Distended 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.

A307 NEUROGASTROENTEROLOGY & MOTILITY CAID (CHRONIC ATRIAL AND INTESTINAL DYSRHYTHMIA) SYNDROME: A SEVERE LATE-ONSET PEDIATRIC INTESTINAL PSEUDO-OBSTRUCTION

Abstract Background Pediatric intestinal pseudo-obstruction (PIPO) is a rare, heterogeneous and severe gut motility disorder. It is associated with a high morbidity and mortality rate. The etiology of PIPO can be either primary (sporadic or familial), secondary or idiopathic. In primary forms, 50 to 75% of patients will present symptoms in the first month of life and 80% by the end of the first year of life. In 2014, Chetaille et al. described the CAID syndrome related to a recessive SGOL1 mutation as a new form of PIPO associated with cardiac dysrhythmia. Aims Our aim is to describe the clinical presentation and the specific digestive and nutritional features of pediatric patients with SGOL1 mutation. Methods Monocentric, retrospective and descriptive study. We enrolled children and adolescents aged less than 18 years. All data were collected from patients’ files. Results 8 patients were included (5 girls), two of them were first-degree related. They all had a typical clinical presentation of PIPO (excessive abdominal distension, abdominal pain and vomiting) but with a later onset than usually seen in primary PIPO (median (range) age: 6.3 years [2-15.6]). The median age (range) at diagnosis was 7.8 years [4-15.7]. In most patients contrast studies showed massively distended small bowel and colon. Antroduodenal manometry was performed in 6 patients and was abnormal with a neuropathic pattern. Others were diagnosed using the ESPGHAN criteria (2018 Jun;66(6):991-1019). All patients needed parenteral nutrition at a median (range) age of 11.8 years [6.5-15.9] due to failure to thrive, intestinal failure and electrolytic disorders. Seven patients needed an ileostomy. One out of 8 patients was off PN at 18 years. Three patients had sinus dysfunction: one at the time of PIPO diagnosis and two sometimes after. All of them required a pacemaker. One patient died in her twenties and it wasn’t related to PIPO or its possible complications. Conclusions Recessive SGOL1 mutation, a new cohesinopathy affecting the gut and heart rhythm, represents a late-onset but severe form of PIPO. It is usually associated with sinus dysfunction and cardiac dysrhythmia. However, digestive symptoms appear first. Long term outcome is still to describe. Funding Agencies None

Mesenteric small cell lymphocytic lymphoma presenting as acute intestinal obstruction: A rare case scenario

Small-cell lymphocytic lymphoma is a rare type of B-cell non-Hodgkin lymphoma. It is known as one of the indolent lymphomas. Moreover, sigmoid volvulus as an initial presentation is extremely uncommon. We encountered a unique case of mesenteric small cell lymphocytic lymphoma that presented with sigmoid volvulus as the initial clinical presentation. A 55-year-old male presented with 7-day history of abdominal pain, abdominal distension for 6 days, and non-passage of stool and flatus with recurrent vomiting for 3 days. Abdominopelvic computed tomography revealed a distended small bowel with volvulus of sigmoid colon with twisting of its mesentery with inter-ileal as well as free peritoneal collections of fluid. A manual untwisting counterclockwise of the volvulus followed by resection and anastomosis at a point where the bowel has apparent normal thickness and color along with excisional biopsy of the enlarged lymph node. Histopathology confirmed the diagnosis of small-cell lymphocytic lymphoma. Mesenteric lymphomas are less likely to present with sigmoid volvulus as the initial clinical presentation due to their extraluminal location and also they are indolent in course. Early diagnosis and its management reduce morbidity and mortality.

SAT680 Mounjaro: A Side Effect

Abstract Disclosure: K. Rao: None. E. Kyei Nimako: None. Mounjaro : A Side Effect Dr K Rao, Dr Evans-Nimako, Internal Medicine, North Alabama Medical Center Introduction: Mounjaro has been heralded as a new miracle drug both in the world of diabetes management and weight loss with its pending FDA approval in the latter category. Although common contraindications are known the wider spectrum and prevalence of side effects including diabetic retinopathy, acute kidney injury and gallbladder disease are still being identified. In this case we present a patient with Mounjaro induced AKI and ileus. Case Presentation: We present the case of a 64year-old diabetic, hypertensive male presenting with a 3-day history of nausea vomiting indigestion and excessive burping one day after taking his first dose of Mounjaro. The Patient was started at a walk-in clinic on 2.5 mg subcutaneously however on the very next day he noticed the onset of cramping abdominal pain with multiple episodes of vomiting and watery diarrhea. The patient has not had any other new foods, sick contacts or preceding illnesses. He had a history of previous hernia surgery, cholecystectomy and exploratory laparotomy some 18 years ago due to concerns for nonresolving small bowel obstruction. On examination he was afebrile but tachycardic and in mild distress. His abdomen was soft and nondistended. Bowel sounds were faint but present. He had generalized tenderness without evidence of rebound or guarding. Initial investigations demonstrated a white cell count of 14.7(10E3/ul), creatinine 1.7mg/dl, potassium 4.5mmol/L, blood glucose 176mg/dl and lactate of 2mmol/L. His urine analysis showed small volume ketones, glucosuria and trace leukocyte esterase with 3-5 white blood cells. CT of the abdomen and pelvis with contrast showed distended small and large bowel loops with fluid air levels but no transition point indicative of underlying ileus. The patient was hospitalized in total for approximately six days post the onset of his symptoms and treated with supportive measures including antiemetics, IV fluids and antacids. He never had any fevers or leukocytosis during his stay. His electrolytes remained within normal limits. Conclusion: Due to the impending widespread use and increasing popularity of Mounjaro this case presentation is aimed at raising awareness of potential side effects and their severity. We also hope to contribute towards further knowledge about specific subset of patients who may be more susceptible to the gastrointestinal side effects of Mounjaro. Particularly those patients who have had previous colonic or multiple abdominal surgeries or history of bowel obstruction. In this case the patient received the medication at a walk-in clinic this also highlights the dangers of lack of established care and monitoring of Mounjaro. Presentation: Saturday, June 17, 2023

Role of computed tomographic enterography for evaluation of small bowel diseases: A cross-sectional study

Background: Computed tomographic enterography (CTE) is a newer non-invasive modality having distinct advantages over conventional CT and capsule endoscopy. Objectives: This technique allows faster evaluation of small bowel diseases in the endoscopically inaccessible segments. Being an operator-independent procedure, CTE is widely available and allows a better depiction of extra enteric complications. The aim is to evaluate CTE features of various small bowel diseases and the role of 2% mannitol for adequate small bowel distension. Materials and methods: A cross-sectional study comprising 105 patients had presented with small bowel diseases. Patients in the age group of 10 to 85 years with complaints of fever, abdominal pain, nausea, vomiting, altered bowel habits, loss of appetite and loss of weight were included in this study. CTE images were analyzed to compare the diagnosis with the available histopathological and ultrasonography results. Results: Among the study population, the majority had presented CTE features such as symmetrical wall thickening (53.3%), peri-bowel inflammatory changes (61%), mucosal hyperenhancement (39%), and mural stratification, i.e., target sign (33.3%). The majority of diagnoses of CTE were ileocecal tuberculosis (11.5%), small bowel inflammation (7.6%), and Crohn’s disease (6.7%). Other conditions such as small bowel neoplastic masses, diverticula, ischemic bowel disease, bowel strictures, intussusception, and ulcerative colitis. Conclusion: CTE has the vital role of first-line modality in the work-up of suspected small intestinal diseases and helps evaluate disease activity before endoscopy, particularly in inaccessible segments. It allows a better depiction of extra enteric complications of the bowel.

Comparison of the Efficacy of Diluted Polyethylene Glycol and Low-Density (0.1% w/v) Barium Sulfate Suspension for CT Enterography.

To compare small bowel distension and side effects between a diluted polyethylene glycol (PEG) solution and a low-density (0.1% w/v) barium sulfate suspension (LDBSS) for CT enterography (CTE) preparation. Total 173 consecutive patients who underwent CTE were enrolled in this study. The LDBSS (1 L) was used in 50 patients, and the diluted iso-osmotic PEG solution (1 L) was used in 123 patients. Two blinded radiologists independently scored jejunal and ileal distensions on a 5-point scale. To compare side effects between the two groups, the patients reported whether they had immediate complications after the administration of the oral contrast media. For ileal and jejunal distension, the diluted PEG solution showed no difference from the LDBSS for either reader (ileum: reader 1, median, 4; 4, interquartile range, 3-4; 3-4, p = 0.997; reader 2, median, 4; 4, interquartile range, 3.3-4.0; 3-4, p = 0.064; jejunum: reader 1, median, 2; 2, interquartile range, 2-3; 2-3, p = 0.560; reader 2, median, 3; 2, interquartile range, 2-3; 2-3, p = 0.192). None of the patients complained of immediate complications following administration of either of the oral contrast media. The diluted PEG solution showed comparable bowel distension compared to LDBSS and no immediate side effects; thus, it can be a useful alternative.

PSAT007 Pheochromocytoma Presenting With Small Bowel Obstruction

Abstract Background Pheochromocytoma is a rare catecholamine producing tumor arising from the adrenal gland with estimated prevalence of 0.1%-0.6%. Most common signs and symptoms of pheochromocytoma, i.e. headache, palpitations and sweating are non-specific and often mimic other diseases. The association between pheochromocytoma and small bowel obstruction however is rarely recognized. Case 55-year-old Russian male with past medical history of alcohol abuse, smoking and hypertension presented to ER with chest pain, abdominal pain, nausea, vomiting, poor appetite, diarrhea and 20 lbs weight loss for 2-3 months. On presentation, patient was hypertensive with blood pressure of 225/137 mm/Hg and heart rate of 126 beats/minute. He appeared uncomfortable, skin was flushed, and he was noted to be tachycardic with distended abdomen and sluggish bowel sounds. Initial laboratory studies revealed hyperkalemia of 7.8 mmol/L, CO2 13 mmol/L, anion gap 21 mEq/L, acute kidney injury with creatinine 1.34 mg/dL, venous pH 7.18, lactic acid of 5.7 mmol/L. A polymerase chain reaction test for COVID-19 was negative. Alcohol and urine drug screen were negative. Persistent diarrhea, abdominal pain with distention prompted evaluation with abdominal X-ray which showed distended small bowel loops. As part of the hypertensive crisis work up, CT angiogram of the chest, abdomen and pelvis with contrast was done and it demonstrated an enhancing left adrenal mass 4.6×4.5 cm with 35 Hounsfield units on the non-contrast study and 95 Hounsfield units on the venous phase. Evaluation of plasma hormone levels revealed elevated metanephrines >5,000 pg/mL (n 0-88 pg/mL) and normetanephrine >6,000 pg/mL (n 0-137 pg/mL). The 24-h urinary catecholamines were highly elevated with metanephrine >9,000 ug (n 58-276 ug/24hr) and normetanephrine >12,000 ug (n 156-729 ug/24hr). Patient was initially treated with Labetalol infusion with noted improvement in diarrhea. His hospital course was complicated by an acute myocardial infarction with cardiac thrombus. Patient was stabilized with Prazosin and discharged from the hospital. One month later he underwent left laparoscopic adrenalectomy. Gross pathology showed 5.1×4.5×3.8 cm adrenal mass with immunohistochemical staining supporting a diagnosis of pheochromocytoma. Discussion Recognition of clinical features of pheochromocytoma is often challenging but important due to its high morbidity and mortality rates. Small bowel obstruction in association with pheochromocytoma is uncommon. In smaller case series, ileus, megacolon, and bowel infarction was observed in patients with larger adrenal masses, typically >70 grams and catecholamine levels more than 4 times the upper limit of normal. This case highlights the importance of maintaining high index of clinical suspicion in early recognition of the gastrointestinal manifestations of pheochromocytoma and its potentially catastrophic consequences. References (1) Hodin R, Diagnosis, and management of pheochromocytoma. Curr Probl Surg. April 2014 Apr;151-87. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

S2738 Isolated Celiac Artery Vasculitis Presenting as Ileus in a Patient With Ulcerative Colitis

Introduction: Small case series have reported an association between IBD and large vessel vasculitides, ANCA-associated vasculitis, and cutaneous vasculitis. Gastrointestinal (GI) involvement of vasculitis can be a severe complication, resulting in mesenteric ischemia, ileus, or GI bleeding, and often requires aggressive medical or surgical interventions. We report a case of celiac artery vasculitis presenting as abdominal pain and ileus in a patient with ulcerative colitis (UC). Case Description/Methods: A 69 year old male with an 11 year history of UC in remission on infliximab and azathioprine (AZA) presented to the emergency room with abdominal pain and constipation for five days. He had decreased AZA from 200 mg to 100 mg one month prior. Initial CT abdomen and pelvis showed stranding surrounding the celiac artery, fluid-filled small bowel loops, and segmental areas of distal colon collapse with proximal colon distention. He developed progressive small bowel and colonic distention with cecum diameter of 10 cm. A colonoscopy was performed for decompression. He had no evidence of active UC. EGD demonstrated dusky appearing gastroesophageal junction and inflammation with cratered ulcers in the gastric cardia and body. Biopsies confirmed ischemic necrosis. CTA demonstrated perivascular inflammation of a patent celiac artery without evidence for dissection, suggestive of acute vasculitis. ESR and CRP were 50 mm/hr and 7.8 mg/dL respectively. Myeloperoxidase, serine-proteinase 3, rheumatoid factor, ANA, were negative. He was started on methylprednisolone IV with oral prednisone taper at discharge, and AZA was increased to 200 mg daily. A CT one month later showed minimal residual inflammation. ESR and CRP had normalized. (Figure) Discussion: We present the first case of isolated celiac artery vasculitis in a patient with IBD. A diagnosis of IBD often precedes vasculitis, and patients are typically on immunosuppressive therapy at the time of onset. Anti-TNF agents have been implicated as a potential inciting cause. Although it is unclear whether long-term anti-TNF therapy precipitated vasculitis in our patient, the dose reduction in AZA prior to presentation may have unmasked vasculitis. This was supported by his rapid clinical and radiographic improvement with combination of steroids and increased AZA dose despite continuation of infliximab. This case highlights the importance of maintaining a high degree of suspicion for vasculitis in patients with IBD on immunosuppressive therapy presenting with ischemia or ileus.Figure 1.: A 69 year old male underwent EGD for evaluation of abdominal pain and NG tube placement; he was found to have inflammation with a dusky appearing mucosa at the gastroesophageal junction (GEJ) (A). Non-bleeding gastric ulcers with overlying pigment (Forrest Class IIc) were identified (B). H&E stain image shows the GEJ biopsy with extensive ischemic necrosis and hemorrhage (C). Initial CTA abdomen/pelvis shows fat stranding surrounding the celiac artery (D).

CHILAIDITI SYNDROME ABOUT A CASE: THE EXPERIENCE OF THE MEDICAL CLINIC THE STARS OF BAMAKO

The chilaiditi syndrome is a pathology characterized by the interposition of the small or colonic intestines in the space between the lower surface of the diaphragm and the liver. We report the case of a 39-year-old man, worker, operated 3 months ago for acute appendicitis who presented with abdominal pain, acute urinary retention and occlusive syndrome. The CT scan was performed and revealed small bowel obstruction and Chilaïditi syndrome with interposition of distended small bowel loops in the right inter hepato-diaphragmatic area and bilateral basal broncho-pneumopathy. An exploratory laparotomy made it possible to treat this Chilaïditi syndrome and intestinal obstruction with the discovery of a colon tumor of the transverse colon. The purpose of this work is to provide the diagnostic and etiological interest of computed tomography and the complications related to chilaiditi syndrome.

P30 A case of small bowel and leukocytoclastic vasculitis associated with acitretin therapy

Introduction/BackgroundAcitretin is an oral retinoid that is used to treat a number of skin conditions including acne. It is generally well tolerated and common side-effects such as gastrointestinal upset, mucosal and skin reactions are usually mild. However, we present what we believe to be the first reported case of small bowel and leukocytoclastic vasculitis (LCV) caused by acitretin and this required prompt treatment with intravenous glucocorticoids and cyclophosphamide to induce remission.Description/MethodA 53-year-old caucasian male presented to the Emergency Department with severe bilateral foot pain for four days and a purpuric rash which initially affected the soles of his feet and spread to affect all four limbs, both hands and abdomen. He was three weeks into his second course of acitretin 20mg daily for a flare of psoriasis, having ceased treatment three months before due to a suspected iatrogenic rosacea type reaction. He had generalised abdominal pain and recent constipation. Observations demonstrated a sinus tachycardia at 130 beats per minute only and examination revealed widespread patchy non-blanching palpable purpura and deep ulcers over the soles of both feet. There was mild abdominal distension and global tenderness but no peritonism. The remainder of the physical examination was unremarkable. Initial blood tests showed: haemoglobin 156 g/L, white cell count 13 x 109/L (neutrophilia: 10.6 x 109/L), platelets 514 x 109/L, CRP 123 mg/L, ESR 12 mm/hr, normal renal and liver function. Detailed immunology, microbiology and viral screens were negative including anti-neutrophil cytoplasmic antibodies (ANCA) and cryoglobulins. Urine dipstick was unremarkable. Abdominal x-ray showed distended small bowel loops and CT demonstrated significant intestinal wall oedema suggestive of small bowel vasculitis. Skin biopsy demonstrated typical changes of leukocytoclastic vasculitis. After surgical review he was managed conservatively on the high dependency unit with intravenous methylprednisolone 1g daily for three days followed by intravenous hydrocortisone and one dose of cyclophosphamide (15mg/kg). Total parenteral nutrition was initiated, and his bowel symptoms settled after two weeks. His skin significantly improved and he was discharged after four weeks’ inpatient stay. Actretin was stopped indefinitely, and he has remained in remission over three years later. Prednisolone was successfully tapered at a slow rate, and no further cyclophosphamide was required. His psoriasis is currently managed well with oral methotrexate.Discussion/ResultsLCV is a small vessel vasculitis which mostly occurs in the cutaneous form but can be life-threatening with systemic involvement. Around 50% of cases are idiopathic, with infections (15-20%), autoimmune diseases (15-20%) and malignancy (<5%) being well-recognised causes.Drug-induced LCV accounts for nearly 15% of cases and antibiotics, non-steroidal anti-inflammatories, anti-epileptics and TNF-alpha blockers are well-known precipitants. It usually occurs within three weeks after commencement of the medication, and the timing of re-introduction of acitretin in our patient makes it likely to be the cause. Up to 90% of LCV cases resolve within weeks to months after addressing the precipitating cause, with or without oral steroids. However, a 2% mortality is reported, likely due to systemic involvement and given the severity of our patient’s presentation, it was decided to commence immunosuppression in view of the skin biopsy and CT findings. (A biopsy of the small bowel was considered but would have delayed treatment).To our knowledge there are no published case reports linking LCV and small bowel vasculitis to acitretin therapy. However, there have been several case reports of LCV and other vasculitides caused by all-trans-retinoic acid (ATRA) and isotretinoin (first generation retinoids). Yamada et al. (1999) reported a severe case of haemonecrosis of the ileum, as a complication of ATRA treatment for acute promyelocytic leukaemia. Surgical intervention was required and histology demonstrated LCV.Isotretinoin was attributed to cause 5 out of 11 LCV cases reviewed by Dwyer et al. (1989). Turan et al. (2012) reported a case of a Henoch-Schonlein Purpura secondary to isotretinoin that improved with discontinuing treatment and three weeks of fluocortolone 20mg daily. More recently, a case of diffuse alveolar haemorrhage due to isotretinoin-induced granulomatosis with polyangiitis was described by Assuncao et al. (2018), which remitted with intravenous methylprednisolone and cyclophosphamide.Key learning points/ConclusionAlthough very rare, consider retinoids including acitretin in cases of drug-induced LCV and small bowel vasculitis.Symptoms usually improve on cessation of the treatment alone, but immunosuppression might be required for more severe cases.Future case series could help guide treatment choices.

A case of jejunal adenocarcinoma missed at cross-sectional techniques and diagnosed by capsule endoscopy

A 50-year-old woman with Lynch syndrome presented to the emergency department with a 1-week history of abdominal pain and vomiting. The patient had undergone recent gastroscopy and colonoscopy, with no pathologic findings. During physical examination she described mesogastric abdominal pain, and laboratory evaluation showed anemia (hemoglobin 8 g/dL). A plain abdominal x-ray revealed mild small-bowel distension and a few air-fluid levels. The patient was admitted for further evaluation. Abdominal CT with contrast medium and CT enterography were performed; neither examination detected pathologic findings except for a single enlarged jejunal mesenteric lymph node (11 × 12 × 12 mm) with moderate contrast enhancement (A).

Influence of oral contrast type and volume on patient experience and quality of luminal distension at MR Enterography in Crohn’s disease: an observational study of patients recruited to the METRIC trial

ObjectivesTo compare the distention quality and patient experience of oral mannitol and polyethylene glycol (PEG) for MRE.MethodsThis study is a retrospective, observational study of a subset of patients enrolled in a multicentre, prospective trial evaluating the diagnostic accuracy of MRE for small bowel Crohn’s. Overall and segmental MRE small bowel distention, from 105 patients (64 F, mean age 37) was scored from 0 = poor to 4 = excellent by two experienced observers (68 [65%] mannitol and 37 [35%] PEG). Additionally, 130 patients (77 F, mean age 34) completed a questionnaire rating tolerability of various symptoms immediately and 2 days after MRE (85 [65%] receiving mannitol 45 [35%] receiving PEG). Distension was compared between agents and between those ingesting ≤ 1 L or > 1 L of mannitol using the test of proportions. Tolerability grades were collapsed into “very tolerable,” “moderately tolerable,” and “not tolerable.”ResultsPer patient distension quality was similar between agents (“excellent” or “good” in 54% [37/68] versus 46% [17/37]) with mannitol and PEG respectively. Jejunal distension was significantly better with mannitol compared to PEG (40% [27/68] versus 14% [5/37] rated as excellent or good respectively). There was no significant difference according to the volume of mannitol ingested. Symptom tolerability was comparable between agents, although fullness following MRE was graded as “very tolerable” in 27% (12/45) of patients ingesting PEG, verses 44% (37/84) ingesting mannitol, difference 17% (95% CI 0.6 to 34%).ConclusionMannitol-based solutions and PEG generally achieve comparable distension quality and side effect profiles, although jejunal distension is better quality with mannitol. Neither distension quality nor side-effect profile is altered by ingestion of more than 1 L of mannitol.Key Points• Mannitol-based and PEG-based oral preparation agents generally achieve comparable distension quality for MRE with the exception of the jejunum which is better distended with mannitol.• Mannitol-based and PEG-based oral preparation agents used for MRE have similar side effect profiles.• Neither distension quality nor side-effect profile is altered by ingestion of more than 1 L of mannitol.

P-B03 Gastric Band Tubing Causing Small Bowel Obstruction

Abstract Background Laparoscopically adjustable gastric bands (LAGB) have been widely employed as a means of weight loss in bariatric surgery over the past two decades. Although now largely superseded by other bariatric surgical techniques, complications from gastric bands continue to be encountered in surgical practice. We report an unusual case of small bowel obstruction due to an internal hernia caused by gastric band tubing resulting in closed loop small bowel obstruction. This is not commonly encountered and emergency general surgeons need to have a high index of suspicion for this condition as a possible cause for small bowel obstruction. Methods A 40 year old male presented with abdominal pain, vomiting and failure to open bowels or pass flatus for nine days. Twelve years previously (2008) he had had Roux n Y gastric bypass (RYGB), followed by by laparoscopic gastric banding of the RYGB about two years later (2010) also in the private sector. He had a soft but distended abdomen, and empty rectum on rectal examination. CT scan abdomen reported as: Multiple loops of distended small bowel demonstrated. No air seen in rectum, indicative of small bowel obstruction. No pneumoperitoneum. There is dilatation of the mid and distal small bowel seen to an apparent transition point in the mid abdomen where a loop is noted associated with the tubing for the inflation device for the gastric band. This appears to be centred on the cause of obstruction and appears tied around the base of mesentery and may be creating a closed loop obstruction, by having created an internal hernia. This patient had an internal hernia around loop of the gastric band tubing with resultant closed loop small bowel obstruction. The patient underwent diagnostic laparoscopy with ileo-caecal resection and primary anastomosis. He made successful recovery. Deflated gastric band remains in-situ. Results While small bowel obstruction is most commonly due to adhesions in individuals who have had previous laparotomy, it is important to bear in mind other causes such as internal hernias particularly in cases of those with history of previous gastric banding or Roux n Y gastric bypass. Early intervention may be necessary to reduce the likelihood of bowel ischaemia and bowel resection. Laparoscopy is a useful tool in the management of small bowel obstruction. Keywords: gastric band, small bowel obstruction, closed loop, emergency surgery, laparoscopy Conclusions Connection tubing causing small bowel obstruction and colonic erosion as a rare complication after laparoscopic gastric banding: a case report. Liza BK Tan, Jimmy BY So, and Asim Shabbir - J Med Case Reports. 2012; 6: 9. Acute small bowel obstruction due to the connecting tube of a gastric band. Federico Oppliger, M.D. Gonzalo Wiedmaier, M.D. Juan. Published April 07 2017. https://doi.org/10.1016/j.soard.2014.03.021 An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. M A Zappa, E Lattuada, E Mozzi, M Francese, I Antonini, S Radaelli, G Roviaro. Obes Surg . 2006 Jul;16(7):939-41. doi: 10.1381/096089206777822250 Total small bowel herniation through the space between the connecting tube of gastric band and abdominal wall: A case report of a surgical emergency. Tarek Hashem, Soliman M Soliman, Sherif Wagih 2. Int J Surg Case Rep. 2017;30:66-68. doi: 10.1016/j.ijscr.2016.11.021. Epub 2016 Nov 17

Role of Laparoscopy in the Surgical Management of Acute Small Bowel Obstruction: Fact or Fiction?

Background: Laparotomy (open surgery) is considered the standard approach for acute small bowel obstruction (ASBO). However, with the advent of minimally invasive surgery, the laparoscopic approach is gaining popularity. There is no consensus on the appropriate setting for laparoscopic therapy for small bowel obstruction (SBO).Aim and objectives: The purpose of this study is to evaluate the outcomes of laparoscopic surgery for ASBO.Patients and methods: We retrospectively evaluated the prospectively collected data of all the 38 patients who had undergone laparoscopy for ASBO, performed by a single surgeon at our institution, due to adhesions (30 patients), internal hernias (five patients), midgut malrotation (one patient), ileo-ileal intussusception (one patient), and superior mesenteric artery (SMA) syndrome (one patient) from 2012 to 2020. Data were extracted from the hospital electronic medical records (EMR) for the following parameters of each individual patient: age, sex, clinical presentation, preoperative investigation findings, final diagnosis, surgical details, operating time, time to postoperative oral feeds, length of hospital stay, complications, recurrences, and time taken to resume normal activity. A preoperative abdominal contrast-enhanced computed tomography (CECT) was performed in all the cases. Patients with peritonitis and septic shock were excluded from the study. Results: The mean age of the 38 patients was 58 years (ranged between 33 and 83 years) with a standard deviation (SD) of 16.5. The mean age of the female patients in the study was 60.5 years with an SD of 16.6, while the mean age of the male patients was 54.9 years (SD = 16.2). The age difference between male and female patients in the study was not statistically significant (p = 0.36). The mean operating time was 74.4 minutes (range: 60-90 minutes, with an SD of 7.2). The mean time to oral liquid/soft diet was 2.5 days. The mean postoperative stay was 5.7 days. Three patients (8%) underwent conversion to open surgery, out of which two patients had multiple complex bowel-to-bowel and bowel-to-parietes adhesions, and in one patient, massive distension of small bowel caused technical difficulties.Conclusion: Laparoscopic management of ASBO is feasible, effective, and safe. Optimum surgical techniques, the surgeon's experience with the procedure, and stringent patient selection criteria enable a high probability of success.

Ascariasis in a 75-year-old man with small bowel volvulus: a case report

BackgroundAscaris lumbricoides and Ascaris suum are the most common soil-transmitted helminths of humans and pigs, respectively. The zoonotic potential of A. suum has been a matter of debate for decades. This study was aimed to present a case of human ascariasis caused by A. suum in southern Italy.Case presentationA 75-year-old man presented to the department of surgery in Avellino (southern Italy) complaining of abdominal pain and vomiting. Physical examination revealed bloating and abdominal tenderness. A computed tomography scan showed air-fluid levels and small bowel distension. During exploratory laparotomy a small bowel volvulus with mesenteritis was evident and surprisingly an intraluminal worm was detected. The worm was removed with a small enterotomy and identified as an adult female of A. suum based on morphological and molecular analysis. Faecal examination revealed the presence of unfertilized Ascaris eggs with an intensity of 16 eggs per gram (EPG) of faeces. The patient was treated with mebendanzole 100 mg twice a day for 3 days. The post-operative course was regular with re-alimentation after 3 days and discharge after 12 days.ConclusionsThis report shows as A. suum can function as a relevant agent of human zoonosis. Therefore, in patients with bowel obstruction with no evident aetiology a helminthic infestation should be considered for an accurate diagnosis, especially in patients living in rural areas.

S3023 Mesenteric Lymphadenopathy From Recurrent Giardiasis: A Rare Cause of Small Bowel Obstruction in a Patient With X Linked Agammaglobulinemia

Introduction: Giardiasis, the most common parasitic infection of the human intestine, is caused by the binucleated protozoan parasite Giardia duodenalis (G intestinalis, giardia lamblia). This infection is commonly reported in developing countries; however, it remains one of the most common parasitic infections in the United States. This infection is also often found in populations with immunodeficiency disorders, such as X Linked agammaglobulinemia. Here, we discuss the case of a patient with X linked agammaglobulinemia who presented with a rare complication of small bowel obstruction (SBO) due to recurrent giardiasis. Case Description/Methods: A 59-year-old male with medical history of X linked agammaglobulinemia, bronchiectasis, COPD, iron deficiency anemia, intestinal malabsorption presented with the complaints of abdominal discomfort and intractable vomiting. The patient also reported similar complaints in the past. Review of systems unremarkable. Initial lab tests revealed leukocytosis (WBC 14.5 K/micro-L), Na 133 mmol/L, K 4.0 mmol/L, BUN 17 mg/dl, Cr 1.17 mg/dl, LFT with in normal limits. X Ray abdomen suggestive of ileus rather than small bowel obstruction. Stool studies positive for calprotectin and lactoferrin. EGD showed giardiasis, colonoscopy biopsies negative for IBD and cancer. CT Abd is unremarkable except for persistent prox. Jejunal luminal narrowing. MR Enterography positive for mesenteric lymphadenopathy causing persistent small bowel obstruction (Fig 1). Discussion: X linked agammaglobulinemia is an inherited immunodeficiency disorder characterized by a failure to produce mature B lymphocytes and antibodies. Because of the lack of antibodies, patients most often present with recurrent upper respiratory tract infections, followed by gastrointestinal infections. Patients with giardiasis present with chronic diarrhea, bloating, nausea and vomiting. Functional dyspepsia, irritable bowel syndrome and cancer are additional intestinal manifestations of giardiasis. The pathophysiology is thought to be due increased enterocyte apoptosis, intestinal barrier dysfunction, malabsorption and increased intestinal transit rates caused by the host’s pathogen immune response. SBO from giardiasis is very rarely reported and has been hypothesized to relate to altered intestinal motility. More research is needed to study the details of the mechanism causing this complication.Figure 1.: Massively distended small bowel loops (shown by orange arrow).

VP11.18: Foregut and midgut duplication cysts with ileal atresia

Foregut and midgut duplication cysts associated with ileal atresia are not common gastrointestinal tract malformation. Thoracal and abdominal cystic masses was found in a young mother primigravida at 27 weeks of pregnancy on ultrasound. There was huge cystic mass measuring 44.0 x 42.0 mm unilaterally in the right inferoposterior hemithorax and cystic mass in central-left abdomen with segmental small bowel distention. Our preliminary diagnosis was CCAM type I or foregut duplication cyst. Delivery occurred by Caesarean section at 39 weeks with delivering a baby boy weighing 3700g. He had episodic bloody stool and dispnoe. Performed thoracal MRI and huge cystic mass measuring 55.0 x 52.0 mm was found in the right posteroinferior hemithorax, diagnosing CCAM Type 1 or foregut malformation. Neonate was taken up for thoracotomy on first month of life and huge cystic mass was resected and histopatological findings confirmed foregut duplication cyst. The baby was discharge home. A period of bloody stool was repeated and later he was entered to clinic with profuse intestinal bleeding. The exploratory laparotomy was done, distal ileal atresia with perforated terminal ileal duplication cyst was confirmed at surgery. Mentioned above segment of small bowel was resected and sometime later he was discharged home with recovery. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Clearing the obstructed small bowel via an orifice in the caecum after a resected appendix: a case report and presentation of the technique

A patient suffering from a mechanical obstruction of the distal sigmoid colon for several days, caused by a tumour invading the bowel circuitously, is reported. Intraoperatively, an extensive distension of the whole colon and the small intestine was noted. The operation consisted of a sigmoidectomy (with the tumour) followed by an end-colostomy on the descending colon (Hartmann operation). The colon was then cleared by “milking” the faecal contents to the end of the sigmoid colon. The distended small bowel was successfully cleared via an orifice in the caecum after a resected appendix. Although the presented technique seems to be simple, the authors did not find a similar method of clearing the small bowel in the literature.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

Successful endoscopic management of adult ileocecal intussusception secondary to a large ileal lipoma.

A 90-year-old man presented to our hospital with abdominal pain, nausea, and loss of appetite that started the day before arrival. Initial CT revealed a target sign with a low-density mass at the center located in the terminal ileum (Fig. 1). Although a severely distended small bowel and ascites were present, physical and serum laboratory findings were not suggestive of peritonitis. From the CT findings, the patient was diagnosed with adult intussusception secondary to a lipoma. Because vital signs were stable and abdominal pain was under control without administration of anesthetics, we attempted endoscopic reduction under fluoroscopic guidance (Video 1, available online at www.VideoGIE.org).