Dilated Small Bowel Research Articles

Small Bowel Obstruction Masking a Perforated Dermoid Ovarian Cyst.

A 58-year-old female presented with abdominal pain, vomiting and constipation. Laboratory tests indicated elevated white blood cell count and C-reactive protein levels. Imaging via CT scan revealed a large cystic mass in the right ovary, abscesses and generalized small bowel distension, which initially raised suspicion of the existence of ovarian cancer with peritoneal carcinomatosis. Despite conservative management, the patient's condition did not improve, prompting a laparotomy. Intraoperative findings included generalized peritonitis, significant small bowel dilation due to inflammatory adhesions and a perforated dermoid ovarian cyst. The cyst was resected and a prophylactic ileostomy was installed. Histopathological examination confirmed the diagnosis of a benign dermoid ovarian cyst. This case illustrates the rare presentation of a perforated dermoid cyst mimicking peritoneal carcinomatosis and emphasizes the importance of considering such complications in the differential diagnosis of bowel obstruction and peritoneal disease. Early recognition and appropriate surgical intervention are crucial for optimal outcomes.

Reliability of MR Enterography Features for Describing Fibrostenosing Crohn Disease.

Background Clinical decision making and drug development for fibrostenosing Crohn disease is constrained by a lack of imaging definitions, scoring conventions, and validated end points. Purpose To assess the reliability of MR enterography features to describe Crohn disease strictures and determine correlation with stricture severity. Materials and Methods A retrospective study of patients with symptomatic terminal ileal Crohn disease strictures who underwent MR enterography at tertiary care centers (Cleveland Clinic: September 2013 to November 2020; Mayo Clinic: February 2008 to March 2019) was conducted by using convenience sampling. In the development phase, blinded and trained radiologists independently evaluated 26 MR enterography features from baseline and follow-up examinations performed more than 6 months apart, with no bowel resection performed between examinations. Follow-up examinations closest to 12 months after baseline were selected. Reliability was assessed using the intraclass correlation coefficient (ICC). In the validation phase, after five features were redefined, reliability was re-estimated in an independent convenience sample using baseline examinations. Multivariable linear regression analysis identified features with at least moderate interrater reliability (ICC ≥0.41) that were independently associated with stricture severity. Results Ninety-nine (mean age, 40 years ± 14 [SD]; 50 male) patients were included in the development group and 51 (mean age, 45 years ± 16 [SD]; 35 female) patients were included in the validation group. In the development group, nine features had at least moderate interrater reliability. One additional feature demonstrated moderate reliability in the validation group. Stricture length (ICC = 0.85 [95% CI: 0.75, 0.91] and 0.91 [95% CI: 0.75, 0.96] in development and validation phase, respectively) and maximal associated small bowel dilation (ICC = 0.74 [95% CI: 0.63, 0.80] and 0.73 [95% CI: 0.58, 0.87] in development and validation group, respectively) had the highest interrater reliability. Stricture length, maximal stricture wall thickness, and maximal associated small bowel dilation were independently (regression coefficients, 0.09-3.97; P < .001) associated with stricture severity. Conclusion MR enterography definitions and scoring conventions for reliably assessing features of Crohn disease strictures were developed and validated, and feature correlation with stricture severity was determined. © RSNA, 2024 Supplemental material is available for this article. See also the article by Rieder and Ma et al in this issue. See also the editorial by Galgano and Summerlin in this issue.

Reliability of CT Enterography for Describing Fibrostenosing Crohn Disease.

Background Standardized methods to measure and describe Crohn disease strictures at CT enterography are needed to guide clinical decision making and for use in therapeutic studies. Purpose To assess the reliability of CT enterography features to describe Crohn disease strictures and their correlation with stricture severity. Materials and Methods A retrospective study was conducted in 43 adult patients with symptomatic terminal ileal Crohn disease strictures who underwent standard-of-care CT enterography at a tertiary care center at the Cleveland Clinic between January 2008 and August 2016. After training on standardized definitions, four abdominal radiologists blinded to all patient information assessed imaging features (seven continuous measurements and nine observations) of the most distal ileal stricture in two separate sessions (separated by ≥2 weeks) in random order. Features with an interrater intraclass correlation coefficient (ICC) of 0.41 or greater (ie, moderate reliability or better) were considered reliable. Univariable and multivariable linear regression analysis identified reliable features associated with a visual analog scale of overall stricture severity. Significant reliable features were assessed as components of a CT enterography-based model to quantitate stricture severity. Results Examinations in 43 patients (mean age, 52 years ± 16 [SD]; 23 female) were evaluated. Five continuous measurements and six observations demonstrated at least moderate interrater reliability (interrater ICC range, 0.42 [95% CI: 0.25, 0.57] to 0.80 [95% CI: 0.67, 0.88]). Of these, 10 were univariably associated with stricture severity, and three continuous measurements-stricture length (interrater ICC, 0.64 [95% CI: 0.42, 0.81]), maximal associated small bowel dilation (interrater ICC, 0.80 [95% CI: 0.67, 0.88]), and maximal stricture wall thickness (interrater ICC, 0.50 [95% CI: 0.34, 0.62])-were independently associated (P value range, <.001 to .003) with stricture severity in a multivariable model. These three measurements were used to derive a well-calibrated (optimism-adjusted calibration slope = 1.00) quantitative model of stricture severity. Conclusion Standardized CT enterography measurements and observations can reliably describe terminal ileal Crohn disease strictures. Stricture length, maximal associated small bowel dilation, and maximal stricture wall thickness are correlated with stricture severity. © RSNA, 2024 Supplemental material is available for this article. See also the article by Rieder et al in this issue. See also the editorial by Galgano and Summerlin in this issue.

TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE

Abstract Case Report A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF. Discussion We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.

Delineating Gastrointestinal Dysfunction Variants in Severe Burn Injury Cases: A Retrospective Case Series with Literature Review

Background: Severe burns can significantly impact various organ systems, including the gastrointestinal (GI) system. GI complications are frequently observed in patients with over 20% total body surface area (TBSA) burn. Objectives: This case series delves into the intricate phenomenology of post-burn GI dysfunction, challenging conventional cause-and-effect paradigms. Our aim is to discern, comprehend, and explore variables influencing positive and negative outcomes, laying the foundation for further research given the current heterogeneity in the literature. Methods: Severe burn patients with GI dysfunction identified between April 1, 2022, and July 31, 2022, from the institutional database are included in this retrospective case-series, and comparisons were made across baseline and treatment conditions across participants. Data were collected on demographics, burn characteristics, complications, and treatment outcomes. Results: We analysed 12 patients with severe burns and GI dysfunction and categorized them into two patterns: Pattern A, characterised by early onset symptoms, gastric and small bowel dilatation, and a relatively benign course with high recovery rates was observed in 6 patients; and Pattern B, characterised by late-onset symptoms, colonic dilatation, shock, and a high mortality rate due to megacolon was seen in 6 patients. Conclusion: The post-burn GI dysfunction observed in our study is a complex interplay of multiple factors. Adequate fluid resuscitation, timely excision of necrotic tissue, staged food ingestion, specific nutrient administration, and appropriate use of antibiotics and judicious use of selective digestive decontamination (SDD) are essential strategies to prevent and treat this syndrome.

Retroperitoneal hernia following laparoscopic living-donor nephrectomy: a case report and review of literature

BackgroundThe laparoscopic approach is the standard of care for living-donor nephrectomy. A rare postoperative complication is small bowel obstruction due to a retroperitoneal hernia. We present a case of an incidental finding of a retroperitoneal hernia in a patient with a history of laparoscopic donor nephrectomy.Case presentationAn adult male presented with diffuse abdominal pain, vomiting, and obstipation for 12 h. He had undergone laparoscopic donor nephrectomy two months prior. Plain abdominal radiograph revealed a dilated small bowel with homogenous opacity in the left lumbar region. Due to worsening diffuse abdominal pain and a high clinical suspicion of intestinal strangulation and ischemia after conservative management, an exploratory laparotomy was performed. Intraoperatively, an incarcerated small bowel segment herniating through an 8 cm descending mesocolon defect into the retroperitoneal space was discovered, forming a closed-loop obstruction. The bowel segment was reduced, and the mesocolon defect was repaired. The patient was discharged five days postoperatively with good recovery.ConclusionRetroperitoneal hernia following laparoscopic living-donor nephrectomy is a rare but significant complication. Mitigation to prevent mesenteric defect creation, routine inspection, and closure of the defect can reduce the risk of hernia. Non-specific abdominal pain in patients with a history of laparoscopic donor nephrectomy prompts rapid imaging evaluation to aid in the early diagnosis of possible retroperitoneal hernia and its intervention.

Towards an EKG for SBO: A Neural Network for Detection and Characterization of Bowel Obstruction on CT.

A neural network was developed to detect and characterize bowel obstruction, a common cause of acute abdominal pain. In this retrospective study, 202 CT scans of 165 patients with bowel obstruction from March to June 2022 were included and partitioned into training and test data sets. A multi-channel neural network was trained to segment the gastrointestinal tract, and to predict the diameter and the longitudinal position ("longitude") along the gastrointestinal tract using a novel embedding. Its performance was compared to manual segmentations using the Dice score, and to manual measurements of the diameter and longitude using intraclass correlation coefficients (ICC). ROC curves as well as sensitivity and specificity were calculated for diameters above a clinical threshold for obstruction, and for longitudes corresponding to small bowel. In the test data set, Dice score for segmentation of the gastrointestinal tract was 78 ± 8%. ICC between measured and predicted diameters was 0.72, indicating moderate agreement. ICC between measured and predicted longitude was 0.85, indicating good agreement. AUROC was 0.90 for detection of dilated bowel, and was 0.95 and 0.90 for differentiation of the proximal and distal gastrointestinal tract respectively. Overall sensitivity and specificity for dilated small bowel were 0.83 and 0.90. Since obstruction is diagnosed based on the diameter and longitude of the bowel, this neural network and embedding may enable detection and characterization of this important disease on CT.

A rare case of Pouch of Douglas hernia- Atypical presentation in a postnatal mother

Background: Internal hernias are quite rare which constitutes right and left paraduodenal, trans-mesenteric hernia and pelvic hernias. Case presentation: 23 year old female postnatal mother delivered 4 months back, IUCD was inserted post delivery now presented with C/O greenish discharge PV and vaginal fullness. Ultrasound showed few dilated small bowel loops.Computed tomography revealed multiple dilated fluid filled small bowel loops suggestive of subacute small bowel obstruction. Herniation of the small bowel loops into the POD is noted.MRI revealed the small bowel loops in POD herniating through fornix into the vagina. Intraoperatively , small bowel loops were seen herniating through a defect in the POD on the right side into the fornix and formed a sac within the vagina. A sealed perforation was seen within the herniated loop and short segment gangrene was identified. Resection and anastomosis of bowel loop along with closure of defect in broad ligament defect was done. Conclusion: Pelvic hernia through the defect in cul-de-sac is very rare and high clinical suspicion is needed to diagnose this rare condition. Radiological knowledge of this rare entity in a patient with small bowel obstruction aids in early diagnosis and intervention avoiding the complications of bowel ischemia.

Lipoma of the Ileum: A Rare Cause of Intussusception in Adults

Bowel intussusception is a rare entity in adults. Symptoms are nonspecific and most of diagnoses are made by computed tomography scan. We report the case of an adult with bowel obstruction due to an ileoileal intussusception caused by a lipoma.A 44-year-old male patient with colicky epigastric pain since the day before, bilious vomiting, abdominal distension and epigastrium tenderness. Plain abdominal radiography revealed dilation of small bowel with gas-fluid levels and computed tomography scan suggested an ileoileal intussusception. We performed bowel resection comprising the lesion, removal of the regional lymph nodes and a primary anastomosis. The histopathology report revealed a lipoma. Patient was discharged on the fifth postoperative day.A lipoma is a rare cause of intussusception, with a challenging diagnosis, because of nonspecific symptoms. An early computed tomography scan is essential for the diagnosis and prompt surgical resection is recommended.

Concomitant Bouveret’s syndrome and gallstone ileus: case report and literature review

Gallstone ileus and Bouveret's syndrome are rare gallstone complications; therefore, their combination is even rarer. The delay of diagnosis is associated with high rates of morbidity and mortality. We reported a 65-year-old woman presented with a three-day history of epigastric and lower right abdominal pain, nausea, and vomiting. A radiopaque shadow was noted on an abdominal X-ray in both the right upper and lower quadrants. In addition to the cholecysto-duodenal fistula, the CT abdomen revealed a combined ileal gallstone ileus with small bowel dilatation and stone in the second portion of the duodenum (Bouveret's syndrome). Initial attempts to extract duodenal stones endoscopically were unsuccessful. Therefore, the patient underwent an exploratory laparotomy and removal of both ileal and duodenal stones. The patient had an uneventful postoperative course. Serious complications include obstruction of the gastric outlet or the small intestine due to gallstone ileus, Bouveret's syndrome, or both. Despite the high failure rate, endoscopic extraction of the stone alone or in combination with lithotripsy is the standard treatment for Bouveret's syndrome. Furthermore, surgical intervention is the standard treatment for gallstone ileus. Gallstone ileus and Bouveret's syndrome remain diagnostic and therapeutic challenges, which necessitate an immediate multidisciplinary approach to prevent substantial morbidity and mortality. Further reports or larger-scale studies are encouraged.

Fetal MRI Revealing a Rare Jejuno-Ileal Atresia: Apple Peel Intestinal Atresia

Apple peel intestinal atresia is a rare congenital malformation. Prenatal diagnosis can be done with obstetric ultrasound and confirmed by Fetal magnetic resonance imaging. We report a case of jejuno- ileal atresia (JIA) diagnosed during obstetric ultrasound showed small bowel dilation associated with hydramnios. Neonatal abdominal x-ray of the newborn confirmed the signs of intestinal occlusion. The aim of our work is to make a focus on this uncommon neonatal condition as well as the benefits of the antenatal diagnosis for adequate and timely management.

Gossypiboma – “string of pearls” sign may be diagnostic: A case report

Gossypiboma is a retained non-absorbable material composed of the common cotton matrix. It is an unexpected surgeon’s “never event” with serious medicolegal implications. We present a case of a young woman who came to our facility 6 days after an emergency cesarean section for prolonged labor in a private hospital with features in keeping with post-operative peritonitis. Pre-operative abdominal radiographs revealed bowel loops that were majorly gasless, except for a row of small round pockets of gas running horizontally across the right hemi-abdomen, giving the “string-of-pearls” sign. She was optimized for an emergency laparotomy. The intraoperative finding was a retained sponge walled off by loops of the dilated small bowel. Within this cavity was found 400 mL of pus. The sponge was removed with ease and the pus was drained with a good post-operative outcome. The finding of a gasless abdomen on a plain radiograph is a thing of concern as small bowel obstruction with or without bowel ischemia is the most feared cause of a gasless abdomen which can be life threatening. Therefore, a gossypiboma should always be considered in a post-surgical patient with abdominal radiographic findings of a gasless abdomen; in particular, with the “string-of-pearls” appearance present. This case highlights that retention of foreign bodies after surgery is a persisting “never event” and as such there is the need to comply with current recommendations on the prevention of retained foreign bodies. The most important approach to reducing the incidence of gossypiboma is prevention. Thus, awareness of this problem is mandatory to avoid unnecessary morbidities.

Small bowel obstruction in infants due to complicated Meckel’s diverticulum: A case series

Objectives: Our purpose is to illustrate the radiological aspects of Meckel’s diverticulum as an etiology of small bowel obstruction in infants. Material: We report a group of 4 patients with Meckel’s diverticulum complicated with small bowel obstruction that underwent surgery. We reviewed patient records, clinical presentation, ultrasound and CT imaging and intraoperative findings. Results: All included patients presented symptoms of bowel obstruction, one patient presented acute abdomen symptoms. The median age of our group was 5 years, all patients were males. All patients underwent radiological explorations. Ultrasound showed small bowel dilatation in all cases, and CT scan confirmed small bowel obstruction with ischemic complications in one patient. All of the 4 patients had laparotomy with the finding of MD responsible of small bowel obstruction in all cases, with on case of perforated loop and latero-caecal abscess. The obstruction was secondary to fibrous adhesions in three cases and the omphalomesenteric duct in one cases. All the patients had normal evolution with no post-operative complications. Conclusion: Meckel’s diverticulum represents a rare embryological remnant. It is a differential diagnosis in pediatric bowel obstruction and remains an intraoperative surprise despite the very abvanced imaging studies.

1072 Diaphragm Disease: NSAID-Induced Small Bowel Strictures. the Challenges of Surgical management

Abstract Non-steroidal anti-inflammatory drugs (NSAIDs) are used commonly, yet there is little literature surrounding NSAID-induced small bowel strictures, particularly those requiring surgery. We present the case of a 42-year-old female treated surgically over six years. This patient had used NSAIDs for several years; she was referred due to weight loss, anaemia and abdominal pain. Computerised topography (CT) scan showed small bowel obstruction. Initial treatment was laparotomy with small bowel resection. Histology revealed six strictures in the jejunum with incomplete obstruction – attributed to NSAIDs. Despite counselling her NSAID usage persisted and over the next two years she was treated for jejunitis and had a perforated duodenal ulcer repaired. At this point the patient ceased NSAID use, however the next twelve months saw three presentations with small bowel obstruction, all managed conservatively. This case is concordant with literature suggesting strictures can continue to develop despite NSAID cessation. She was placed on the surgical waiting list but symptoms worsened – anaemia requiring transfusions; hypokalaemia requiring IV replacement and 38-kilogram weight loss. She received total parenteral nutrition before surgery. She underwent another bowel resection with anastomosis. Initially she regained weight and biochemistry stabilised, however further obstruction developed the next year at the anastomosis site. This case highlights the difficulties managing this disease – nutrition, haematology and strictures developing years after NSAID cessation. It raises questions over surgery, choice of anastomosis and how to manage this ongoing dilated small bowel segment.

195 Small bowel obstruction through peritoneal defect herniation after a totally extraperitoneal hernia repair- A unusual complication case series

Abstract The rates of major complications associated with totally extraperitoneal (TEP) inguinal hernia repair are reportedly low, and intra-abdominal complications are rare. However, here we present a case series with small bowel obstruction through herniation of the small bowel into the peritoneal defect after a TEP, which is a rare complication. The first case, a 71year old male two weeks post-TEP left inguinal hernia repair, presented with abdomen pain, vomiting, distension, and bowels not opened for three days with elevated inflammatory markers. Computed Tomography of the abdomen and pelvis (CTAP) demonstrated small bowel obstruction secondary to a loop of inflamed small bowel adherent to the anterior abdominal wall in the left inguinal region. During emergency diagnostic laparoscopy found to have a small bowel loop passing through a peritoneal defect just lateral to the medial umbilical ligament, converted to laparotomy, and small bowel resection was performed. In the second case, a 61-year-old male presented with similar complaints and elevated inflammatory markers two days post bilateral TEP. The CTAP showed dilated small bowel with a transition point in the left iliac fossa. Emergency diagnostic laparoscopy found a peritoneal defect on the left groin with small bowel herniation. The bowel-reduced back and the defect was closed with sutures. Small bowel obstruction due to a peritoneal defect after TEP is a rare but potentially fatal complication. Therefore, the clinician should have a low threshold for surgery, as it is unlikely to resolve with conservative treatment like the adhesional bowel obstruction.

P-097 FEMORAL AND OBTURATOR HERNIA INCARCERATED: A CASE REPORT

Abstract Obturator hernia is a very rare type of abdominal wall hernia, accounting for less than 1% of all abdominal wall hernias. They can be confused with femoral hernias as well as they can arise simultaneously, just like in this clinical case. A 82 year old female, with multiple comorbidities including a right inguinal hernioplasty, was brought to our emergency department complaining of abdominal pain, distension and vomiting in the last 24 hours. On physical examination, there where abnormally active, high-pitched bowel sounds, abdominal distension and pain on left lower quadrant but no tenderness. Palpation of groin area showed an incarcerated left femoral hernia, apparently containing only omentum. As the patient maintained left lower abdominal pain, we proceed to a CT scan, which demonstrated small bowel dilation with air-fluid levels consistent with a small bowel obstruction originating from an obturator hernia. Open tension-free mesh repair of femoral hernia was done and no need for ressection since it only contained omentum, without ischemic signs. Open transperitoneal nonmesh repair of obturator hernia was performed after hernia reduction. There was no irreversible ischemia. Evolution during hospitalization was uneventful. Regarding obturator hernias, there is no optimal approach since it is a very rare type of hernia, so it probably depends on patient condition and surgeon experience. A transperitoneal approach is preferred when there's signs of bowel obstruction, as we proceed on this clinical case.

Open approach for ileocolic resection in Crohn's disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral center.

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.

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...

Falciform ligament hernia: combination of key CT findings

A male patient in his early 90s with no history of abdominal surgery was referred to us for abdominal pain and vomiting. An abdominal computed tomography (CT) demonstrated dilated small bowel with a double beak sign and poorly enhanced wall, which indicated a closed-loop obstruction that leads to strangulation. A closed-loop bowel was located in front of the anterior and medial segments of the liver and to the right of the round ligament of the liver on axial images. Sagittal images revealed that the round ligament has deviated downward and 2 adjacent narrowed intestines were located at its cranial side. These CT findings suggested the hernia orifice was in the falciform ligament. Emergency surgery for highly suspected bowel ischemia revealed the falciform ligament hernia. A combination of the CT findings played a key role, including the double beak sign, the location of the closed-loop small bowel, and the downward deviation of the round ligament, although preoperative CT diagnosis of falciform ligament hernia is a diagnostic challenge.

E020 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

Abstract Background/Aims Pneumatosis intestinalis (PI) is a rare complication of systemic sclerosis (SSc), characterised by submucosal and/or subserosal collections of free gas, forming cystic lesions within the gastrointestinal (GI) tract. Methods A 67-year-old man with SSc-myositis overlap syndrome presented acutely unwell with worsening abdominal pain, bloating, bloody diarrhoea and vomiting for three weeks. He was afebrile and haemodynamically stable. His abdomen was distended with generalised tenderness but soft and regular bowel sounds were audible. There were no palpable organomegaly or signs of peritonism. He had raised CRP, serum amylase, serum lactate and pre-renal acute kidney injury. He tested positive for ANA Hep2 (speckled) and anti-Mi-2b. His contrast-enhanced CT abdomen and pelvis displayed extensive pneumatosis changes, moderately dilated small bowel loops and pneumoperitoneum without portal venous gas or acute thrombotic occlusion in the main-stem superior or inferior mesenteric arteries. He was managed conservatively with bowel rest, elemental diet, cycling antibiotics for small intestinal bacterial overgrowth (SIBO) and commenced on end-of-life care as surgical exploration was deemed too risky considering that he has exceedingly poor cardiac reserve. He made a surprisingly excellent recovery and his repeat CT scans at approximately 11 weeks showed a complete resolution of pneumatosis intestinalis and pneumoperitoneum. Results PI in SSc generally runs a benign course and is usually managed conservatively. The development of PI is multifactorial, involving a complex interplay between mechanical, biochemical, bacterial and drug factors. PI is usually asymptomatic but patients can present with GI and constitutional symptoms or peritonism. CT scan is the most preferred diagnostic modality for PI. Conservative management is preferable to surgical intervention after careful exclusion of acute surgical causes. The underlying cause of PI should be appropriately addressed and managed in all cases. The management of PI is based on the severity of symptoms and it includes bowel rest, elemental diet or parenteral nutrition, antibiotics, high concentration oxygen, hyperbaric oxygen therapy and/or octreotide. Our patient was managed conservatively as he did not exhibit clinical signs of peritonism or bowel ischaemia and surgical interventions were deemed too risky. He was treated with and has responded well to cycling oral antibiotics for SIBO which was thought to be contributory to his PI. Conclusion This case illustrates that PI with or without pneumoperitoneum could be a rare complication of SSc, and contrary to common belief, it is usually benign and managed conservatively with favourable outcome. An accurate interpretation of its clinical significance is crucial as acute presentations and ambiguous imaging findings can simulate acute surgical emergency leading to diagnostic dilemma and unnecessary or risky surgical interventions. However, emergency laparotomy should be considered in patients who exhibit signs of peritonism or bowel ischaemia and therefore timely involvement of surgeons and multidisciplinary team is essential. Disclosure K. Lim: None. S. Knights: None. J. Pauling: None. J. Gotto: None.