Distended Small Bowel Research Articles

Quality, clinical influence and tolerance of computed tomography enteroclysis in patients with suspected small bowel disease

Computed tomography enteroclysis (CTE) may be superior to other small bowel imaging techniques, detecting subtle mucosal lesions and extraluminal pathology. This study aimed to define the technical success, clinical influence and tolerance of CTE in patients with suspected small bowel disease. CTE scans of 42 consecutive patients (aged 21-78 years, 12 men) were reviewed by a single radiologist for technical adequacy and diagnosis. A panel of gastroenterologists reviewed clinical information. At a telephone interview, tolerance of CTE was graded numerically from 1 (unbearable) to 10 (excellent) and descriptively as unbearable, fair, good or excellent. Good or optimal distension of small bowel was achieved in 98%. The entire small bowel was imaged in 88%. Eighteen patients had a normal small bowel, whereas 12 (29%) had active small bowel Crohn disease, 4 intussusception, 3 small bowel diverticula and 7 having other diagnoses. Mesenteric lymphadenopathy was evident in 11 and fat stranding in 5. CTE resulted in a new or altered diagnosis in 13 (31%) patients and identified more extensive Crohn disease in a further 8 (19%). A change in management plan was instituted in 18 (43%) patients, with subsequent clinically significant improvement in 12. 33 (85%) described the procedure as 'fair' or 'unbearable' rather than 'good' or 'excellent'. The median tolerance score was 3 out of 10. CTE provided high-quality images in nearly all patients and had an effect on diagnosis, management or outcome in most, but was not well tolerated.

Splenic Hematoma Following Colonoscopy

Purpose: We present a case of a perisplenic hematoma following colonoscopy which was managed non-operatively and without the need for blood transfusions. A 53 year old woman underwent a colonoscopy to evaluate severe laxative-dependent constipation. Colonoscopy showed diverticulosis and 4 small rectal polyps excised by cold biopsy. The procedure was not considered technically difficult and no abdominal pressure was applied. A few hours later she complained of mild diffuse abdominal pain and bloating. Abdominal x-ray was negative for free air but showed significant distension of small and large bowel. Her vital signs remained stable and after passing flatus in the recovery area she felt better and was discharged. Her symptoms gradually worsened over the next 3 days and she developed pain localized to the left abdomen and shoulder. She presented to the ED on the fourth day post colonoscopy. In the ED she was afebrile with a HR of 103 and BP of 142/80. Abdominal examination revealed tenderness on the left side of the abdomen with no guarding, rebound or rigidity and normal bowel sounds. Labs showed a mild neutrophilic leukocytosis and anemia with an Hct of 33 (baseline-45). CT scan of the abdomen revealed a large complex perisplenic hematoma with tiny splenic lacerations, hemorrhage around the liver, in the left paracolic gutter and the pouch of Douglas [Image]. She was admitted, put on bedrest, given IV fluids and analgesia. Her pain gradually improved and a follow-up CT scan on day 5 revealed no significant changes from her previous scan. She did not require blood transfusions. Her clinical picture continued to improve and on hospital day 6 she was discharged. The first case of colonoscopy complicated by splenic injury was reported in 1974. A review of the literature reveals only 11 reported cases since then that have been managed non-operatively and without the need for blood transfusions (this case being the 12th). Although it appears to be a rare complication, splenic injury should be included in the differential of abdominal pain following colonoscopy. Though splenic hemorrhage usually presents with hemodynamic instability and signs of peritonitis, our case demonstrates that this entity can also present in a more insidious way.Figure: Perisplenic hematoma.

Prevention of Small Bowel Distention During Transgastric Natural Orifice Translumenal Endoscopic Surgery (NOTES)® Using a Novel Intestinal Occlusion Device

Background: Bowel distention from lumenal gas insufflation reduces the peritoneal operative domain during NOTES procedures, increases the risk for iatrogenic injury and leads to post-op patient discomfort. Such distention is identified as a potential barrier to the clinical practice of NOTES by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR); however, to date no reliable technique has been described. This group first studied the use of the CODA endovascular balloon catheter (Cook Inc.) which expands to a consistent and predictable size. Although effective, the use of this device led to duodenal ischemia during the procedure with subsequent perforation in 2 of 4 animals, and it was apparent that a more compliant device would be required for safe duodenal occlusion. Aim: To develop and evaluate a disposable balloon catheter with compliant, non-traumatic characteristics for safe and effective duodenal occlusion during NOTES procedures. Methods: A total of 28 adult swine (mean wt 32 kg) underwent NOTES procedures utilizing the self-approximating translumenal access technique (STAT). A 190cm long, 5.5 Fr biliary extraction catheter was modified into an intestinal occlusion catheter (IOC) by securing a large volume, low pressure ARM balloon (Sandhill Inc.) to the distal end of the catheter with suture. The balloon tip was grasped by endoscopic forceps, the catheter introduced parallel to scope, and positioned in the duodenal bulb where 1cc/kg of air was inflated to maintain intestinal occlusion for the duration of the procedure. Bowel distension was assessed subjectively during the procedure using a 4 point Likert scale (none to severe). The animals were survived for 2 weeks, and necropsy was performed to assess for deleterious effects. Results: IOCs were successfully placed in all 28 animals; mean deployment time was 287 ± 66 sec, initial balloon volume was 36 ± 4 mls, and mean bowel occlusion time was 195 ± 72 min. The IOC failed in 6 animals (21%) due to balloon leak (5) or back migration into the stomach (1) with distention rated as severe in 5 of these 6 cases. In the remaining animals, bowel distention was rated as none (15), minor (4), moderate (3), severe (0). One significant complication occurred (forceps perforation due to an attempted blind deployment). Conclusions: The IOC significantly improved the intra-abdominal working domain with enhanced visualization of the viscera while requiring minimal time and expense. Although the perforation mandates improvement and standardization in the deployment technique, we are encouraged by our experience using the IOC and believe that it holds promise as an adjunct for NOTES.

Hypotonic MR duodenography with water ingestion alone: feasibility and technique

To date, cross-sectional imaging of the duodenum has a number of inadequacies, most likely a reflection of its tortuous and complex anatomical course, resulting in somewhat suboptimal imaging. The purpose of this study was to describe and assess the feasibility of performing a 'tubeless', per-oral, single contrast, hypotonic magnetic resonance (MR) duodenography technique. Secondly, to assess the efficacy of intravenous Buscopan in facilitating duodenal distension at cross-sectional MR imaging. Ten healthy volunteers prospectively underwent MR imaging of the duodenum pre- and post-Buscopan immediately after consuming 1,000 ml of water. Images were qualitatively (using a visual assessment grading scale of 1-3) and quantitatively evaluated with regard to degree of small bowel distension by two observers. The contrast medium was successfully ingested and MR examination was completed in all participants. Quantitatively and qualitatively, the per-oral, hypotonic duodenography technique yielded superior distension scores and was significantly greater in diameter in comparison with the per-oral non-hypotonic duodenography technique (p < 0.003, p < 0.002). Per-oral, single-contrast, hypotonic MR duodenography is a feasible, simple, fast mode of investigation of the duodenum, which does not involve radiation and represents a useful technique in the armamentarium of the radiologist.

Small bowel MRI enteroclysis or follow through: Which isoptimal?

To determine if a nasojejunal tube (NJT) is required for optimal examination of enteroclysis and if patients can be examined only in the supine position. Data were collected from all patients undergoing small bowel (SB) magnetic resonance imaging (MRI) examination over a 32-mo period. Patients either underwent a magnetic resonance (MR) follow-through (MRFT) or a MR enteroclysis (MRE) in the supine position. The quality of proximal and distal SB distension as well as the presence of motion artefact and image quality were assessed by 2 radiologists. One hundred and fourteen MR studies were undertaken (MRFT-49, MRE-65) in 108 patients in the supine position only. Image artefact was more frequent in MRE than in MRFT (29.2% vs 18.4%), but was not statistically significant (P=0.30). Adequate distension of the distal SB was obtained in 97.8% of MRFT examinations and in 95.4% of MRE examinations, respectively. Proximal SB distension was, however, less frequently optimal in MRFT than in MRE (P=0.0036), particularly in patients over the age of 50 years (P=0.0099). Image quality was good in all examinations. All patients could be successfully imaged in the supine position. MRE and MRFT are equivalent for distal SB distension and artefact effects. Proximal SB distension is frequently less optimal in MRFT than in MRE. MRE is, therefore, the preferred MR examination method of the SB.

Head-to-Head Comparison of Oral Contrast Agents for Cross-sectional Enterography: Small Bowel Distention, Timing, and Side Effects

Head-to-Head Comparison of Oral Contrast Agents for Cross-sectional Enterography: Small Bowel Distention, Timing, and Side Effects

Comparison of MR enteroclysis with colonoscopy in Crohn′s disease-first locust bean gum study from Turkey

Background/Aim:The aim of this study was to compare magnetic resonance enteroclysis (MRE) findings with those of colonoscopy, using locust bean gum (LBG) as an oral contrast agent in the diagnosis and follow-up of patients with Crohn's disease.Materials and Methods:Nine patients with histologically proven Crohn's disease were enrolled in this study; MRE was performed within a week of colonoscopy. All patients were examined using a 1.5 T MR Scanner after per os administration of 850 mL of a combination of LBG and mannitol. After intravenous administration of 50 mg Eritromisin and 40 mg Scopolamine, images were obtained using a T2-weighted, balanced GRE, fat-suppressed T1-weighted sequence, before and after intravenous gadolinium administration. Bowel wall thickness and enhancement of inflamatory bowel wall were measured.Results:The oral ingestion of LBG was well tolerated and allowed optimal small and large bowel distention in all patients. MR findings correlated with the colonoscopy results. Additional inflammatory lesions of the colon and mesenteric inflamatory changes such as lymphadenopathy, conglomerate tumor, and fistulas were demonstrated. Contrast enhancement of the affected bowel wall was markedly increased and positive correlation was obtained between bowel wall enhancement and bowel wall thickness.Conclusion:Gadolinium-enhanced MRE with oral locust bean gum is very efficient in the detection and follow-up of the intestinal and extraintestinal findings of Crohn's disease.

MRI Small-Bowel Follow-Through: Prone Versus Supine Patient Positioning for Best Small-Bowel Distention and Lesion Detection

The purpose of this study was to assess whether prone or supine imaging provides superior small-bowel loop distention during MRI small-bowel follow-through examinations and whether either position is better with regard to lesion detection and evaluation. Forty consecutively enrolled clinically referred patients with known or suspected small-bowel abnormalities prospectively underwent 62 MRI small-bowel follow-through examinations in both the prone and the supine positions. Images were blindly and independently reviewed by two observers. Each small-bowel segment was assessed with a 3-point scoring system, and differences in bowel distention in the prone and supine positions were evaluated with a paired Wilcoxon's test. Differences between rates of lesion detection and characterization (e.g., ulceration, stricturing) were analyzed with a paired Student's t test. Interobserver agreement was estimated with the kappa coefficient. In both normal and diseased small bowel, the prone position had statistically significantly higher distention scores than did the supine position (p < 0.05) with a high level of interobserver agreement. This finding, however, did not translate into improved lesion detection or characterization (p > 0.05). Although use of the prone position results in superior small-bowel distention during MRI small-bowel follow-through, both the prone and supine positions are equal in terms of lesion detection and feature visualization.

MRI of the small bowel: can sufficient bowel distension be achieved with small volumes of oral contrast?

Sufficient luminal distension is mandatory for small bowel imaging. However, patients often are unable to ingest volumes of currently applied oral contrast compounds. The aim of this study was to evaluate if administration of low doses of an oral contrast agent with high-osmolarity leads to sufficient and diagnostic bowel distension. Six healthy volunteers ingested at different occasions 150, 300 and 450 ml of a commercially available oral contrast agent (Banana Smoothie Readi-Cat, E-Z-EM; 194 mOsmol/l). Two-dimensional TrueFISP data sets were acquired in 5-min intervals up to 45 min after contrast ingestion. Small bowel distension was quantified using a visual five-grade ranking (5 = very good distension, 1 = collapsed bowel). Results were statistically compared using a Wilcoxon-Rank test. Ingestion of 450 ml and 300 ml resulted in a significantly better distension than 150 ml. The all-over average distension value for 450 ml amounted to 3.4 (300 ml: 3.0, 150 ml: 2.3) and diagnostic bowel distension could be found throughout the small intestine. Even 45 min after ingestion of 450 ml the jejunum and ileum could be reliably analyzed. Small bowel imaging with low doses of contrast leads to diagnostic distension values in healthy subjects when a high-osmolarity substance is applied. These findings may help to further refine small bowel MRI techniques, but need to be confirmed in patients with small bowel disorders.

Head-to-Head Comparison of Oral Contrast Agents for Cross-sectional Enterography

To determine small bowel distention, scanning time, and side effects of commercially available oral contrast agents used in cross-sectional enterography. Ten healthy volunteers ingested 2000 mL of water, methylcellulose, polyethylene glycol (PEG), or 1350 mL of low-concentration barium (LCB) followed by 500 mL water on different days. Magnetic resonance imaging occurred every 10 minutes from 30 to 90 minutes after ingestion. Small bowel distention was compared between time points and agents. Volunteers ranked side effects, drinking difficulty, and preference. By quantitative assessment, PEG and LCB distended small bowel loops better than water and methylcellulose (P < 0.0001). Time to optimal distention of the terminal ileum was from 51 to 72 minutes. Water and methylcellulose had the fewest side effects. Water was the most preferred contrast and PEG the least. Polyethylene glycol and LCB distend small bowel better than water and methylcellulose. Polyethylene glycol was the most difficult to drink and least preferred agent.

Extreme gastric dilation caused by chronic lead poisoning: A case report

Lead is a toxic metal that affects many organ systems and functions in humans. In the majority of adults, chronic lead poisoning comes from exposures to work places and can occur in numerous work settings, such as manufacturing, lead smelting and refinement, or due to use of batteries, pigments, solder, ammunitions, paint, car radiators, cable and wires, certain cosmetics. In some countries, lead is added to petrol. We present a rare case of gastric dilation caused by long-term petrol ingestion. A 16-year-old young man was admitted to our hospital due to a 6-mo history of exhaustion, dizziness, nausea, abdominal cramps and constipation. X-ray examination revealed dilated stomach descending into the pelvis and small bowel distension. After a long clinical observation, we found that the reason for the chronic lead poisoning of the patient was due to a 3-year history of petrol ingestion. The patient spontaneously recovered and stomach returned to its normal position and size. Lead poisoning should be taken into consideration in all unexplained cases of gastric dilation.

CT enteroclysis: Multidetector technique (MDCT) versus single-detector technique (SDCT) in patients with suspected small-bowel Crohn’s disease

This study was done to evaluate the diagnostic role of enteroclysis with multidetector computed tomography (MDCT) and single-detector CT (SDCT) in patients affected by small-bowel Crohn's disease. Forty-five patients underwent abdominal SDCT (n=20) or 16-row MDCT (n=25) after administration of methylcellulose by nasojejunal tube. Each examination was assessed for small-bowel distension and site and characteristics of the diseased loops. The two CT techniques were then compared. Results were compared with double-contrast enteroclysis performed in all patients and with ileoscopy performed in 28 patients. In comparison with double-contrast enteroclysis, sensitivity, specificity and diagnostic accuracy were 90%, 71% and 89% for SDCT and 92%, 83% and 90% for MDCT. Ileoscopy confirmed the absence of disease in five patients and the presence of Crohn's disease in 20. Compared with SDCT, MDCT reduced scanning time and respiratory artefacts and permitted better multiplanar reconstructions. MDCT is superior to SDCT because it allows a better spatial resolution and improves depiction of the pathological patterns of Crohn's disease.

Spontaneous intramural intestinal haematoma

An 83-year-old man presented with a 3-day history of progressive abdominal pain and vomiting. He had a 20year history of hypertension and atrial fibrillation andwas taking antihypertensive agents and warfarin. The physical examination showed diffuse abdominal tenderness without rigidity. The routine complete blood count, serum biochemistry profiles were unremarkable except for an increased C reactive protein and prolonged prothrombin time. A plain abdominal radiograph showed distended small bowel loops (Fig. 1). Computed tomography (CT) of the abdomen, without i.v. contrast, showed marked thickening of the wall of the upper jejunum (Fig. 2). The density of the thickened bowel wall ranged from 40 to 60 Hounsfield Units (HU), similar to the density of blood in the abdominal aorta. Anticoagulant-induced intramural intestinal haematomawas diagnosed. The patient received conservative treatment with i.v. fluids and was discharged after7 days.A follow-upabdominalCTscanshowed that the intramural intestinal haematoma had largely resolved (Fig. 3).Hehashadno recurrences and continues todowell. Spontaneous intramural intestinal haematoma is a rare complication of anticoagulant therapy. It is often not suspected clinically and the diagnosis is usually made after abdominal imaging or when exploratory laparotomy is carried out. The non-contrast CT appearance of spontaneous intramural intestinal haematoma was originally described by Plojoux et al. as a hyperdense bowel wall with density ranging from 50 to 80 HU, depending on the time interval between the onset of bleeding and the CT examination. The following CT characteristics should suggest the diagnosis: circumferential wall thickening, intramural hyperdensity, luminal narrowing and intestinal obstruction. In general, conservative therapy is the treatment of choice, whereas surgical intervention is indicated

Laparoscopic Management of a Primary Small Bowel Volvulus

Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.

Volvulus of Gallbladder: Report of a Case

This report describes a 76-year-old female who presented with progressive abdominal pain, nausea and vomiting for 4 days. Abdominal ultrasound and computed tomography of the abdomen and pelvis showed a distended small bowel, ascending colon with collapse of the descending colon. Bowel obstruction was the tentative preoperative diagnosis based on clinical symptoms and imaging studies. Gallbladder volvulus with a gangrenous change was the definite diagnosis following a celiotomy. Cholecystectomy was performed smoothly. The postoperative course was uneventful and the patient was discharged 10 days after surgery. This case highlights the difficulty of preoperative diagnosis for gallbladder volvulus; accurate diagnoses in most cases are made intraoperatively in spite of currently available imaging studies. Prompt management with open or laparoscopic cholecystectomy decreases the mortality rate due to fatal complications resulting from gallbladder rupture.

Colonic perforation caused by anorectal manometry

Dear Editor: A 63-year-old male visited our hospital with a chief complaint of an anal protruding mass. On rectal examination, there were grade III hemorrhoids with partial mucosal prolapse. Anorectal manometry (ARM) was performed in order to inspect the anorectal function. ARM was done with using an eight-channel water-perfused system (TA 6000 Micropulsing®, Gould, Valley View, OH, USA) and a balloon-attached catheter (Zinetics Manometric Catheter®, Medtronic, Copenhagen, Denmark). The manometry results showed paradoxical contraction of the anal sphincter when straining but no other unusual features. During the examination, the patient only expressed a slight discomfort in the lower abdomen. When he arrived at home, he felt lower abdominal pain and had a large amount of hematochezia. The frequency and amount of hematochezia decreased, and at first, he observed this symptom without informing the clinician of it. He visited hospital after 2 days and complained of abdominal distension and nausea. His vital signs were as follows: a blood pressure of 129/ 108, a heart rate of 127 beats per minute, a respiratory rate of 22 breaths per minute, and a temperature of 36.5°C. The abdominal examination was notable for diffuse abdominal tenderness with guarding. The laboratory studies showed a white blood cell count of 13,580/mm, a hemoglobin level of 16.6 g/dl, and a platelet count of 188,000/mm. The plain abdominal films showed distended small bowel loops with air-fluid levels. A computed tomography showed a short segment of wall disruption on the sigmoid colon and a collection of fluid and extraluminal air surrounding the sigmoid colon. He was taken to the operation room for exploration. Exploratory laparotomy through a lower midline incision showed a severely distended small bowel. However, there was no fecal or purulent material throughout the peritoneal cavity. Examination of the sigmoid colon and rectum showed a full-thickness perforation at the level of the rectosigmoid junction. We performed a Hartmann’s procedure, with resection of the sigmoid colon and upper rectum, closure of the rectum beneath the site of perforation, and sigmoid end colostomy. A perforation of about 8 cm in length was measured in the resected specimen. Gas was passed through the stoma on the fourth postoperative day, and the postoperative course was uneventful. Manometry is an objective method of assessing anal sphincter function and it is an important tool for managing defecatory disorders. Manometry has been widely used for investigating patients with fecal incontinence to identify the presence of sensory or muscular defects, as well as to define functional weakness of the internal and/or external anal sphincter. Manometry is also used before performing procedures to document those sphincter functions that may affect continence or require optimizing continence. In addition, manometry has been regard as a safe procedure because there have been no reports on complications or problems while performing manometry. Lee et al. reported that they experienced two cases of colorectal rupture during the measuring the maximum tolerable volume [Lee et al. (1998) Colorectal rupture: an unusual complication of anorectal manometry. Korean J Gastrointest Motil 4:118–122]. Both patients were in their Int J Colorectal Dis (2008) 32:219–220 DOI 10.1007/s00384-007-0312-0

Acute small bowel obstruction as a result of a Meckel's diverticulum encircling the terminal ileum: A case report

BackgroundIn the developed world, small bowel obstruction accounts for 20% of all acute surgical admissions. The aetiology for majority of these cases includes postoperative adhesions and herniae. However, a relatively uncommon cause is a Meckel's diverticulum. Although this diagnosis is primarily reported in the adolescent population, it should also be considered in adults.Case PresentationIn the present report, we present a rare case where a fit and healthy 74-year-old gentleman, with no previous history of abdominal surgery, presented with the cardinal symptoms and signs of small bowel obstruction as the result of a Meckel's diverticulum encircling his terminal ileum. Initial investigations included a supine abdominal x-ray showing dilated loops of small bowel and computerised tomographic imaging of the abdomen, which revealed a stricture in the terminal ileum of unknown aetiology. At laparotomy, multiple loops of distended small bowel were seen from the duodeno-jeujenal junction to the terminal ileum, which was encircled by a Meckel's diverticulum. The Meckel's diverticulum was then divided to release the obstruction, mobilised and subsequently removed. Finally, the small bowel contents were decompressed into the stomach and the nasogastric tube aspirated, before returning the loops of bowel into the abdomen in sequence. The patient made a good postoperative recovery and was discharged home 5 days later.ConclusionThis report highlights the importance of considering a Meckel's diverticulum as a cause of small bowel obstruction in individuals from all age groups and especially in a person with no previous abdominal pathology or surgery.

Small bowel faeces sign in patients without small bowel obstruction

To evaluate frequency and clinical relevance of the 'small bowel faeces' sign (SBFS) on computed tomography (CT) in patients with and without small bowel obstruction (SBO) presenting with acute abdominal or acute abdominal and flank pain. Abdominal CTs of consecutive patients presenting to the emergency department with abdominal or flank pain over a 6 month period were retrospectively reviewed by six radiologists, independently, for the presence of the SBFS. Examinations with positive SBFS were further evaluated in consensus by three radiologists, blinded to the final diagnosis. The small bowel was graded as non-dilated (<2.5 cm) and mildly (2.5-2.9 cm), moderately (3-4 cm) or severely (>4 cm) dilated. The location of SBFS and presence of distal small bowel collapse indicative of SBO was recorded. Imaging findings were subsequently correlated with the final diagnosis via chart review and compared between patients with and without SBO. Of 1642 CT examinations, a positive SBFS was found in 100 (6%) studies. Of 100 patients with a positive SBFS, 32 (32%) had documented SBO. The remaining 68 patients had other non-obstructive diagnoses. SBFS was located in proximal, central, distal and multisegmental bowel loops in one (3.1%), eight (25.0%), 21 (65.6%) and two (6.3%) patients with SBO, and in zero (0%), 10 (14.7%), 53 (77.9%) and five (7.4%) of patients without SBO (p<0.273). The small bowel was non-dilated and mildly, moderately or severely dilated in one (3%), five (16%), 20 (62%) and six (19%) patients with SBO, and in 61(90%), seven (10%), zero (0%) and zero (0%) patients without SBO. Normal or mildly dilated small bowel was seen in all (100%) patients without SBO, but only in six (19%) of 32 patients with SBO (p<0.0001). Moderate or severe small bowel dilatation was seen in 26 (81%) patients with SBO (p<0.0001), but it was absent in patients without SBO. Distal small bowel collapse was found in 27 (84.4%) of 32 patients with SBO, but not in patients without SBO (p<0.0001). A combination of SBFS, moderate or severe small bowel distension and distal collapse was found in 23 (71.9%) patients with SBO (p<0.0001), but was not found in patients without SBO. A SBFS is more frequent in patients presenting with acute abdominal/flank pain without bowel obstruction. When seen in association with moderate or severe small bowel dilatation, a SBFS is significantly more common in patients with SBO. When a SBFS is associated with normal or mildly dilated small bowel, the majority of patients have no bowel obstruction.

Bowel Ischaemia Mimicking: A Gastric Volvulus

A 79 year old woman was transferred to the intensive care unit a week following hemiarthroplasty to the right hip. She complained of epigastric pain and nausea. Examination demonstrated a tender epigastrium but there was no evidence of peritonism. The point we would like to highlight in this case, is not only the way the bowel ischeamia presented, but the approach to repair of a paraoesophageal hernia. On reviewing the literature, there has been no documentation of bowel ischaemia causing distension of the proximal structures to the extent it causes herniation of the stomach through a lax hiatus. This was well demonstrated in this patient as her previous chest radiograph on admission did not show a paraoesophageal hernia. CASE REPORT A 79 year old woman was transferred to the intensive care unit a week following hemiarthroplasty to the right hip. She complained of epigastric pain and nausea. Examination demonstrated a tender epigastrium but there was no evidence of peritonism. Her lactate was 6 mmol/l and a chest radiograph demonstrated an obvious paraoesophageal hernia (Figure 1). Figure 1 Figure 1: Chest radiograph clearly demarcating the boundry of a parapespohageal hernia. The working diagnosis was a gastric volvulus. A nasogastric tube was immediately placed to decompress the stomach to reduce the ischaemia secondary from the distension. Her condition was stabilised and she was taken to theatre for a laparotomy. At surgery, there was necrotic small bowel in the distribution of the superior mesenteric artery as well as patchy necrosis to the transverse colon. There was gross distension of the proximal small bowel with a reducible and viable stomach. The point we would like to highlight in this case, is not only the way the bowel ischeamia presented, but the approach to repair of a paraoesophageal hernia. On reviewing the literature, there has been no documentation of bowel ischaemia causing distension of the proximal structures to the extent it causes herniation of the stomach through a lax hiatus. This was well demonstrated in this patient as her previous chest radiograph on admission did not show a paraoesophageal hernia. There are 2 approaches when considering open repair of a paraoesophageal hernia, a transthoracic or transabdominal route. Both have their associated morbidities and benefits. A transthoracic approach is of value when there is concern of diaphragmatic rupture (delayed presentation) or in a chronic paraoesophageal hernia where there might be adhesion to the lung. It also gives one the choice to extend the incision and convert it to a thorocolaparotomy. A transabdominal Bowel Ischaemia Mimicking: A Gastric Volvulus 2 of 3 approach is of value in the elderly with associated comorbidities and in those with poor pulmonary functions. It is especially of value in the acute setting of a trauma patient suspected of having a diaphragmatic rupture to rule out other intra-abdominal injuries. A transabdominal route was decided in this lady not only due to her age and significant co-morbidities, but also we wanted to perform a safe and expedient operation with minimal impact to her physiological status. In this patient group, we would reduce the stomach, excised the sac, close the crura and perform a gastropexy. The gastropexy usually involves anchoring the fundus to the diaphragm and the greater curvature along the anterior abdominal wall, sufficient enough to allow good closure of the laparotomy wound. A gastrostomy is not performed as there is no added benefit to the above gastropexy. An antireflux procedure is usually performed but is dependent on the patient symptoms as well as the pre-operative oesophageal function tests. In conclusion, one should consider all factors including age, urgency of operation, possibility of diaphragmatic rupture, chronicity of hernia giving rise to adhesions, co-morbid factors and performance status in deciding the approach to surgery. CORRESPONDENCE TO Mr.R.Jeganathan, Thoracic Surgery, Ground Floor West Wing, Royal Victoria Hospital, Grovenor Road, Belfast BT12 6BA N.Ireland, United Kingdom Tel: 0044-2890-632016 / 0044-2890-633345 E-mail: reubenj@hotmail.com

Cine magnetic resonance imaging of the small bowel: comparison of different oral contrast media

To evaluate several substances regarding small bowel distension and contrast on balanced steady-state free precession (bSSFP) cine magnetic resonance (MR) images. Luminal contrast was evaluated in 24 volunteers after oral application of two different contrast agent groups leading to either bright lumen (pineapple, blueberry juice) or dark lumen (tap water, orange juice) on T1-weighted images. Bowel distension was evaluated in 30 patients ingesting either methylcellulose or mannitol solution for limiting intestinal absorption. Fifteen patients with duodeno-jejunal intubation served as the control. Quantitative evaluation included measurement of luminal signal intensities and diameters of four bowel segments, qualitative evaluation assessed luminal contrast and distension on a five-point scale. Quantitative and qualitative evaluation of the four contrast agents revealed no significant differences regarding luminal contrast on bSSFP images. Quantitative evaluation revealed significantly lower (P<0.05) small bowel distension for three out of four segments (qualitative evaluation: two out of four segments) for methylcellulose in comparison to the control. Mannitol was found to be equal to the control. Oral ingestion of tap water or orange juice in combination with mannitol is recommended for cine MR imaging of the small bowel regarding luminal contrast and small bowel distension on bSSFP sequences.