, for which multiple surgical interventions may be required. These procedures carry a risk of adhesion formation, which presents a challenge if further abdominal surgery is required later in life for pheochromocytoma. Retroperitoneoscopic adrenalectomy provides a safe approach in such patients, as the need to perform risky adhesiolysis and mobilize adjacent organs is obviated. Presentation: Saturday, June 17, 2023

A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy

BackgroundSmall bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management. MethodsClinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation. ResultsThe nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775–0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686–0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model’s area under the curve was 0.815 (95% confidence interval, 0.683–0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present. ConclusionThe clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.

Idiopathic sclerosing mesenteritis presenting with small bowel volvulus in a patient with antiphospholipid syndrome: A case report

Sclerosing mesenteritis is a rare disorder involving inflammation of the mesentery. Its etiology remains unclear, but it is believed to be associated with previous abdominal surgery, trauma, autoimmune disorders, infection, or malignancy. Clinical manifestations of sclerosing mesenteritis are varied and include chronic abdominal pain, bloating, diarrhea, weight loss, formation of an intra-abdominal mass, bowel obstruction, and chylous ascites. Here, we present a case of idiopathic sclerosing mesenteritis with small bowel volvulus in a patient with antiphospholipid syndrome. A 68-year-old female presented with recurrent small bowel obstruction. Imaging and pathological findings were consistent with sclerosing mesenteritis causing mesenteric and small bowel volvulus. Computed tomography scans also revealed pulmonary embolism, and the patient was started on a high dose of corticosteroid and a therapeutic dose of anticoagulants. The patient subsequently improved clinically and was discharged. The patient was also diagnosed with antiphospholipid syndrome after a hematological workup. Sclerosing mesenteritis is a rare condition, and patients with no clear etiology should be considered for treatment with immunosuppressive therapy.

Iterative evaluation of novel access techniques for small bowel obstruction: combining image guided, percutaneous, and endoscopic methods

ObjectiveTo avoid the need for extensive adhesiolysis in patients with small bowel obstruction (SBO). We evaluated the feasibility of using advanced imaging, percutaneous access, and endoscopy as alternative therapies for...

Salvage surgery is an effective alternative for J-pouch afferent limb stricture treatment

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms. All consecutive eligible patients with ileal pouch-anal anastomosis and afferent limb stricture were identified from our institutional review board-approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study. Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch-anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repairsite. All patients had their ileostomy closed 3.2 (2.99-3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6-5.8) years later. Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms.

Recurrent Small Bowel Obstruction and Perforation as a Complication of EFEMP1-Associated Systemic Venous Amyloidosis

Abstract Introduction/Objective Amyloidogenic protein EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP1) is a newly described age-related systemic venous amyloidosis. EFEMP1 venous deposition has recently been reported in postmortem gastrointestinal specimens in which the deceased presented with gastrointestinal bleeding. Methods/Case Report We report a case of a 53-year-old female with long-standing seronegative spondylitis, and multiple recurrent small bowel obstructions and perforations status post surgical interventions who presented with 3 days of generalized abdominal pain, 10/10 in severity with nausea, emesis and absence of bowel movement. Abdominal CT scan confirmed closed loop obstruction in the left hemi-abdomen. An emergent partial duodenectomy was performed with extensive lysis of adhesion which revealed a perforated jejunal diverticulum with abscess formation. Microscopic examination demonstrated the presence of eosinophilic, amorphous, acellular material in the venules of the duodenum wall. Congo red stain demonstrating the presence of amyloid deposits and the specimen was sent for amyloid typing. Liquid chromatography tandem mass spectrometry demonstrated a peptide profile consisting of serum amyloid P, apolipoprotein A4, apolipoprotein E, and abundant peptides associated with EFEMP1/FBLN3 consistent with a recently described age-related venous amyloidosis derived from EFEMP1 protein. Results (if a Case Study enter NA) N/A. Conclusion EFEMP1-associated systemic venous amyloidosis has a predilection for females with a median age of 75 years and almost exclusively occurs in the gastrointestinal tract. We report this case for its novelty, unique clinical presentation and to emphasize awareness of this entity as we learn more about its etiology, presentation, management, and prognostication.

Jejunal Intussusception Secondary to Large Inflammatory Fibroid Polyp

Abstract Introduction/Objective Inflammatory fibroid polyp (IFP) is a benign mesenchymal lesion that can arise throughout the gastrointestinal tract but are most common in the stomach, followed by the ileum and more rarely in the duodenum and jejunum. Clinical manifestations include intestinal obstruction, abdominal pain, intussusception, and bleeding. Histologically these are characterized by submucosal location, bland spindle stromal cells, abundant eosinophils and lack of lineage specific markers. Methods/Case Report We report the case of a 68-year-old woman with history of recurrent small bowel obstruction due to Crohn’s disease who presented with jejunal intussusception that required ileocolic resection. Gross examination revealed a 4.2 cm well-circumscribed, lobulated mass with a gray-white and fleshy cut surface. Histologic sections showed a submucosal, nodular proliferation of bland spindle cells embedded within a loose, edematous stroma associated with abundant eosinophils. No hypercellularity, necrosis, hemorrhage, or mitotic figures were identified. Immunohistochemical studies revealed that the lesional cells were positive for vimentin and negative for desmin, SMA, S100, CD1a, CD117, DOG1, ALK, Melan-A, HMB-45, CD34, and STAT6. Ki-67 proliferative index was &amp;lt;1%. The mass was classified as an IFP. Results (if a Case Study enter NA) NA Conclusion IFPs usually express CD34 and negative cases have been described as atypical IFPs. Activating mutations of PDGFRA appear to define this lesion molecularly and are responsible for the recruitment of eosinophils. PDGFRA mutations have been detected in both CD34 positive and negative cases suggesting they represent variants of the same entity. The putative origin of this lesion is hypothesized to be a distinct type of stromal cell: the telocyte. Surgical excision is curative for symptomatic IFP.

S2147 That's a Lot of Air! a Case of Incidental Pneumatosis Intestinalis

Introduction: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of gaseous cysts in the submucosa and subserosa of the gastrointestinal tract with an incidence of 0.03%. Common causes include pulmonary disease, chemotherapy, ileal surgeries or bowel obstruction with rare causes linked to lactulose or sorbitol-containing compounds. Management is usually conservative after excluding emergent surgical causes like bowel ischemia or bleeding. We describe a case of PCI found incidentally on imaging in a male with cerebral palsy. Case Description/Methods: A 24-year-old male with an extensive medical history notable for cerebral palsy, epilepsy, tracheostomy and gastrostomy dependence and recurrent small bowel obstructions, presented for evaluation after an outpatient computed tomography (CT) chest demonstrated extensive pneumatosis involving the imaged transverse colon. On review, the patient had a history of abdominal distention and intermittent alternating constipation and liquid stools. Physical examination revealed abdominal distention without tenderness or stool in the rectal vault. Workup revealed normal complete blood count, metabolic profile and lactic acid. CT of the abdomen showed extensive pneumatosis involving the colon (Figure). Considering that the patient had no signs of acute abdomen, he was managed conservatively with gastric decompression. Care was taken to avoid hypoxia and hypotension. Serial abdominal exams and X rays showed improvement and he was restarted on tube feeds which he tolerated well and was discharged home. A few days later, he presented with hematochezia and repeat CT abdomen redemonstrated colonic pneumatosis, however now with new free air. He was managed conservatively again with colonic decompression and slow introduction of feeds and was stable for discharge. Discussion: Pneumatosis cytoides intestinalis is an uncommon condition that can present from asymptomatic abdominal distention to diarrhea and hematochezia. In our case, the proposed mechanism could be related to recurrent bowel obstructions, pulmonary disease or the sorbitol content of his anti-seizure medications. Management is usually conservative with surgery reserved for toxic patients and hyperbaric oxygen used in select patients. Although this patient had hematochezia, he was able to be managed conservatively without surgery. Therefore, in most patients, despite concerning features, PCI may be appropriately managed without surgical intervention.Figure 1.: Diffuse Colonic Pneumatosis and Dilatation.

S3370 Chronic Intestinal Obstruction in Surgically Treated Hirschsprung’s Disease: A Rare Presentation

Introduction: Hirschsprung’s Disease (HD) is exceedingly rare and represents a failure of ganglion cell migration to the gut. Longitudinal studies examining long-term outcomes of surgically treated HD are extremely limited. We discuss a patient who underwent surgical treatment for HD as an infant and presented in adulthood with severe abdominal pain and weight loss. Case Description/Methods: A 34-year-old female presented with severe abdominal pain and 15-pound weight loss over 1 month. She had a history of HD that involved the entire colon diagnosed at 6 months which was treated with the Duhamel procedure at age 1. Her postoperative course was complicated by recurrent small bowel obstruction (SBO) requiring multiple surgeries for adhesiolysis. She continued to pass gas; bowel movements were at baseline. Physical exam revealed mild distention and tenderness in the periumbilical region. CT showed marked small bowel dilation proximal to the anastomosis, multiple areas of focal narrowing, and significant stool burden (Figure A). Endoscopy revealed nonobstructive ileal stenosis proximal to the anastomosis and ileal ulcerations with biopsies showing acute and chronic inflammation with cryptitis (Figure B). Empiric treatment for small intestinal bacterial overgrowth and Hirschsprung-associated enterocolitis were initiated without improvement. She was also trialed on mesalamine with no benefit. Manometry revealed impaired recto-anal inhibitory reflex possibly due to residual HD and Type 1 dyssynergic defecation. She was started on prucalopride with some improvement of her abdominal pain. Providing non-invasive venting options remains an ongoing challenge. Discussion: The curative treatment for HD is surgical resection and the limited studies on long-term outcomes of these patients have demonstrated that constipation or diarrhea are common, and obstructive symptoms or dyssynergia are rare. Potential reasons for the complications presented in this case include mechanical obstruction from strictures and possible residual aganglionosis from insufficient resection. Additionally, prolonged bowel dilation may lead to impaired motility, evacuation difficulties, chronic dilation, and ischemic changes. There is a need for longitudinal studies at dedicated colorectal centers to provide effective transition of care from childhood to adulthood as well as a formalized approach to the management of postoperative complications of HD in adulthood, especially as these issues closely relate to functional status and quality of life.Figure 1.: A: CT demonstrating areas of narrowing and marked dilation proximal to the anastomosis B: Endoscopic view of the ileum demonstrating ulceration and stenosis at the anastomosis site.

S3359 Diaphragm Disease: A Crohn's Mimicker?

Introduction: Diaphragm disease of the small bowel is a rare disease typically associated with NSAID use. The disease is characterized by multiple strictures appearing as ‘pinhole’ sized lumens caused by mucosal thickening. Often the condition goes misdiagnosed until the lumen is visualized, with clinical presentations initially consisting of recurrent bowel obstructions, anemia and/or protein loosing enteropathy. Case Description/Methods: A 50-year-old male with a history of hypertension, incarceration, and prior recurrent small bowel obstructions and prior exploratory laparotomy with lysis of adhesions, presented with recurrent abdominal pain, nausea, vomiting and constipation. A year prior to presentation, the patient was hospitalized for similar symptoms, with colonoscopy demonstrating a fibrotic stricture at the ileocecal valve, which was only able to be traversed after balloon dilation. The mucosa appeared endoscopically normal, however, biopsies of the terminal ileum demonstrated chronic active focal ileitis, suggestive of Crohn’s disease. The patient then experienced two more hospitalizations for small bowel obstruction, which resolved with supportive care and steroid administration. During this hospitalization, CT scan demonstrated a small bowel obstruction with several transition points in the mid small bowel. Intravenous corticosteroids were started, and nasogastric tube was placed with improvement. He adamantly denied any current or past prolonged NSAID use. It was decided that patient would benefit from a surgical small bowel exploration. Several strictures were seen in the proximal small bowel, and therefore proximal and distal resection of jejumum with a primary end-to-end enteroenterostomy anastomosis was performed. Histopathological evaluation of the resected specimen showed small bowel with circumferential membranes with submucosal neuromuscular and vascular hyperplasia, displaced mucosal glands, and associated mucosal active and chronic ileitis with ulceration, compatible with a diagnosis of diaphragm disease. (Figure) Discussion: NSAIDs can have deleterious effects on the small bowel including, ulceration, structuring, erosion formation, perforation and/or the formation of fibrous diaphragms that can lead to obstruction. Diaphragm disease is uncommon, especially in the absence of prior NSAID use. Clinically, it is important to recognize this group of patients as obstructive symptoms due to structuring/diaphragm disease are unlikely to resolve without some form of surgical intervention.Figure 1.: a + b) Submucosal fibrosis and neuromuscular and vascular hyperplasia. c) Focal narrowing and proximal dilation of a loop of small bowel with transition point within the mid small bowel.

P33 The successful use of Belimumab in recurrent small bowel obstruction secondary to Lupus Enteritis

P33 The successful use of Belimumab in recurrent small bowel obstruction secondary to Lupus Enteritis

Water-soluble contrast in the management of adhesive small-bowel obstruction: a Canadian centre's experience with guideline development and implementation.

Background:Orally administered water-soluble contrast (WSC) can track resolution of small-bowel obstruction (SBO), but no universal pathway for its use exists. We developed and implemented an evidence-based guideline for the use of WSC in the management of adhesive SBO, to be implemented across hospitals affiliated with the University of Toronto.Methods:We performed a systematic review and created a clinical practice guideline for WSC use in the management of adhesive SBO. The guideline was approved through consensus by an expert panel and implemented in 2018. We performed a prospective cohort study of guideline implementation at 1 pilot site (a large academic tertiary care centre), facilitated by the centre’s acute care general surgery service. Primary outcomes included compliance with the guideline and hospital length of stay (LOS). Secondary outcomes included rates of failure of nonoperative management, morbidity, mortality and readmission for recurrence of SBO within 1 year. Patients with adhesive SBO admitted in 2016 served as a control cohort.Results:We analyzed the data for 152 patients with adhesive SBO admitted to the centre, 65 in 2016 (historical cohort), 56 in January–June 2018 (transitional cohort) and 31 in July–December 2018 (implementation cohort). There was a significant increase in compliance with the WSC protocol in 2018, with the proportion of patients receiving WSC increasing from 45% (n = 25) in the transitional cohort to 71% (n = 22) in the implementation cohort (p < 0.001). The median LOS did not differ across the cohorts (p = 0.06). There was a significantly lower readmission rate in the transitional and implementation cohorts (13 [23%] and 9 [29%], respectively) than in the historical cohort (29 [45%]) (p = 0.04). Among patients assigned to nonoperative management initially, a significantly higher proportion of those who received WSC than those who did not receive WSC went on to undergo surgery (14.6% v. 3.6%, p = 0.01), with no difference in median time to surgery (p = 0.2).Conclusion:An evidence-based guideline for WSC use in SBO management was successfully developed and implemented; no difference in LOS or time to surgery was seen after implementation, but rates of immediate operation increased and readmission rates decreased. Our experience shows that implementation of an evidence-based clinical practice guideline is feasible through multidisciplinary efforts and coordination.

Recurrence of Small Bowel Obstruction in Adults After Operative Management of Adhesive Small Bowel Obstruction: A Systematic Review.

The objective of this article is to review the existing literature on postoperative recurrence of adhesive small bowel obstruction (ASBO). We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Cochrane Library, and Google Scholar, to identify randomized controlled trials (RCTs) and observational studies investigating recurrence after operative management of ASBO. Our search yielded one RCT, one prospective study, and eight retrospective studies, totaling 36,178 patients. We used Cochrane risk-of-bias tool and the Newcastle-Ottawa scale to assess the risk of bias in the reviewed studies (RCTs and observational studies, respectively). Operative management was associated with a lower risk of recurrence than conservative management, while the difference in recurrence between laparoscopic and open surgery was inconclusive. Diffuse adhesions were associated with a greater risk of recurrence than single band adhesions. We conclude that the “common knowledge” that surgery increases the risk for recurrence of ASBO is outdated and should no longer be applied when determining treatment modalities for ASBO. While conservative treatment still has its place, we need not fear the possibility of shifting patients to operative management earlier.

EP-90 Bouveret Syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum

Abstract Aims Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. We present a case of a 68-year-old with recurrent small bowel obstruction secondary to a large gallstone impacted in the fourth part of the duodenum and cholecysto-duodenal fistula. We describe our atypical approach to surgical retrieval. Methods The patient presented acutely with abdominal pain and vomiting, on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation and clinical deterioration. Endoscopic management was not available locally. The stone could not be milked proximally for retrieval via pyloroplasty. Subsequently, high-pressure water flushes delivered via the gastrostomy expelled the stone distally. The stone was then retrieved via a jejunotomy at the DJ flexure. Results The patient required a 2-day high dependency unit admission and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow-up appointment. Conclusions This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered safe option in patients with large, impacted stone and multiple co-morbidities.