Small Bowel Diameter Research Articles

Early Initiation of Adalimumab Significantly Diminishes Postoperative Crohn's Disease Endoscopic Recurrence and Is Superior to 6-Mercaptopurine Therapy: An Open-Label, Randomized Controlled Study.

Postoperative recurrence (POR) is the rule in patients with Crohn's disease (CD), mitigated with prophylactic therapy. The evidence for therapeutic choice and timing of intervention is lacking. We aimed to compare the rates of POR in patients treated early with prophylactic 6-mercaptopurine (6-MP) or adalimumab. We conducted a prospective single-center randomized open-label clinical study in which patients in surgical remission following their first ileocecectomy were randomized to receive early treatment with 6-MP or adalimumab. Patients were followed up clinically every 3 months and underwent endoscopy at weeks 32 and 58 postoperatively. The primary endpoint was endoscopic recurrence (ePOR) at 1 year (week 58), defined as a Rutgeerts score ≥ i2. We enrolled 35 patients (25 males, mean age 35 ± 1.4 years, median disease duration 5 ± 6.1 years) following ileocecectomy. Of these, seven (20%) were current smokers and nine (26%) biologics-experienced. Patients allocated to adalimumab had significantly less ePOR than patients treated with 6MP at week 32 (21% vs. 69%, p = 0.004) and 58 (47% vs. 75%), (p = 0.03, HR = 0.39, 95% CI = 0.16-0.93). POR was associated with an increased diameter of the resected small bowel surgical specimen, lower baseline body mass index (BMI), increased week 18 fecal calprotectin, increased week 18 serum alanine aminotransferase and decreased week 18 hemoglobin level. Adalimumab was more effective than 6-MP in preventing ePOR. Increased operative small bowel diameter and lower postoperative BMI were associated with ePOR. At eighteen weeks, serum hemoglobin, ALT and fecal calprotectin levels were predictive of endoscopic disease recurrence. (ClinicalTrials.gov ID NCT01629628).

Accurately evaluating for a small bowel obstruction using an abdominal radiograph, by a new method: The Bowel-Spine Ratio

IntroductionA well-established method does not exist to rule out a small bowel obstruction using an abdominal xray series with significant accuracy. The hypothesis of the study is that the ratio of an average small bowel diameter to lumbar spine diameter over 0.5 is most likely a small bowel obstruction. MethodsAn x-ray abdominal series measurement technique was applied to 41 subjects with a chief complaint of “abdominal pain” as part of a randomized retrospective case review to predict an obstruction v. non obstruction. A total number of 81 abdominal pain subjects with a mean age of 46.7 years were selected with 40 excluded due to normal small bowel gas pattern. The subject's medical information was unknown to the authors when reading their images. The measurement technique involved averaging the largest and smallest small bowel short axis diameters with comparison to the lowest clearly visible lumbar body width. The subjects' medical course as described in the medical chart or subsequent computed tomography scans were used as the referencing standard to determine presence of obstruction vs non-obstruction. ResultsThis method, called the Bowel-Spine Ratio (BSR), resulted in a sensitivity of 0.882 (0.622–0.979; 95% CI), specificity of 0.957 (0.760–0.998; 95% CI), accuracy of 94.7% (80.9%–99.1%; 95% CI) and a positive likelihood ratio of 21 for predicting a small bowel obstruction. ConclusionThe abdominal series Bowel-Spine Ratio is a simple yet effective technique to screen for a small bowel obstruction using limited resources and to avoid unnecessary computed tomography scans with the potential to reduce health care costs. Implications for practice: Clinicians could have increased confidence in utilizing abdominal radiographs to evaluate for small bowel obstruction.

Preoperative small bowel dilation is associated with ileus after right colectomy

• Existing prediction models for postoperative ileus are suboptimal. • The relationship between preoperative bowel dysfunction and ileus is unclear. • Small bowel dilation significantly increases the risk of postoperative ileus. • Future prediction models for ileus should incorporate small bowel diameter. • Consider earlier parenteral nutrition in affected patients with malnutrition. The relationship between preoperative bowel dysfunction and postoperative ileus has not been explored clinically. We hypothesized chronic partial obstruction, based on preoperative small bowel diameter, is associated with ileus after colon surgery. This was a retrospective case-control study of patients undergoing right colectomy or ileocolic resection with primary anastomosis. Patients who developed ileus were compared to those who did not. Postoperative ileus occurred in 22 of 69 patients (32%). Preoperative small bowel dilation with maximum diameter >3 cm was present in 13 patients (19%) with 7 developing ileus (54%; p=0.06). In a multivariable model, small bowel dilation >3 cm (OR 4.6; 95% CI: 1.3-16.6) and preoperative weight loss >10 pounds (OR 9.8; 95% CI: 1.6-57.9) were independently associated with ileus. Colorectal surgery patients with preoperative bowel dilation have an increased risk of postoperative ileus. This knowledge can better inform patient expectations for recovery and help guide perioperative nutritional management, particularly with patient selection for parenteral nutrition.

Predicting the Need for Surgery in Uncomplicated Adhesive Small Bowel Obstruction: A Scoring Tool

IntroductionNonoperative treatment can be attempted for uncomplicated adhesive small bowel obstruction (ASBO), but carries a risk of delayed surgery. Highlighting initial parameters predicting risk of failure of nonoperative management would be of great interest. MethodsPatients initially managed conservatively for uncomplicated ASBO were retrospectively analyzed. Univariate and multivariate analysis were performed to identify predictive failure's factors. Based on the risk factors, a score was created and then prospectively validated in a different patients' population. ResultsAmong 171 patients included, 98 (57.3%) were successfully managed conservatively. In a multivariate analysis, three independent nonoperative management failure's factors were identified: Charlson Index ≥4 (P = 0.016), distal obstruction (P = 0.009), and maximum small bowel diameter over vertical abdominal diameter ratio >0.34 (P = 0.023). A score of two or three was associated with a risk of surgery of 51.4% or 70.3% in the retrospective analysis and 62.2% or 75% in the validation cohort, respectively. ConclusionsThis clinical-radiological score may help guide surgical decision-making in uncomplicated ASBO. A high score (≥2) was predictive of failure of nonoperative management. This tool could assist surgeons to determine who would benefit from early surgery.

137 Multi-Center Analysis of Point-of-Care Ultrasound in the Diagnosis of Small Bowel Obstruction and Prediction of Surgical Intervention

The management and diagnosis of small bowel obstruction (SBO) relies on diagnostic imaging. While multiple studies have evaluated the performance of POCUS in diagnosis of SBO, further studies are needed to help establish if and how the test can be used in clinical practice. We sought to analyze the prognostic ability of POCUS to diagnosis SBO and identify patients requiring surgical intervention. 401 patients with suspected SBO who were prospectively enrolled at five separate emergency departments (ED) of tertiary care hospitals were included in this study. Clinician pretest probability, patient symptoms, physical examination and POCUS findings including bowel dilation, peristalsis, wall edema, abdominal free fluid, and transition points were used to determine the most reliable findings in diagnosis and severity grading of SBO. All POCUS images were reviewed and interpreted by an independent reviewer, who made a prediction of whether or not a SBO was present. Radiologist CT interpretations and applicable surgeon intra-operative findings were used as a reference standard. All findings were placed into a nomogram, to calculate an appropriate predictive model for POCUS as an imaging modality for SBO. The discriminative ability of the nomogram was tested using C statistics, calibration plots, and Kaplan-Meier curves. The derivation cohort included 401 patients who underwent POCUS for suspected SBO (mean age 55 years, 41% female). All patients underwent abdominal CT and 31% of the patients had a SBO by CT. Of the 124 patients diagnosed with SBO, 35% required surgical intervention and 91% of these patients were positive for SBO by POCUS. There was an 84% agreement between POCUS reviewer and radiologist/surgeon findings. A stepwise selection of clinically important variables showed identified small bowel diameter, positive free fluid in the abdomen, clinician pretest probability, and patient age as relevant factors in the identification of SBO. The nomogram revealed good predictive ability as indicated by a high C-statistic for SBO diagnosis. When combined with clinical factors including physician gestalt and patient demographics, POCUS is a reliable method of accurately diagnosing SBO and identifying patients who may need a surgical intervention. This holds true across multiple emergency departments and ultrasound users.

Computed Tomography Findings Predicting the Need for Surgery in Cases of Small Bowel Obstruction: Emphasis on Duodenal Distension.

The aim of the study is to retrospectively evaluate the utility of computed tomography (CT) findings, especially newly defined duodenal distension, for predicting the need to operate on small bowel obstruction (SBO) cases. During a 51-month period, 228 patients (100 women and 128 men; mean age, 55 years) were included in this study, among 438 patients who were hospitalized with a prediagnosis of SBO. The final study population was then divided into 2 groups: a surgery group (n = 76) and a conservative group (n = 152). The CT findings of the SBO patients whose treatment decisions and outcomes were unknown were examined by 2 gastrointestinal radiologists with consensus. Statistical analyses were conducted using univariate and binary logistic regression analyses. According to the univariate analysis, the degree of obstruction (P = 0.001), small bowel diameter (P = 0.014), and presence of mesenteric fluid (P < 0.001), intraperitoneal free fluid (P = 0.04), intra-abdominal free gas (P < 0.001), and duodenal distension (P < 0.001) showed statistically significant differences between the surgery and conservative groups. However, there were no statistically significant group differences regarding the presence of a transition point, small bowel feces or mesenteric congestion. According to the binary logistic regression analysis, the degree of obstruction (P = 0.012), presence of mesenteric fluid (P = 0.008), intra-abdominal free gas (P = 0.019), and duodenal distension (P < 0.001) were significant predictors of the need for surgery in SBO cases. Duodenal distension as a CT finding predicted the need for surgery in SBO cases.

Development of a nomogram to predict small bowel obstruction using point-of-care ultrasound in the emergency department

ObjectiveEarly diagnostic prediction in patients with small bowel obstruction (SBO) can improve time to definitive management and disposition in the emergency department. We sought to develop a nomogram to leverage point-of-care ultrasound (POCUS) and maximize accuracy of prediction of SBO diagnosis. MethodsUsing data from a prospective cohort of 125 patients with suspected SBO who were evaluated with POCUS in the ED, we developed a nomogram integrating age, gender, comorbidities, prior abdominal surgery, physician's pre-test probability, and POCUS findings to determine post-test risk of SBO. The primary outcome was to develop a nomogram to allow calculating output probabilities for predictive models using POCUS findings. The discriminative ability of the nomogram was tested using a C-statistics, calibration plots, and receiver operating characteristic curves. ResultsThe derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: small bowel diameter (odds ratio [OR] per 1 mm increase, 1.10; 95% CI, 1.03–1.17; P = 0.001), positive free intraperitoneal fluid between bowel loops (OR, 8.19; 95% CI, 2.62–25.62; P < 0.001), clinician's moderate (OR, 5.94; 95% CI, 0.83–42.57; P = 0.08) or high pretest probability (OR, 11.26; 95% CI, 1.44–88.25; P = 0.02), and patient age (OR per 1 year increase, 1.03; 95% CI, 1.00 to1.07; P = 0.08).The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C-statistic of 0.89 for the SBO diagnosis. ConclusionA unique nomogram incorporating patient age, physician pretest probability of SBO, and POCUS measurements of small bowel diameter and the presence of free intraperitoneal fluid between bowel loops was developed to accurately predict the diagnosis of SBO in the emergency department. The nomogram should be externally validated in a novel cohort of patients at risk for SBO to better assess predictability and generalizability.

Small Bowel Dilatation Predicts Prolonged Parenteral Nutrition and Decreased Survival in Pediatric Short Bowel Syndrome.

To analyze risk factors and prognostic significance of small bowel (SB) dilatation in children with short bowel syndrome (SBS). In SBS, the remaining SB may dilate as part of intestinal adaptation. The impact of dilatation on parenteral nutrition (PN) dependence and survival has not been studied systematically. SB diameter of SBS children (n = 61) was measured in contrast SB series (n = 169, median age 0.94, range 0.32-2.7 years) during 2002 to 2015, and expressed as millimeters (SB width) and as ratio to L5 vertebra height (SB diameter ratio). Linear regression was used to examine risk factors for dilatation. PN weaning and survival were analyzed with Cox proportional hazards regression. Maximal SB diameter ratio during follow-up was predicted by PN dependence and SB atresia, while maximal absolute SB width by birth weight, age, PN duration, and remaining bowel length. Weaning off PN was 14-fold more likely in patients with maximal SB diameter ratio <2.00 compared with >3.00 (P = 0.005), and 5.4-fold more likely when maximal SB width was <20 mm compared with >30 mm (P = 0.023). After adjustment for age, remaining SB length, and the presence of ileocecal valve, both estimates of maximal SB dilatation remained significant independent predictors for weaning off PN. When all measurements were included, the cumulative survival was worse if SB diameter ratio exceeded 2.00 (P = 0.002-0.042). SB dilatation predicts prolonged PN duration and decreased survival in SBS children. Measurement of maximal SB diameter standardized to L5 vertebra height may be a valuable objective tool for patient follow-up and assessment of prognosis.

Small bowel dilation in children with short bowel syndrome is associated with mucosal damage, bowel-derived bloodstream infections, and hepatic injury

Liver disease occurs frequently in short bowel syndrome. Whether small bowel dilation in short bowel syndrome could influence the risk of liver injury through increased bacterial translocation remains unknown. Our aim was to analyze associations between small bowel dilation, mucosal damage, bloodstream infections, and liver injury in short bowel syndrome patients. Among short bowel syndrome children (n = 50), maximal small bowel diameter was measured in contrast series and expressed as the ratio to the height of the fifth lumbar vertebra (small bowel diameter ratio), and correlated retrospectively to fecal calprotectin and plasma citrulline-respective markers of mucosal inflammation and mass-bloodstream infections, liver biochemistry, and liver histology. Patients with pathologic small bowel diameter ratio >2.17 had increased fecal calprotectin and decreased citrulline (P<.04 each). Of 33 bloodstream infections observed during treatment with parenteral nutrition, 16 were caused by intestinal bacteria, cultured 15 times more frequently when small bowel diameter ratio was >2.17 (P<.001). Intestinal bloodstream infections were predicted by small bowel diameter ratio (odds ratio 1.88, P=.017), and their frequency decreased after operative tapering procedures (P=.041). Plasma bilirubin concentration, gamma-glutamyl transferase activity, and histologic grade of cholestasis correlated with small bowel diameter ratio (0.356-0.534, P<.014 each), and were greater in the presence of intestinal bloodstream infections (P<.001 for all). Bloodstream infections associated with portal inflammation, cholestasis, and fibrosis grades (P<.031 for each). In linear regression, histologic cholestasis was predicted by intestinal bloodstream infections, small bowel diameter ratio, and parenteral nutrition (β=0.36-1.29; P<.014 each), while portal inflammation by intestinal bloodstream infections only (β=0.62; P=.033). In children with short bowel syndrome, small bowel dilation correlates with mucosal damage, bloodstream infections of intestinal origin, and cholestatic liver injury. In addition to parenteral nutrition, small bowel dilation and intestinal bloodstream infections contribute to development of short bowel syndrome-associated liver disease.

Small Bowel Dilatation in Pediatric Short Bowel Syndrome Associates with Mucosal Damage, Bowel-Derived Bloodstream Infections, and Liver Injury.

Introduction: Adaptive small bowel (SB) dilatation is common in short bowel syndrome (SBS). Whether SB dilatation predisposes to bloodstream infections (BSI) or associates with mucosal damage or liver injury remains unknown. Methods: Among SBS children (n=50), maximal SB diameter was measured in contrast series (n=179), expressed as ratio to fifth lumbar vertebra height (SB diameter ratio), and related to fecal calprotectin and plasma citrulline; markers of mucosal inflammation and mass, BSIs, liver biochemistry, and liver histology. Results: Median length of remaining SB was 38 (interquartile range 25–60) cm, age at contrast series 1.04 (0.34-3.01) years, and SB diameter ratio 2.14 (1.65-2.71). Patients with pathological SB diameter ratio >2.17 predicting prolonged PN-dependence had increased fecal calprotectin (86 vs. 22, p=0.012), plasma bilirubin (8 vs. 6, p=0.033), gamma-glutamyl transferase (52 vs. 20, p<0.001), and aminotransferase concentrations (45 vs. 30; 59 vs. 42, p<0.001-0.019) while decreased plasma citrulline (15 vs. 26, p=0.033) compared to others. All BSIs occurred during parenteral nutrition (PN) and 48% (16/33) of them were caused by intestinal bacteria, cultured 15 times more frequently when SB diameter ratio exceeded 2.17 (Figure 1). In logistic regression, SB diameter ratio was the only predictor of intestinal BSIs (odds ratio 1.88, p=0.017). Histological cholestasis grade was higher when SB diameter ratio exceeded 2.17 vs. ≤2.17 (1.15 vs. 0.21, p<0.001), while cholestasis, portal inflammation, and fibrosis grades were higher in the presence of intestinal BSIs vs. no BSIs (Figure 2). In linear regression, histological cholestasis was predicted by intestinal BSIs, SB diameter ratio, and PN (β=0.36-1.29, p<0.001-0.014), while portal inflammation by intestinal BSIs only (β=0.61, p=0.021). Conclusion: In pediatric SBS, SB dilatation relates with mucosal damage, BSIs of intestinal origin, and cholestatic liver injury, while BSIs of intestinal origin predict both histological cholestasis and portal inflammation. Results suggest the damaged mucosa of excessively dilated SB predisposes to bacterial translocation, which contributes to liver disease development.FIGURE 1: The occurrence of BSIs of intestinal origin according to small bowel (SB) diameter ratio within 6 months of contrast series (n=179).FIGURE 2: Grading of portal inflammation, cholestasis, and fibrosis (Metavir) according to the presence of BSIs of intestinal origin within 6 months of liver biopsies (n=50).

Outcome of fetuses with gastroschisis after modification of prenatal management strategies : Prenatal management and outcome of gastroschisis.

To improve the outcome of fetuses with gastrochisis several studies evaluated prenatal predictors. But there are different guidelines established and therefore the prenatal care is not standardized. With our study we wanted to evaluate the outcome of fetuses with gastroschisis after modification of prenatal management strategiesat the Department of Obstetrics and Gynecology of the University Hospital Münster. In this explorative retrospective study of 39 fetuses with gastroschisis, we compare the clinical outcome between two management groups. In the first group (group 1, n=14) prenatal indication for delivery was confirmed by a subjective evaluation of the small bowel diameter and the wall thickness without established cut-off values for these parameters. In the second group (group 2, n=25) certain limits for the small bowel diameter (25mm) and the wall thickness (2.5mm) were used for fetal surveillance. Noticeable differences between the two groups regarding birth weight, weight centile, arterial pH, small bowel diameter, wall thickness, adverse bowel condition and re-operations could not be observed. In group 2, delivery was earlier (p=0.011), and a lower rate of prenatal complications was observed (p=0.016). To avoid adverse prenatal complications we recommend the observation of fetuses with gastroschisis by sonographic monitoring of the small bowel diameter and the wall thickness.

Quantitative in vivo analysis of small bowel motility using MRI examinations in mice – proof of concept study

Small bowel motility analyses using magnetic resonance imaging (MRI) could reduce current invasive techniques in animal studies and comply with the 'three Rs' rule for human animal experimentation. Thus we investigated the feasibility of invivo small bowel motility analyses in mice using dynamic MRI acquisitions. All experimental procedures were approved by the institutional animal care committee. Six C57BL/6 mice underwent MRI without additional preparation after isoflurane anaesthetization in the prone position on a 4.7 T small animal imager equipped with a linear polarized hydrogen birdcage whole-body mouse coil. Motility was assessed using a true fast imaging in a steady precession sequence in the coronal orientation (acquisition time per slice 512 ms, in-plane resolution 234 × 234 µm, matrix size 128 × 128, slice thickness 1 mm) over 30 s corresponding to 60 acquisitions. Motility was manually assessed measuring the small bowel diameter change over time. The resulting motility curves were analysed for the following parameters: contraction frequency per minute (cpm), maximal contraction amplitude (maximum to minimum [mm]), luminal diameter (mm) and luminal occlusion rate. Small bowel motility quantification was found to be possible in all animals with a mean small bowel contraction frequency of 10.67 cpm (SD ± 3.84), a mean amplitude of the contractions of 1.33 mm (SD ± 0.43) and a mean luminal diameter of 1.37 mm (SD ± 0.42). The mean luminal occlusion rate was 1.044 (SD ± 0.45%/100). The mean duration needed for a single motility assessment was 185 s (SD ± 54.02). Thus our study demonstrated the feasibility of an easy and time-sparing functional assessment for invivo small bowel motility analyses in mice. This could improve the development of small animal models of intestinal diseases and provide a method similar to clinical MR examinations that is in concordance with the 'three Rs' for humane animal experimentation.

Radiographic Characterization of Small Bowel Segments Proximal to the Ileocolonic Anastomosis in Crohnʼs disease (CD): Correlation of Anastomotic Type with Bowel Diameter and Quality of Life

Purpose: The clinical value of finding small bowel (SB) distention on imaging is well-known in surgically naive patients, but chronically distended segments of SB proximal to the ileocecal anastomotic region has also been noted in CD patients. Cross sectional imaging signs of disease activity do not encompass surgically altered SB anatomy. There is no established criteria to interpret bowel distention in the setting of ileocolonic anastomosis, whether it is an end-to-end (E->E) or side-to-side (S->S; “functional end-to-end”) approach. S->S stapled anastomosis transects circular muscle layers and reconstructs the bowel in an anti-peristaltic orientation, which creates a pouch-like structure. In contrast, E->E anastomosis re-establishes the luminal continuity as a tube. We wanted to find the prevalence of chronically distended SB segments in the pre-anastomotic region, its clinical impact, and whether such finding was more common in one surgical approach of anastomosis vs. the other. We examined CT imaging done with oral contrast in CD patients who had undergone ileocecal resection. We correlated clinical parameters, like disease-related quality of life, with imaging patterns. Methods: Our study has an observational design from a consented prospective CD registry. Consecutive patients with imaging and mean quality of life scores (SIBDQ) obtained from clinic visits at the time of imaging were included. A mean of two independent measurements of the maximum cross sectional diameter of the ileum proximal to the anastomotic site was recorded. Both transverse and coronal series were reviewed. Internal validation was done by measuring aortic diameter at the level of diaphragm. We excluded patients with ileostomy and patients who underwent CT exams for evaluating immediate post-operative complications, like SB obstruction. Results: One hundred four patients met criteria. Seventy-eight (75%) had S->S anastomosis and 26 (25%) had E->E. Mean age 44 (SD 12.9), 44% men. 30/104 (29%) had SB diameter >30.0 mm, all of whom but one had S->S anastomosis. Mean diameter in S->S group was 29.3 mm (SD=11.39, 95% CI= 26.7-31.9), and, for the E->E group, was 19.9 mm (SD 4.6 95% CI 18.0-21.7); the difference was statistically significant (t-test P value <0.0001). As distention increased in S->S group, SIDBQ scores worsened (linear regression 95% CI 0.02-0.50 p-value <0.05). Eighty-five percent (17/20) of patients in the upper quartile of SB diameter (>3.6 cm) had mean SIDBQ score <50, suggesting poor quality of life. Thirty-five percent (7/20) of such CT exam reports had bowel caliber reported to be normal. Conclusion: SB distention is commonly encountered in patients with S->S anastomosis, and is clinically relevant, correlating with decreased quality of life scores in CD.

Crohn's disease: small bowel motility impairment correlates with inflammatory‐related markers C‐reactive protein and calprotectin

To evaluate the correlation between the levels of C-reactive protein (CRP), calprotectin, and small bowel motility in patients with Crohn's disease assessed with MRI. This prospective institutional review board approved study included magnetic resonance imaging enterography (MRE) and analyses of inflammatory markers in blood (C-reactive protein) and feces (calprotectin). For cine MRE, a coronal 2D-T2w sequence was used on a 1.5 T MRI system. Small bowel motility was analyzed in 13 patients using dedicated magnetic resonance MR-motility assessment software (Motasso). Contraction frequency, amplitude, amplitude diameter ratio, and luminal diameter were determined as well as the blood levels of CRP (mg L(-1) ) and fecal levels of calprotectin (ug g(-1) ). Statistics were calculated using Pearson's correlation coefficient. A significant inverse linear correlation was found between the contraction frequency and both the level of CRP (r=-0.701, P=0.008) and calprotectin (r=-0.805, P=0.001). Dilatation of small bowel diameter significantly correlated with calprotectin levels (r=0.857, P=<0.001) but not with CRP (r=0.447, P=0.126). The absolute amplitude of the contractions did not correlate neither with the level of CRP (r=-0.527, P=0.064) nor with calprotectin (r=-0.612, P=0.026). The ratio describing the contraction amplitude relatively to the individual luminal diameter significantly correlated with calprotectin (r=0.736, P=0.004) and with CRP (r=0.577, P=0.039). Alterations of small bowel motility during CD flares significantly correlate with the level of calprotectin and CRP indicating that they represent inflammatory activity.

P08.11: Correlation between prenatal ultrasound measurements and newborn outcome in the free loop of the small bowel in gastroschisis. Part II 2008–2010

Gastrochisis is an abdominal wall anterior defect that involved extrusion of fetal intestines. Occur in 0.13 to 1.4 per 10.000 live births. Review from the ultrasound literature report small bowel diameter over 11 mm to predict adverse neonatal outcome. This study want to add to our 12 gastrosquisis in the last study 8 new more between 2008–2010 to correlated our findings. Data's from 8 fetuses that had gastroschisis. Ultrasound report was made by taking measurements of the free loop in the small bowel (length and the anteroposterior diameter) and 3D images. All studies were performed using an 3700 ALOKA ultrasound system. Data's were analyze in computer statically program (excel 2007). The mean of the length in the free loop was 46 mm the low value was 20 mm and the maximum value of the free loop was 60 mm. The mean of the anteroposterior diameter was 16 mm. The low value was 13.7 mm and the maximum value of the free loop in the anteroposterior diameter was 20 mm. Mean fetal weigh 2315 grams. Mean gestational age to delivery 35 weeks. Thirty seven point five of the newborn had complications 37.5% (obstruction, appendicitis). Mean overall length stay of intensive unit care was 17 days. Measurement of the free loop in the small bowel is a good marker to prevent ischemia (60 mm per 16 mm). Preterm delivery gives better outcome to the newborn with Gastroschisis after 34 weeks and the mean overall length stay in the intensive unit care if half in comparison with the last report. We need more data's to see the best gestational age to delivery fetus with gastroschisis without complications.

Accuracy of Plain Abdominal Radiography in the Differentiation between Small Bowel Obstruction and Small Bowel Ileus in Acute Abdomen Presenting to Emergency Department

IntroductionOur purpose was to evaluate whether plain abdominal radiography (PAR) could accurately differentiate between small bowel obstruction (SBO) and small bowel ileus (SBI) in an emergency setting. We also evaluated the value of known classic signs on the PAR for differentiating between SBO and SBI.MethodsThis retrospective study included 216 emergency room patients who had small bowel distension (maximal small bowel diameter ≥2.5 cm) on the PAR and who underwent successive abdominal computed tomography. One radiologist and one emergency physician retrospectively reviewed PAR in consensus, unaware of the patients' clinical data; they divided the patients into an SBO group and an SBI group according to the radiographic findings. Presence or numeric values of 10 radiographic signs were also recorded. Final diagnoses of SBO and SBI were established by a combined analysis of medical charts, surgical records, radiographic findings on abdominal computed tomography, and small bowel studies. The differential diagnoses based on PAR and the final diagnoses were compared, and the sensitivity and specificity of PAR were calculated. We also evaluated the differences among 10 radiographic signs between the final SBO and SBI groups.ResultsSensitivity and specificity of PAR for SBO were 82.0% and 92.4%, respectively. Among the 10 radiographic signs, all except maximal colon diameter were statistically significant predictors on the final diagnosis.ConclusionsPAR is an accurate and effective initial imaging modality for differentiating between SBO and SBI in an emergency setting, and most of the classic radiographic signs have a diagnostic value.

Predictors of Failure of the Laparoscopic Approach for the Management of Small Bowel Obstruction

Small bowel obstruction (SBO) is a common cause of hospital admission. Our objective is to determine variables that correlate with failure of the laparoscopic approach for SBO. Twenty-three consecutive patients underwent diagnostic laparoscopy with curative intent for treatment of SBO by a single surgeon over a 3-year period. The laparoscopic approach was successful in 18 patients (78%); there were five (22%) conversions to laparotomy. The causes of obstruction included adhesive band in 16 patients; and small bowel lymphoma, metastatic esophageal cancer, small bowel gangrene, Meckel diverticulum, gallstones ileus, and incarcerated incisional hernia in two. Using the Fisher two-sided test, no significant predictor for conversion was identified using gender, American Society of Anesthesiologists class, previous bowel obstruction, history of adhesiolysis, abdominal distention, pelvic surgeries, chemotherapy, radiation, malignancy, chronic obstructive pulmonary disease, asthma, coronary artery disease, hypertension, or hypercholesterolenemia. The Wilcoxon two-sided test did not show significance for age, weight, number of previous abdominal surgeries, or small bowel diameter. The postoperative hospital stay was significantly shorter in the laparoscopic group compared with those who needed conversion (3 vs. 9 days) with P = 0.0019. No mortality was noted in any patients. The laparoscopic is safe and feasible for the management of SBO. We believe that the laparoscopic approach should be offered to all patients with SBO unless there is an absolute contraindication to laparoscopic surgery.

A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis.

Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed. The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected.

Sonographic assessment of the extra‐abdominal fetal small bowel in gastroschisis: a retrospective longitudinal study in relation to prenatal complications

An explorative retrospective study following a case-series of fetuses with isolated gastroschisis, to evaluate if small-bowel dilatation may be indicative for emerging obstetric complications. The secondary aim was to establish preliminary normative curves for the external diameter and wall thickness of eventerated fetal small bowel in gastroschisis during the second and third trimester of pregnancy. Fourteen fetuses with isolated gastroschisis were followed at a single center. Repeated ultrasound examinations for fetal surveillance with measurement of fetal small-bowel diameter and wall thickness over the course of pregnancy until delivery were performed. Longitudinal data analysis showed significantly increasing bowel diameter and wall thickness of eventerated small bowel with advancing gestation. Dilatation of small bowel more than 25 mm in the third trimester of pregnancy was associated with an increased risk of short-term prenatal complications as fetal distress or intrauterine fetal death (PPV 100%; 95% CI: 29.2-100%, NPV 100%; 95% CI: 71.5-100%). Dilatation of the extra-abdominal fetal small bowel in the third trimester may allow identifying fetuses with increased risk of fetal distress requiring closer monitoring of fetal well-being or delivery in a short interval to prevent impending fetal death.

Oral contrast agents for small bowel distension in MRI: influence of the osmolarity for small bowel distention

To assess the effect of the osmolarity for small bowel distension in MRI, ten volunteers ingested at two separate occasions negative oral contrast agents with different quantity and osmolarity: (1) a water solution combined with 2.0% sorbitol and 0.2% locus bean gum (LBG) with a quantity of 1500 ml and an osmolarity of 148 mOsmol/l, (2) a water solution combined with 2.0% sorbitol and 2.0% barium sulphate with a quantity of 1000 ml and an osmolarity of 194 mOsmol/l. Small bowel distension was quantified on coronal 2D-TrueFISP images by measuring the small bowel diameters. There were no statistically significant differences in mean small bowel diameter between both contrast agents. The mean small bowel distension was 19.2 mm after ingestion of 1500 ml of sorbitol-LBG solution and 19.0 mm after ingestion of 1000-ml sorbitol-barium sulphate solution. Furthermore, all volunteers found the ingestion of 1000-ml solution more pleasant than the 1500-ml solution. The ingestion of 1000 ml of sorbitol-barium sulphate solution led to a sufficient small bowel distension compared to 1500 ml of sorbitol-LBG solution. The side effect rate of both solutions was low. Based on these data, we recommend a quantity of 1000 ml of sorbitol-barium sulphate solution as an alternative for 1500-ml sorbitol-LBG solution for optimal bowel distension.