Dilated Small Bowel Research Articles

Pseudo-Riglerʼs Sign With Intrabiliary Reflux of Gastrografin Due to Severe Constipation

Introduction: Rigler's triad, a manifestation of gallstone ileus, is constituted by the radiographic finings of ectopic gallstone, pneumobilia and small bowel obstruction. We report this very rare case of pneumobilia and reflux of oral Computerized Tomography (CT) contrast-Gastrografin into the biliary tree, in a patient with bowel obstruction/severe ileus due to constipation without an ectopic gallstone (pseudo-Rigler's sign). Patient was treated with colonic enemas, polyethylene glycol, and nasogastric tube decompression with resolution of these radiological findings. Case report: Here in, we present a case of a 58-year-old man with medical history of systolic congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease who presented with hypoxic respiratory failure due to pneumonia. Patient was intubated and put on mechanical ventilation. Patient was found to have worsening abdominal distension. Physical examination revealed diminished bowel sounds. CT scan of abdomen and pelvis showed diffuse dilation of large and small bowel with abundant stool in the sigmoid colon and rectum, Gastrografin contrast in dilated intrahepatic bile ducts and pneumobilia (Figure 1). The patient was managed with high colonic enemas, polyethylene glycol and nasogastric tube decompression. Electrolytes and renal function were monitored and corrected accordingly. The patient subsequently had bowel movements with resolution of ileus and pneumobilia with contrast drainage from bile ducts.Figure: Intrahepatic ducts with gastrografin.Discussion: Constipation commonly occurs in the elderly population. Severe or chronic constipation can very rarely lead to fecal impaction, intestinal obstruction and pneumobilia. Our patient presented with atypical signs of Rigler's triad (barring the ectopic gallstone) in the setting of chronic constipation. Patient was also found to have reflux of oral contrast material from the duodenum via the ampulla into the common bile duct and dilated intrahepatic biliary tree- which is an extremely rare radiological finding. To our knowledge this is the first reported case of biliary reflux of oral in the setting of chronic constipation.

Refractory Ileal Fecaloma Causing Small Bowel Obstruction

Fecalomas are extremely rare and often occur in the in the rectum and sigmoid colon. In patients with multiple comorbidities limiting clinical decisions, it is important to understand the treatment options available with fecalomas and their outcomes. Here we present a 61-year-old ventilator-dependent male with advanced dementia, status post heart and lung transplant, and status post prior small bowel resection for unclear reasons who presented with abdominal distention and bilious emesis following a recent hospitalization for respiratory failure secondary to pneumonia. Vitals were notable for tachycardia to the 110s and exam was significant for palpable stool along the right side of abdomen. An abdominal radiograph revealed dilated loops of small and large bowel with air-fluid levels (Figure 1). Conservative treatment with a nasogastric tube, crystalloids, and rectal laxatives were unsuccessful. An abdominal CT scan showed a dilated fluid-filled small bowel extending to distal ileum where there was a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with distinct transition point (Figure 2). Multiple attempts at laxatives from patient's gastrostomy tube and rectally were trialed with no significant improvement in patient's abdominal distension and pain. Unfortunately, the patient was a poor candidate for surgery due to his multiple comorbidities. The family ultimately decided to pursue hospice. Fecalomas, or hard intraluminal tumor-like mass of feces, are most commonly found in the rectum and sigmoid colon. It has been more commonly reported in patients with old age, long-term enteral feeding, and neuropsychiatric disease, likely leading to sluggish bowel function. Fecalomas in the small bowel causing obstruction has only been reported in a 10-year-old boy. Fecalomas in the distal colon are often managed by conservative methods such as bowel rest, rectal suppositories, enemas, digital evacuation and rectal decompression. More aggressive treatments include endoscopic disimpaction and surgical intervention for those who are otherwise good surgical candidates. Our case posed a management dilemma in that the fecaloma was located in an aperistaltic segment of the ileum rather than more distally, making colonoscopic decompression difficult, and as patient was not a surgical candidate, surgery was a nonviable option. Since patient has exhausted all conservative managements, comfort care became the best available option.Figure: An abdominal radiograph showing dilated loops of small and large bowel obstruction with air-fluid levels.Figure: An abdominal CT scan showing a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with a distinct transition point.

A Rare Case of Uterine Leiomyosarcoma With Metastasis to the Colon

Laeeq Butt, MD, MBA, Rajiv Mallipudi, MD, Swami Nathan, MD A Rare case of Uterine Leiomyosarcoma with Metastasis to the Colon and Small Bowel Introduction: Uterine leiomyosarcoma is an extremely rare and aggressive malignancy with an overall poor prognosis. It typically metastasizes through hematogenous dissemination to the lungs, bones and brain. However, there have not been many cases of metastasis to the colon. In reported cases the patients presented with acute abdomen secondary to uterine leiomyosarcoma invasion of the small bowel or colon. Here we present an extremely rare case of a leiomyosarcoma of the uterus with metastasis to the colon.Figure: P1: Colonoscopy image of the tumor.Figure: P2: Colon mass pathology shows Spindle Cells (elongated narrow cells) indicative of Sarcoma.Case: 48 year old female with uterine leiomyosarcoma with metastasis presented with acute blood loss anemia, small bowel obstruction and intussusception. Colonoscopy showed a 20mm ascending colon mass with pathology consistent with high grade sarcoma consistent with metastatic leiomyosarcoma (P1,P2). CT scan showed hypodensity in the right quadriceps muscle of 1.2 x 1 cm and intraluminal metastatic lesions causing intermittent intussusception and dilated small bowel loops. Three metastatic lesions in the lung were also identified (P3). Immunohistological staining showed that the colon mass was strongly positive for C-kit, DOG1 and negative for CD34. Karetin stains (MN116, AE1.3 and high molecular weight Keratin) did not stain the tumor. Key sarcoma markers such as Desmin, Actin and smooth muscle were negative. Metastatic tumors on occasion can be dedifferentiated and fail to express expected markers; therefore, pathologist believed that given recent diagnosis this colon tumor must be metastasis from the uterine leiomyosarcoma. Patient was offered palliative chemotherapy and surgical treatment and was lost to follow up post discharge.Figure: P3: Chest X-Ray with metastatic lesions identified.Conclusion: Melenoma is the most comon tumor that metastesizes to the colon. Metastasis to small bowel and colon from uterine leiomyosarcoma is extremely rare and is a sign of advanced disease. The more common sites for metastasis are lung, liver, abdomen, pelvic/aortic lymph nodes. Bone and brain are less common. It is important to differentiate between primary tumors of the colon versus metastatic and immunohistochemistry can be utilized to differentiate between the two. Metastasis to the heart is also possible via direct extension, hematogenous spread, and implantation or via lymphatic route.

Chronic Intestinal Pseudo-obstruction in the Setting of Inactive Systemic Lupus Erythematosus

Chronic intestinal pseudo-obstruction (CIPO) is a rare disorder of intestinal hypomobility, which presents a similar fashion to a bowel obstruction, but without evidence of anatomic obstruction. We present a case of CIPO associated with inactive systemic lupus erythematosus (SLE).A 42 year-old woman with a history of SLE presented with obstipation, with episodic nausea, vomiting, and abdominal pain. No prior history of abdominal surgery. CT abdomen & pelvis did not reveal any anatomic obstruction. Colonoscopy showed no masses. Impaired intestinal motility was confirmed with scintigraphy, consistent with CIPO. Anti-rho antibody was positive. She was treated with laxatives, enemas, and pro-motility agents. Since being diagnosed with SLE patient encountered several complications, including pulmonary hemorrhage, hemolytic anemia, nephritis, and retinitis from hydroxychloroquine. Aside from bowel disturbances, the patient remained asymptomatic between lupus flares. Over several years, the patient developed 6 episodes of acute colonic pseudo-obstruction, treated with intravenous methylprednisolone. Exploratory laparotomy showed a large, dilated colon with fecal impaction, without any anatomic cause of obstruction. A subtotal colectomy and end ileostomy were performed. Pathology showed mucosal ulceration with transmural fibrosis, and pericolic lymph nodes with reactive follicular hyperplasia. She did well initially, but then required several ostomy revisions for pseudoobstruction. Ultimately, her stoma prolapsed, requiring decompression.The etiology of CIPO is unknown, but may involve vasculitis. Several pathologic changes may be observed, including fibrosis. CIPO is often idiopathic, but may occur due to an underlying condition, such as lupus. CIPO usually occurs in the setting of active lupus. No laboratory tests are specific for CIPO; however, 83% of cases have anti-Rho antibodies.To our knowledge, this represents the second reported incidence of intestinal pseudo-obstruction associated with inactive systemic lupus erythematosus. There are less than 35 cases of CIPO associated with SLE published in English. CIPO is a rare and life-threatening complication of lupus. Awareness of the condition may facilitate early recognition and appropriate treatment, which includes intravenous glucocorticoids, immunosuppressants, and promotility agents. When possible, surgery should be avoided, as the condition tends to recur.Figure. X: ray abdomen showing diffusely dilated small bowel loops.Figure: Trichrome stain, showing transmural fibrosis.Figure: Elastic stain to show intimal fibroplasia and luminal stenosis.

A Case of Superior Mesenteric Artery Syndrome in Perianal Crohnʼs Disease

Superior Mesenteric Artery (SMA) syndrome is a rare condition caused by compression of the duodenum between the aorta and SMA due to loss of mesenteric and retroperitoneal fat. Among IBD patients, SMA syndrome occurs more commonly in patients with ulcerative colitis (UC) after ileal pouch anal anastomosis (IPAA). This is the first reported case of SMA syndrome in a patient with perianal Crohn's disease (CD). A 32 year old female with perianal CD and diverting loop sigmoid colostomy on infliximab presented with 1 month of progressive, colicky, postprandial abdominal pain, nausea, sitophobia, diarrhea, and a 7 lb weight loss leading to an episode of orthostatic syncope. Contrast enhanced computed tomography showed distension of the stomach and proximal duodenum, but no obstruction, bowel wall thickening, or intraabdominal abscess. Small bowel follow through showed delayed transit through the duodenum in the region of the SMA as well as small bowel dilation proximal to the region of the SMA consistent with SMA syndrome. Magnetic resonance enterography showed no evidence of active CD. Serum inflammatory markers were within normal limits. Alternative etiologies such as delayed motility from diabetes, hypothyroidism, and other metabolic neuropathies were ruled out, and she was diagnosed with SMA syndrome. Despite modest improvement of her nausea with scheduled metoclopramide, total parenteral nutrition was started for inadequate nutrition prior to hospital discharge. SMA syndrome in IBD patients is most commonly associated with IPAA, which is performed for refractory ulcerative colitis or for resection of IBD-associated colon cancer. One proposed mechanism for this phenomenon is surgery-induced stretching of the SMA, flattening it against the aorta to cause duodenal narrowing. This is the first reported case of SMA syndrome in perianal CD status post diverting loop sigmoid colostomy. Perianal CD is an uncommon variant of CD and phenotypically mimics limited UC. Although our patient's surgery did not involve significant bowel resection as in an IPAA, perhaps this phenotypic similarity and post-surgical anatomic changes predisposed her to increased risk of SMA syndrome. For IBD patients presenting with obstructive symptoms such as nausea, vomiting, sitophobia, and abdominal pain, clinicians must maintain a low threshold for considering SMA syndrome since treatment differs significantly from treatment of IBD exacerbation.Figure: CT abdomen and pelvis axial image showing compression of duodenum between the superior mesenteric artery (SMA) and aorta.Figure: CT abdomen and pelvis sagittal image showing acute angulation of the superior mesenteric artery (SMA) and the aorta.

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).

Adult intussusception: unusual cause

Adult intussusception is a rare entity which accounts for 1-5% of intestinal obstructions in adults and just 5% of all cases of intussusception. The basic pathology and management of intussusception in adults differs from paediatric intussusception. Here we present an interesting case of adult intussusception with an unusual cause. A 33-year-old female presented with features of intestinal obstruction. Colonoscopy was done outside our institution which reported a smooth polypoidal mass in the terminal ileum, biopsy report was pending at that time. CT abdomen revealed dilated small bowel with narrowing in the ileo caecal junction. We proceeded with laparotomy. Intraoperatively dilated ileum with intussusception of the ileocecal junction into the ascending colon was found. Right hemicolectomy with ileotransverse colon anastomosis was done. Histopathology revealed Polyp with intussusception, 5cm from ileocecal junction, with sheets of lymphoid cells showing moderate pleomorphism, infiltrating submucosa, muscularis propria, and serosa, margins uninvolved with lymph node- 3/32 positivity. Immunohistochemistry suggested B- cell lymphoma with CD20 positivity and Bcl 2 focal positivity. Routine treatment of Lymphoma after confirming with biopsy have been Chemotherapy. Role of surgeon in lymphoma is presently limited to biopsy, but there are situations like obstruction and perforation, where surgeon should take the lead role

Primary Surgery for Malignant Large Bowel Obstruction: Postoperative Nasogastric Tube Reinsertion is Not Mandatory.

Malignant large bowel obstructions frequently require emergency surgery. Compliance with enhanced recovery after surgery programmes is significantly reduced due to non-removal of the nasogastric tube in the postoperative period. The first aim of the present study was to research factors associated with the failure of immediate nasogastric tube removal in patients who had undergone emergency surgery for malignant large bowel obstruction. The second aim was to assess the morbidity linked to nasogastric tube reinsertion. This retrospective and monocentric study included all consecutive patients admitted for acute malignant large bowel obstruction who underwent emergency surgery. Patients who were not primarily operated on were excluded (n=178; 69.3%). The group of patients requiring nasogastric tube (NGT) reinsertion was compared with the group that did not require NGT reinsertion. Seventy-nine patients underwent emergency surgery, of which 18 (22.8%) required nasogastric tube reinsertion. There was no difference between the two groups with regard to (a) immediate nasogastric tube removal (p=0.87) and (b) inclusion in an enhanced recovery programme (p=0.75). However, preoperative small bowel dilatation was associated with a reduction in the need for NGT reinsertion (p=0.04). A left-sided tumour was also associated with the need for NGT reinsertion in uni- (p=0.034) and multivariate analysis (OR=8; p<0.05). Surgical access and procedure were not significantly associated with NGT reinsertion. The postoperative course influenced NGT reinsertion, which was significantly associated with postoperative ileus (OR=4; p<0.05) and postoperative morbidity (OR=4; p<0.05). Morbidity was not linked to nasogastric tube removal. Nasogastric tube reinsertion was not affected by immediate removal of the tube. Left-sided tumours and patients at risk of postoperative ileus should be managed with caution. Immediate nasogastric tube removal is not contraindicated in the case of large bowel obstruction because it is not associated with a higher risk of NGT reinsertion.

Congenital anomaly band, a rare cause of intestinal obstruction in children. Case report

Abstract Background Intestinal obstruction in children may be congenital, acquired, intrinsic or extrinsic. Most intestinal obstructions in children are the result of postoperative adhesions. Those caused by anomalous congenital band are extremely rare. Clinical case Patient of a 1-year-old male, with no previous history of abdominal surgery or trauma. He suffered with vomiting of bile content and loss of appetite at home three days before admission. On physical examination, he was irritable, with abdominal distention, absence of peristalsis and abdominal tenderness, with no signs of peritoneal irritation being found. The blood count reported leucocytosis and the x-rays show dilated small bowel loops, fluid levels and absence of air in rectal ampulla. An open laparotomy was subsequently performed, and the intraoperative findings were consistent with a congenital band extending from the anti-mesenteric wall of the jejunum to the root of mesentery, compressing the ileum at 50 cm from the ileocecal valve, causing ischaemia. The band was ligated and divided, with an uneventful postoperative course. He was discharged 4 days later without complications. Conclusions The anomalous congenital band is not associated with abdominal problems, such as remnants of previous laparotomies or embryological structures, such as vitelline vessels or omphalomesenteric yolk duct. These bands seem to have a congenital origin and cause bowel obstruction by trapping between the band and the mesentery. The diagnosis of anomalous congenital band is extremely difficult and no imaging study is useful for the diagnosis, and only exploratory laparotomy or laparoscopy is useful for diagnosis and treatment of this problem.

Obstrucción intestinal debido a hernia estrangulada en el espacio prevesical: presentación de un caso y revisión de la literatura

Introduction: Prevesical space is an infrequent location of hernias. Prevesical hernia is a rare cause of bowel obstruction. We present a case operated at our institution and review the available evidence in literature. Case report: A 67-years-old mail, without any relevant medical history, came to the Emergency Department complaining of suprapubic pain during the last 24 h. Physical examination revealed abdominal distension and suprapubic pain. A CT scan revealed small bowel dilation with a gauge change in the pelvis. Exploring laparotomy was performed, observing a hernia in the prevesical space and 25 cm of ileal loops incarcerated with ischemic aspect. A small bowel resection and latero-lateral manual running suture anastomosis was performed. Histological findings were not relevant. The patient presented an uneventful postoperative course and was discharged the 5th day after surgery. Conclusions: Hernias in the prevesical space are infrequent causes of abdominal pain and bowel obstruction. They are located between lateral umbilical ligaments and bladder fundus, where a ring is located. They must be suspected in cases of inguinal or suprapubic pain without palpable lump in the lower abdominal quadrants. Diagnosis can be only radiologically achieved, by CT scan. Surgical treatment is mandatory, often requiring bowel resection.

Risk factors and outcomes of tapering surgery for small intestinal dilatation in pediatric short bowel syndrome

BackgroundIn remains unclear why in some short bowel syndrome (SBS) patients, the remaining small bowel (SB) dilates excessively leading to requirement of tapering surgery. MethodsAmong SBS children, we retrospectively analyzed risk factors for tapering surgery with logistic regression and compared the outcome of operated patients (n=16) to those managed conservatively (n=44) with Cox proportional hazards regression. ResultsSBS was caused by necrotizing enterocolitis (NEC) (n=31), SB atresia (SBA) (n=13), midgut volvulus (n=12), or gastroschisis (n=4). Patients with spontaneous symptomatic SB dilatation unable to wean parenteral nutrition (PN) underwent tapering surgery at median age of 1.04 (interquartile range 0.70–3.27) years. Missing ICV was related to an 8-fold (p=0.003) increased risk while SBA diagnosis was related to a 13-fold risk of tapering surgery (p<0.001). Increasing SB length and NEC diagnosis were protective of tapering (p=0.027–0.004). Of operated patients, 75% reached enteral autonomy during follow-up and their postoperative adjusted PN weaning rate was similar to nonoperated children (p=0.842). ConclusionSBS children with short remaining SB, missing ICV, and SBA etiology are more likely while NEC patients are less likely than others to necessitate tapering surgery. Postoperative PN weaning rates were comparable to patients who initially had more favorable intestinal anatomy and adapted without surgery.

Cross-sectional imaging in refractory celiac disease.

The purpose of this study is to identify unique imaging findings of refractory celiac disease (RCD) including Type I RCD, Type II RCD versus healed celiac disease (CD). A retrospective study of patients with known CD and refractory symptoms with cross-sectional imaging was performed. We included patients who underwent T cell receptor rearrangement or T-cell immunophenotyping studies on small bowel (SB) biopsies to classify patients into: healed CD, Type I RCD, or Type II RCD. GI radiologists performed a blinded review of the imaging studies. One-hundred eighteen patients (32 healed; 67 Type I RCD; 19 Type II RCD) were included (mean age 53±6years; 62% female). The presence of any fold pattern abnormality was more likely to be found in Type II and Type I RCD than healed CD (53% vs. 43% vs.16%; p=0.009). Type II RCD patients were more likely than Type I RCD and healed CD to have imaging findings of ulcerative jejunitis (26% vs. 6% vs. 3%; p=0.009), SB wall thickening (37% vs. 16% vs. 0%; p=0.002) and SB dilation (26% vs. 7% vs. 6%; p=0.04). Type II RCD demonstrated non-significant trends for decreased number of jejunal folds only, SB mass, mesenteric lymphadenopathy, localized peri-mural edema, and intramural duodenal edema. Fold pattern abnormalities, ulcerative jejunitis, SB wall thickening, and SB dilation are more likely to be identified in cross-sectional imaging of RCD than healed CD. SB dilatation and ulcerative jejunitis are more likely to be found in Type II than Type I RCD.

Small Bowel Obstruction Secondary to a Metamucil Bezoar: Case Report and Review of the Literature

Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient's history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone.

Ileo-ovarian knotting in a case of strangulated inguinal hernia in a 46-year-old female: A first case report

Ileo-ovarian knotting in a case of strangulated inguinal hernia, reported herein, has never been reported before. We believe this case is of great importance because of its absolute rarity. A 46-year-old female came with right inguinal swelling, vomiting, and abdominal distension for 2 years but aggravated during the last week. She had passed stools 24 h ago and was vomiting since then. The abdomen was distended as well as tenderness and guarding was noted in the lower abdomen. Examination revealed strangulated right inguinal hernia with abdominal X-ray suggestive of acute small bowel obstruction. Abdominal ultrasonography revealed dilated small bowel loops and aperistaltic edematous intestines in the right inguinal region; an urgent surgery was, hence, planned. Exploration revealed ileo-ovarian knotting with one-foot gangrene of small bowel and strangulated right ovary. Resection of the right ovary, bowel resection, and end-to-end anastomosis with hernioplasty were performed. The patient recovered well in the postoperative period.

Hirschsprung's disease

Hirschsprung's disease (HD) or congenital aganglionic megacolon is characterized by an absence of ganglion cells in the myenteric Auerbach's plexus, the deep submucosal Henle's plexus, and the submucosal Meissner's plexus in the distal colon. The usual presentation of Hirschsprung's disease can be demonstrated by the following clinical scenario. A 3-day-old male presented with failure to pass meconium within 48 h of birth and progressive abdominal distension. Barium study showed dilated colon with no specific zone of transition. The newborn was delivered at 40 weeks gestation after an otherwise normal pregnancy. Transanal rectal biopsy demonstrated the absence of ganglion cells on multiple sections and special staining. The patient underwent an exploratory laparotomy, upon which he was found to have markedly dilated small bowel and colon up to the area of sigmoid. A transverse loop colostomy was performed. The patient recovered well from the initial surgery and underwent definitive surgical therapy of the HD at a later time. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Prabhakaran S. Absite corner: Hirschsprung's disease. OPUS 12 Scientist 2009; 3(3):44-46.

Multidetector CT enterography of focal small bowel lesions: a radiological–pathological correlation

Focal small bowel lesions present a diagnostic challenge for both the radiologist and gastroenterologist. Both the detection and characterization of small bowel masses have greatly improved with the advent of multidetector CT enterography (MD-CTE). As such, MD-CTE is increasingly utilized in the workup of occult gastrointestinal bleeding. In this article, we review the spectrum of focal small bowel masses with pathologic correlation. Adenocarcinoma, the most common primary small bowel malignancy, presents as a focal irregular mass occasionally with circumferential extension leading to obstruction. Small bowel carcinoid tumors most commonly arise in the ileum and are characterized by avid enhancement and marked desmoplastic response of metastatic lesions. Aneurysmal dilatation of small bowel is pathognomonic for lymphoma and secondary findings of lymphadenopathy and splenomegaly should be sought. Benign small bowel masses such as leiomyoma and adenoma may be responsible for occult gastrointestinal bleeding. However, primary vascular lesions of the small bowel remain the most common cause for occult small bowel gastrointestinal bleeding. The arterial phase of contrast obtained with CTE aids in recognition of the vascular nature of these lesions. Systemic conditions such as Peutz-Jeghers syndrome and Crohn's disease may be suggested by the presence of multiple small bowel lesions. Lastly, potential pitfalls such as ingested material should be considered when faced with focal small bowel masses.

Intussusception following rotavirus vaccination: a reminder for practitioners.

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

Rare Cause of Gastric Outlet Obstruction

Case Report: Patient is a 75-year-old female who presented with 3-week history of nausea, vomiting and diffuse abdominal pain. On physical exam, her abdomen was distended and tender in the RUQ. CT scan of the abdomen and pelvis revealed marked dilation of the stomach with fluid, pneumobilia, and poor gallbladder visualization. The patient had no history of an abdominal surgery or ERCP. EGD showed Grade D esophagitis, excessive fluid in stomach and a large ulcerated area in second part of duodenum. Biopsies were negative for malignancy. A PET scan was suggestive of acute cholecystitis versus a cholocystoenteric fistula or malignancy. Repeat EGD a week later showed total resolution of the ulcerated area in the duodenum. EUS revealed peri-pancreatic inflammation and poor visualization of the gallbladder. Repeat CT scan revealed dilated proximal jejunal small bowel loops with transition zone and a 1.5 cm rounded structure in the jejunum. Patient was thought to have chronic cholecystitis causing perforation of the gallbladder with formation of a cholecystoenteric fistula resulting in gallstone impaction and small bowel obstruction. She underwent laparoscopic small bowel enterotomy with removal of gallstones from distal jejunum and proximal ileum. Patient slowly began eating and was discharged with uneventful post-operative course.Figure 1Figure 2Discussion: Bouveret syndrome is a rare cause of gastric outlet obstruction. It is a variant of gallstone ileus resulting in gastroduodenal obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The average size is 4.6 cm compared to 2.5 cm for gallstone ileus. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test is EGD although CT scan, abdominal ultrasound and plain X-ray can be very helpful. Rigler's triad of pneumobilia, an ectopic gallstone, and dilated small bowel on abdominal x-ray is classic but is only seen in 30-35 % of cases. Classic CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. Although the gastric outlet obstruction is almost always seen on EGD, the obstructing gallstone is seen only in 69 % of cases. Our patient, initially, presented with Bouveret's syndrome which then complicated by gallstone ileus. She was found to have several large stones causing her small bowel obstruction. Treatment options are endoscopic, open surgery or laparoscopic removal of the stones.