Distended Small Bowel Research Articles

CT enterography: technical and interpretive pitfalls.

CT enterography is a first-line test at many institutions to investigate potential small bowel disorders. While numerous articles have focused on the ability of CT enterography to diagnose and stage Crohn's disease, small bowel neoplasia, and malabsorptive or vascular disorders, this article reviews CT enterography limitations, technical and interpretive pitfalls, image review tactics, and complementary radiologic and endoscopic examinations to improve diagnostic accuracy. CT enterography limitations include its inability to demonstrate isolated mucosal abnormalities such as aphthous ulcers and its use of ionizing radiation. The most common technical pitfall of CT enterography is inadequate small bowel distention resulting from inadequate ingestion, gastric retention, or rapid small bowel transit of a large volume of neutral enteric contrast material. Additionally, segments of jejunum are frequently collapsed. Interpretive pitfalls commonly result from peristaltic contractions, transient intussusception and opaque intraluminal debris. Opaque debris is especially problematic during multiphasic CT enterography performed to identify potential small bowel sources of obscure gastrointestinal bleeding. False-negative examinations may result from inadequate radiation dose. Examinations complementary to CT enterography include small bowel follow through, enteroclysis, CT enteroclysis, MR enterography, MR enteroclysis, capsule endoscopy, and balloon-assisted endoscopy. Properly performed and accurately interpreted CT enterography contributes to the diagnosis and management of small bowel disease by itself and as a complement to other radiologic and optical small bowel imaging examinations.

A Comparative Study of Four Oral Contrast Agents for Small Bowel Distension With Computed Tomography Enterography

PurposeTo assess the efficacy of a variety of oral contrast agents in obtaining small bowel distention for computed tomography (CT) enterography examinations. MethodsA retrospective study was developed to quantitatively assess small bowel luminal distension during CT enterography by using 4 contrast agents, which included water, Metamucil, polyethylene glycol, and lactulose. A total of 256 patients were enrolled in the study and included 64 individuals for each oral regimen. The widest loop of small bowel in each of 4 quadrants on representative coronal images was separately measured for luminal distension. Overall distension and the greatest number of “useful” quadrants were evaluated. Overall distension was calculated by summing the 4 quadrant values into an overall luminal diameter distention score (cm). A “useful” quadrant was defined as having a measurement of ≥2 cm. Each “useful” quadrant was assigned a score of 1, with values that ranged from 0-4. ResultsFor overall distension, multivariable liner regression analysis showed that the lactulose group had a significantly higher overall distension value than Metamucil, polyethylene glycol, and water by 0.88, 0.92, and 1.63 cm, respectively, with 95% confidence interval. The categorical multivariable logistic regression analysis showed that the lactulose group had greater odds of having more “useful” quadrants than the Metamucil, polyethylene glycol, and water groups, with odds ratios of 3.51, 2.68, and 9.19, respectively. ConclusionLactulose achieves better small bowel distension for CT enterography studies than the other 3 agents and, therefore, is the preferred oral regimen at our institution.

Jejunojejunal Intussusception following Jejunostomy

Intussusception is an invagination of a segment of the gastrointestinal tract into an adjacent one. Jejunojejunal intussusception is a rare complication of jejunostomy tube placement with an incidence of 1%. We are reporting a case of 35-year-old man who was suffering from severe oral, lesions due to Ingestion of acide agents. He received Witzel jejunostomy for early feeding. Ileus developed postoperatively and plain X-ray of the abdomen showed distended small bowel loop. Abdominal computed tomography revealed target sign as well as the feeding tube in a dilated jejunum and intussusception was diagnosed. Exploratory laparotomy was required due to failure of expectant therapy. Reduction of intussusception was done during exploratory laparotomy. The jejunostomy feeding was continued and the postoperative course was uneventful.

Ascaris lumbricoides - From Bedside to Benchside

38 years old male farmer presented with pain abdomen for six days associated with vomiting and abdomen distension.Patient was conscious cooperative with pulse-106/minute, BP-110/80 mm Hg. No pallor,icterus was present.Abdomen was distended and tender.Respiratory system,Cardiovascular system examination was normal.Blood report revealed a TLC of 13,000/cumm predominantly neutrophilic,Hb-13.2 gm%,ESR-66 mm/hr.Liver function test was normal. Straight X ray abdomen revealed dilated gas filled bowel loops. Sonography of abdomen revealed presence of intestinal ascariasis with “Railway track sign” and “Bull’s eye sign” (Figure 1A and 1B). The patient was given conservative treatment in the form of bowel rest,intravenous fluids and painkillers. After 24 hours of admission, pain subsided. Upper GI endoscopy showed worm movement in duodenam (Figure 2B and 2B) and subsequently with the help of endoscopic snare a worm was taken out (Figure 3).The patient responded to conservative management and on the second day of admission he passed stool. Stool examination revealed presence of fertilized and unfertilized eggs of ascariasis (Figure 4A and 4B). Antihelminthic was administered in the form of albendazole and discharged. Ascaris lumbricoides is one of the commonest helminthic infections worldwide. Adult worms may be present in gastrointestinal system, hepatobiliary system or peritoneal cavity causing a wide range of clinical manifestations [1]. Straight X ray abdomen can reveal moderately distended small bowel loops,sometimes multiple air-fluid levels. Sonography of abdomen confirms the diagnosis of ascariasis by the presence of the typical signs of “bull’seyes” in transverse section and “railway track” appearance in longitudinal sections [2]. The finding of fertile or infertile eggs or an adult worm in the feces may sometimes serve as only an indicator of ascariasis lumbricoides infestation [3].

A Case of Adult Intussusception

Introduction: A 38-year-old Indian man with B-cell adult lymphocytic leukemia on chemotherapy was admitted with diarrhea, nausea, vomiting, and worsening abdominal pain. On presentation, a CT of his abdomen and pelvis found a mild colonic and small bowel distention. The patient was managed with IV fluid hydration and pain medication, and his symptoms improved. Three days later, the patient developed severe colicky abdominal pain. On abdominal exam, he had peri-umbilical tenderness with guarding. The patient was neutropenic and thrombocytopenic throughout his hospital stay, with a WBC of 500/μL and platelets of 16000/μL. Given his acute change in symptoms, another CT scan was performed, which showed small bowel intussusception. Surgery evaluated the patient, and given his neutropenia and thrombocytopenia, opted for conservative management. Five days later, the patient had a repeat CT scan that showed resolution of the intussusception and the patient was eventually discharged home and continued on his chemotherapy regimen. Intestinal invagination or intussusception is the leading cause of intestinal obstruction in children. Intussusception in adults accounts for only 5% of intussuception cases. Intussusception can present as acute, intermittent, cramping, and abdominal pain with nausea and vomiting; however, vague abdominal symptoms is a common presentation. While in children, 95% of cases are idiopathic, about 90% of causes of intussusception in adults are due to a distinct pathologic abnormality. In the small bowel, this consists of benign neoplasms, inflammatory lesions, and adhesions. Malignant lesions are found in only 30% of cases of intussusception in the small intestine, in contrast to 60% in colonic intussusception. Abdominal x-rays often show signs of intestinal obstruction, and can give information regarding the site of obstruction. CT has been reported to be the most useful diagnostic tool for the diagnosis of intussusception, with an accuracy of 58-100% with a finding of a homogenous mass that is target or sausage-shaped. The optimal management of adult intussusception is controversial, particularly in the small bowel. While resection of colonic intussusception is generally advocated due to the high percentage of associated malignancies, small bowel intussusception is less commonly due to malignancy, and thus intraoperative manual reduction with careful palpation of the intestinal wall might allow for limited bowel resection. Intussusception in adults is rare, and can present with non-specific abdominal complaints. Gastroenterologists should be aware of this rare condition for abdominal pain and the current treatment methods.

Sonographic diagnosis of intestinal anisakiasis presenting as small bowel obstruction.

To evaluate the accuracy of ultrasonography (US) in the diagnosis of intestinal anisakiasis presenting as small bowel obstruction. We retrospectively reviewed the clinical features, US examinations, and CT scans of seven patients with intestinal anisakiasis presenting as small bowel obstruction. We compared the performances of US and CT in demonstrating peritoneal fluid, small bowel dilatation, and segmental edema of Kerckring's folds. All patients presented with a history of ingesting raw saltwater fish or squid less than 2 days prior to presentation at the emergency department and had significant levels of Anisakis-specific IgE. Both US and CT revealed small bowel obstruction, with dilated small bowel in all patients and accumulations of free peritoneal fluid in six patients. CT showed segmental wall thickening and luminal narrowing with submucosal edema distal to the distended small bowel; US did so in four patients. Although US was inferior to CT in demonstrating the segmental intestinal edema causing small bowel obstruction, it can be applied in suspected cases of intestinal anisakiasis presenting as small bowel obstruction, particularly where CT is unavailable or there are concerns about radiation exposure.

Familial visceral myopathy diagnosed by exome sequencing of a patient with chronic intestinal pseudo-obstruction

A 55-year-old woman with a history of bowel dysmotility presented with abdominal distension and peritonitis. Family history included premature deaths with intestinal symptomatology, suggesting autosomal dominant inheritance. Computed tomography showed a distended small bowel. Symptoms were alleviated by enterocutaneous stomas. Initial ileal biopsy suggested neuropathy; however, exome sequencing revealed an Arg148Ser mutation in the enteric smooth muscle actin gamma 2 (ACTG2) gene. Histological reassessment showed abnormal muscularis propria and smooth muscle actin, with the same findings in sibling, confirming familial visceral myopathy. Thus, noninvasive genomic analysis can provide early and specific diagnosis of familial visceral myopathy, which may help to avoid inappropriate surgery.

MR enterography imaging of Crohn's disease in pediatric patients.

SummaryBackgroundCrohn disease (CD) is a chronic inflammatory process of gastrointestinal tract, which frequently affects children. Recent advances in Magnetic Resonance Imaging (MRI) technique have made small bowel imaging possible, what is extremely useful in pediatrics.The purpose of this article is to describe the characteristic MR enterography findings and to present the advantages of this modality in pediatric patients.Material/MethodsA group of 40 patients referred from the Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw was included in the analysis. The patients’ age ranged from 7 to 18 years (mean age 14 years). Among the study participants, 28 patients were diagnosed with CD, whereas 12 patients had a history of ulcerative colitis or were strongly suspected of CD based on clinical data.The examinations were performed on GE Signa HD 1,5 T system. Small bowel distention was achieved by oral administration of 600–1000 ml of hyperosmotic solution of polyetylenglycol (PEG). Prior to the examination, 20–40 mg of a spasmolytic drug, hioscine-N-butylobromide (Buscolysin®), was administrated to reduce peristaltic movements.ResultsThe abnormal small bowel segments were found in 21 patients and the features of colonic disease were detected in 5 patients. In 2 patients the lesions involved both small and large bowel. In 16 subjects mural changes were not found. Among studied patients, following signs of small bowel inflammation were fund: bowel wall thickening (n=21), submucosal edema (n=8), segment wall hyperenhancement (n=18), deep ulceration (n=6), fistula (n=3), stenosis (n=7), mesenteric signs such as hyperemia (n=9), fibrofatty proliferation (n=8) and lymphadenopathy (n=28).ConclusionsMR enterography is an excellent examination, which provides an accurate information about severity and activity of and complications related to CD. It is especially valuable in children, because of lack of the negative consequences of repeated exposure to ionizing radiation.

Imaging the small bowel

Radiologic investigations continue to play a pivotal role in the diagnosis of pathologic conditions of the small intestine despite enhancement of capsule endoscopy and double-balloon endoscopy. Imaging techniques continue to evolve and new techniques in MRI in particular, are being developed. Continued advances in computed tomography (CT) and MRI techniques have reinforced the importance of these imaging modalities in small bowel assessment. The more invasive enteroclysis technique yields better small bowel distension for both CT and MRI when compared with peroral enterography, but no clinically significant difference is seen in terms of diagnostic accuracy. Recent concern regarding radiation exposure means that MRI is gaining in popularity. Fluoroscopic studies such as barium follow through and small bowel enteroclysis are being replaced by the cross-sectional alternatives. Contrast-enhanced ultrasound is showing results comparable with CT and MRI, but concern remains regarding reproducibility, especially outside centres that specialize in advanced sonographic techniques. CT and MRI enterography are comparable first-line modalities for patients with suspected small bowel disease, but magnetic resonance enterography is favoured given the absence of ionizing radiation. Capsule endoscopy is a reasonable alternative investigation in exploration of chronic gastrointestinal blood loss, but is best kept as a second-line test in patients with other symptoms.

Minimally Invasive Surgery in the Management of Adhesive Small Bowel Obstruction: A Rare Case

Introduction: We present the management of a patient who failed conservative management of adhesive small bowel obstruction (ASBO), which was treated with laparoscopic lysis of adhesions. Presentation of Case: A 66 year old, hypertensive, diabetic patient with previous gynaecological surgery presents with symptoms of intestinal obstruction for 2 days. Clinical & radiological features are consistent with the diagnosis of SBO. Conservative treatment was started but the patient failed to show any signs of resolution. Laparoscopic adhesiolysis was successfully performed on thin adhesions between the liver and the anterior abdominal wall (possible Fitz-Hugh Curtis syndrome), which trapped the small bowel. The patient was discharged on day 4 of admission. Discussion: ASBO is a very common and actual disease and its management deserves great attention. Although surgeons are hesitant to perform laparoscopy in patients with distended small bowel due to adhesive obstruction, laparoscopic surgery performed by experienced surgeons offers the opportunity of shorter hospital stay, quick recovery and less morbidity, including wound sepsis and incisional hernia when compared with laparotomy. Conclusion: Minimally invasive surgery (MIS) in ASBO is not standard of care, however, selected patients may benefit from the advantages of this approach. Once the necessary expertises are available, an attempt to treat these patients with MIS may be safe, and as such, should be entertained.

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

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

Quantitative and qualitative bowel analysis using mannitol, water and iodine-based endoluminal contrast agent on 64-row detector CT

Objective:To assess the performance of mannitol as a luminal contrast as compared to water and positive contrast in evaluation of bowel on multidetector computed tomography (MDCT).Materials and Methods:Three hundred patients were randomly selected for this study and were divided equally into three groups. Each subject received 1500 ml of oral contrast. Group 1 received 3% mannitol in water, group 2 received diluted iodinated positive contrast, and group 3 received plain water without additives. Qualitative and quantitative analysis for distension, fold visibility, and overall image quality were analyzed by actual diameter measurement and point scale system at different bowel levels. One-way analysis of variance (ANOVA) followed by Tukey's HSD Post-hoc test and Pearson's Chi-square (exact test) test were applied.Results:Group 1 showed better results for small bowel distension, intraluminal homogeneity, and visibility of mucosal folds on quantitative and qualitative analysis with statistically significant P value (P<0.001). The ileo-caecal junction distension and mural feature visibility was better with mannitol (P < 0.001). No significant difference in distension of stomach and duodenum was found between the three groups.Conclusion:Mannitol as endoluminal contrast increases the diagnostic accuracy of the investigative studies in comparison to water and iodine-based contrast by producing significantly better bowel distension and visibility of mural features with improved image quality without additional adverse effects.

Can postoperative complications be predicted by a routine CT scan on day 5? A study of 78 laparoscopic colorectal resections

Postoperative computed tomography (CT) scan patterns after colorectal resection are difficult to analyze for both clinicians and radiologists. This study aimed to assess the role of single CT scan on postoperative day 5 in predicting postoperative morbidity. From October 2007 to August 2009, 78 patients undergoing laparoscopic colorectal resection were enrolled in a research study involving a routine contrast-enhanced multi-detector CT scan on postoperative day 5. Two groups were defined: patients with intra-abdominal postoperative morbidity requiring specific management, i.e., surgical or radiological procedure, and/or antibiotic therapy ("complications" group), and patients with uneventful postoperative outcome ("uneventful" group). CT findings were compared between the two groups with Fisher's exact test or chi-square test. Postoperative abdominal complications occurred in 16 patients (21%). Of the CT findings on day 5, pneumonia, pulmonary embolism, portal or mesenteric thrombosis, operative area fat infiltration, peritoneal effusion, pneumoperitoneum, intra-abdominal collection, parietal inflammation or collection, and subcutaneous emphysema were observed in both groups without any significant difference. Only small bowel distension [25% (4/16) in the "complications" group vs. 5% (3/62) in the "uneventful" group; p=0.029] and pleural effusion [81% (13/16) vs. 48% (30/62); p=0.024, respectively] were observed significantly more often in the "complications" group. This study suggested that abdominal complications cannot be predicted by a CT scan on day 5 after laparoscopic colorectal resection. Thus, it cannot be recommended for routine use.

CT enteroclysis in the developing world: How we do it, and the pathology we see

IntroductionImaging and diagnosis of small bowel disease is challenging, especially in developing countries where access to supplementary imaging equipment is not readily available. Imaging of the small bowel has evolved from small bowel follow-through to the first enteroclysis by Pesquera in 1929. This technique evolved over time with advances in enteral intubation catheters, enteral contrast media and techniques for infusing enteral contrast. Objective(1) Describe our modification of performing CTE and (2) to show pathology and discuss its relevance in our clinical practice. Materials and methodsThis was a retrospective study that included 73 patients since the introduction of our modified technique of performing CT enteroclysis (CTE) using saline vaculitres, intravenous line connection sets and a drip stand. We recorded patient data in Microsoft Corporation Excel 2007 to include indications for the CTE, patient demographics and imaging findings related to small bowel pathology with associated extra luminal findings and incidental extra-intestinal non small bowel findings that was statistically analyzed. ResultsOf the 73 patients included in the study 42 where females and 31 males. 15 (20.5%) had small bowel pathology and 12 (16.4%) had non-small bowel pathology that could explain the clinical symptoms. Malabsorption/chronic diarrhea group was the largest indication for referral (26% of referrals). Most prevalent small bowel findings were in the inflammatory bowel subgroups where 30% had imaging features of active inflammatory bowel disease. ConclusionDecades of experience have shown that only small bowel examinations that uniformly distend the small bowel lumen can confidently confirm or rule out small bowel pathology. With our modified technique performed, with readily available and affordable infusion equipment and enteral contrast we achieve diagnostic quality small bowel distention to demonstrate and diagnose with confidence small bowel pathology in our population. This is of particular value in developing countries where we are resource limited and expensive equipment and contrast material is often not available.

Acute intestinal obstruction as the first manifestation of tuberculous peritonitis

A case of dynamic ileus resulting from tuberculous peritonitis (TBP) is presented, which was treated with exploratory laparotomy and administration of antituberculosis therapy. TBP accounts for 0.1–0.7% of all cases of TB and usually presents as a subacute disease. Acute abdomen sometimes complicates TB, mainly because of intestinal perforation or obstruction. A 20-year-old Pakistani male presented with symptoms and signs of intestinal obstruction. An exploratory laparotomy revealed ascites, small bowel distention due to adhesions around the terminal ileum, whitish nodules covering the inflamed peritoneum and omentum, enlarged mesenteric lymph nodes, and a saccular-shaped whitish mass measuring 11x7x5 cm at the right iliac fossa. Adhesiolysis, removal of the abovementioned mass, and an appendectomy was performed, and samples were obtained for microbiological and histological examination. The tuberculin skin test was positive, and since the intraoperative findings were highly suggestive of TBP, initiation of antituberculosis therapy on the 11th postoperative day was decided. Finally, the diagnosis of TBP was established both microbiologically and histologically. The patient successfully completed a 6-month regimen of antituberculosis drugs. Acute abdomen necessitating exploratory laparotomy is a rare first manifestation of TBP. Early initiation of antituberculosis therapy should take place if intraoperative findings strongly favour the diagnosis of TBP.

Impact of magnetic resonance enterography in the management of small bowel Crohn’s disease

Magnetic resonance enterography (MRE) is a relatively new imaging modality that involves small bowel distension with orally administered fluid. Few studies have assessed its impact on patient management. The aim of this study was to determine whether MRE influenced the management of patients with established small bowel Crohn's disease (CD). From a prospectively maintained database of patients with inflammatory bowel disease, we identified patients with small bowel CD who underwent MRE between January 2007 and December 2010. The results of the MRE and subsequent changes in patient management within 1 month were evaluated. Thirty women and 27 men with CD were included. Seven patients (12%) had a normal MRE. Forty-two of 57 (74%) patients had a change in management, and 41/50 (82%) patients with an abnormal MRE had changes in management (P<0.0008). After MRE, 20/42 (47%) patients had surgery and 22/42 (53%) had changes in medical treatment. Patients with stricturing disease had more surgical intervention (P=0.02), and patients with active disease on MRE had more medical intervention (P=0.0001). Patients with two or more abnormalities on MRE had more surgery compared with medical therapy (P=0.02). The majority of patients with small bowel CD had a change in management as a result of the MRE. Because of its high clinical impact on patient management, MRE should become one of the preferred methods of small bowel evaluation in CD. Specific MRE findings may help to stratify treatment options, however, further work is required to validate this.

Fetal megacystis as a prenatal challenge: megacystis–microcolon–intestinal hypoperistalsis syndrome in a male fetus

The prenatal detection of megacystis is only the first step towards identifying the etiology and deciding on suitable treatment for this condition. Here we present a report highlighting the difficulties in the prenatal diagnosis of this severe fetal anomaly. A 28-year-old healthy primigravida was referred at 24 weeks' gestation to a tertiary hospital after an ultrasound scan at 18 weeks revealed megacystis and unilateral hydronephrosis in a male fetus with normal karyotype. On referral, a further ultrasound examination revealed a large bladder with a dilated posterior urethra (the ‘keyhole sign’) and normal wall thickness. Based on these findings, posterior urethral valves (PUV) syndrome was first suspected. Following weekly clinical and ultrasound surveillance, a progressive and unexpected increase in the amniotic fluid index (AFI) was observed in the third trimester, with polyhydramnios and grade IV hydronephrosis (Figures 1 and 2). These findings were suggestive of the rare megacystis–microcolon–intestinal hypoperistalsis syndrome (MMIHS). At 32 weeks' gestation, fetal magnetic resonance imaging (MRI) showed a dilated bladder measuring 135 × 111 × 86 mm that was compressing the abdominal organs, and severe bilateral hydronephrosis (21 mm right and 18 mm left); in addition, the stomach was clearly visible, but not the intestines (Figure 3). Vesicocentesis was performed for fetal urinalysis (sodium, potassium, calcium, phosphorus, creatinine, urea, total proteins and β2-microglobulin), and amniocentesis for evaluation of digestive enzymes (including γ-glutamyl transferase, alkaline phosphatase and biliary salts); findings from these tests were consistent with MMIHS. A Cesarean section was performed at 33 weeks, after spontaneous rupture of membranes. The neonate weighed 2950 g and had Apgar scores of 8 and 8 at 1 and 5 min, respectively. During the neonatal period the diagnosis was confirmed, and vesicostomy and total parenteral nutrition were needed. At 12 months, the infant had normal physical and neurological development, but still needed parenteral nutrition and vesicostomy. MMIHS is a rare congenital disease with fewer than 200 cases described in the literature, most of whom died in the first year of life1-4. It is characterized by a functional neonatal bowel obstruction with dilated small bowel, microcolon and non-obstructive urinary bladder distension. The etiology of the disease is unknown1-3. The prenatal sonographic features of MMIHS include megacystis, hydronephrosis, hydroureters, normal or decreased AFI in the second trimester, and polyhydramnios, intestinal and/or stomach dilatation in the third trimester1, 5-9. The fetal sex should also be considered, because MMIHS occurs 3–4 times more frequently in females2-5, 8, 9, although, as our case shows, the diagnosis should not be ruled out in male fetuses. The presence of oligohydramnios, progressive bladder wall thickening, hydronephrosis, echogenic kidneys and dilated posterior urethra are more suggestive of obstructive uropathy caused by a distal urethral obstruction such as PUV5, 9-11. For this reason, amniotic fluid analysis and fetal urinalysis are also helpful in the prenatal diagnosis of MMIHS6, 9, 12, as elevated digestive enzymes and high calcium levels, respectively, can be indicative of the disease6. Fetal MRI may also improve the diagnosis, especially when upper gastrointestinal tract distension (esophagus, stomach or small bowel) and microcolon are observed13. Despite the absence of pathognomonic findings of this rare syndrome, prenatal diagnosis is mandatory for optimal counseling and postnatal treatment.

An 85-year-old male with abdominal pain and previous gastric surgery

An 85-year-old Caucasian male presented as an emergency to hospital with a 3-week history of increasing colicky abdominal pain, anorexia and constipation. He had undergone an operation for peptic ulcer disease over 30 years previously. On examination the patient had a distended abdomen, which was tympanic to percussion. An upper midline laparotomy scar was apparent. A clinical diagnosis of small bowel obstruction was made. A CT scan of the abdomen and pelvis was requested. Selected images of the portal venous phase CT examination of the abdomen and pelvis with oral and intravenous contrast are shown in Figure 1. What do they demonstrate? What is the differential diagnosis? Figure 1. Selected coronal, axial and sagittal images from a portal venous phase study of the abdomen and pelvis. (a) Thickened segment of distended small bowel with intramural gas (arrows), (b) intraluminal curvilinear focus of calcification (arrow), (c) intraluminal ...

An Intestinal Occlusion Device for Prevention of Small Bowel Distention During Transgastric Natural Orifice Transluminal Endoscopic Surgery

Bowel distention from luminal gas insufflation reduces the peritoneal operative domain during natural orifice transluminal endoscopic surgery (NOTES) procedures, increases the risk for iatrogenic injury, and leads to postoperative patient discomfort. A prototype duodenal occlusion device was placed in the duodenum before NOTES in 28 female pigs. The occlusion balloon was inflated and left in place during the procedure, and small bowel distension was subjectively graded. One animal had no balloon occlusion, and 4 animals had a noncompliant balloon placed. The balloon maintained its position and duodenal occlusion in 22 animals (79%) in which the bowel distention was rated as none (15), minor (4), moderate (3), or severe (0). The intestinal occlusion catheter failed in 6 animals (21%) because of balloon leak (5) or back-migration into the stomach (1), with distention rated as severe in 5 of these 6 cases. The intestinal occlusion catheter that maintains duodenal occlusion significantly improves the intraabdominal working domain with enhanced visualization of the viscera during the NOTES procedure while requiring minimal time and expense.

MRI enterography with divided dose oral preparation: Effect on bowel distension and diagnostic quality

Aim:To assess the impact of an extended oral preparation magnetic resonance (MR) enterography protocol on bowel distension, timing of imaging, and the quality of diagnostic images.Materials and Methods:An analysis of 52 patients who underwent divided oral preparation and 39 patients who underwent standard preparation for MR enterography examination was done. Distension was assessed by measuring the transverse diameters of the jejunum, ileum, and the ileocecal region. Diagnostic quality of the examination was assessed subjectively by two radiologists and graded as poor, diagnostic, and excellent (Grades 1-3). Correlation between bowel diameter and diagnostic quality was assessed using regression analysis.Results:The mean diameters of the jejunum, ileum, and colon in patients who underwent divided preparation were 1.90 ± 0.47, 2.14 ± 0.41, and 4.27 ± 0.96 cm, respectively, and the mean diameters in patients who underwent standard preparation were 1.46 ± 0.47, 2.02 ± 0.47, and 4.45 ± 0.90 cm, respectively. A total of 96.6% of patients on divided dose had diagnostic distension of the bowel (Grades 2 and 3). A total of 87.9% of the patients on standard dose had diagnostic distension of the bowel (Grades 2 and 3). A greater number of patients who underwent divided preparation had diagnostic quality examinations compared to those given standard preparation (96.6% vs. 87.9%). A greater number of patients who underwent divided preparation had Grade 3 quality examinations compared to those on standard preparation (75.5% vs. 68.5%). There was significant difference between diagnostic (Grades 2 and 3) and optimal grades (Grade 3) of the jejunal diameters in patients having divided or standard preparation (89.7% vs. 66.6%, P < 0.05; 40.8% vs. 25%, P < 0.05, respectively). Linear regression showed a positive correlation between increasing bowel diameter and diagnostic grade of the examination (ρ = 0.76).Conclusion:Using an extended oral preparation with divided dose resulted in the majority of patients being scanned in a single visit to the MRI suite. Dividing the oral contrast into aliquots can promote uniform distension of the entire small bowel and provide better bowel distension and improve the diagnostic quality.