Small Bowel Necrosis Research Articles

An adult case of large defect of small mesenteric hiatal hernia causing small bowel obstruction

BackgroundSmall mesenteric hiatal hernias (SMHHs) are defined as a small group of internal hernias (IHs) that frequently diagnosed in children. However, SMHHs are relatively rare in adults. Bowel loop herniation via an abnormal mesenteric defect can lead to strangulated intestinal obstruction. Congenital SMHHs are commonly observed in pediatric patients, with some cases involving neonatal death.Case presentationA 24-year-old healthy male patient visited our hospital with a 2-day history of a sudden onset lower abdominal pain. He was initially diagnosed with enteritis. However, his symptoms worsened, and he was brought to our hospital. Contrast-enhanced computed tomography (CT) scan showed formation of a closed loop in the small intestine within the pelvis and signs of ischemia. As the patient was diagnosed with small bowel obstruction (SBO) caused by IH, emergency laparoscopic surgery was performed to loosen the obstruction. The patient was found to have ascites and small-bowel necrosis. A part of the small intestine that measured 30 cm was strangulated via a large-diameter defect (17 × 11 cm) in the ileal mesentery. Via a small abdominal incision, the necrotic bowel was resected, and the mesenteric defect was repaired.ConclusionSMHHs are rare in adults, and they should be considered as potential causes of strangulated intestinal obstruction in adults without a history of laparotomy or trauma.

Massive enteric necrosis caused by histiocytic sarcoma embolism: a case report

BackgroundHistiocytic sarcoma (HS) is a rare disease characterized by the presence of neoplastic histiocytes. We herein report an unusual case of HS that caused massive tumor embolism-related transmural necrosis of the small intestine.Case presentationA 64-year-old man presented with multiple nodules in the lungs, bone, mediastinum, and subcutaneous tissues that were incidentally detected on preoperative computed tomography for early transverse colon cancer. Approximately two months later, the patient presented with signs of peritoneal irritation suggestive of small intestinal necrosis. Emergency surgery was performed and the necrotic small intestine was resected. Pathological examination revealed small bowel necrosis due to multifocal HS embolism. The postoperative course was uneventful. The patient was unsuccessfully treated with chemotherapy for HS and died 122 days postoperatively.ConclusionsHS can cause massive enteric necrosis due to tumor embolism. Clinicians should be aware of this rare presentation of HS.

EP112 - An Unusual Case of Seed Bezoars Intestinal Perforation

Abstract Introduction Seed bezoars are a distinct subgroup of phytobezoars, caused by the accumulation of indigestible vegetable or fruit seeds in the intestinal lumen. Intestinal obstruction due to plant seeds is seldom encountered because of their relatively smaller size, and intestinal perforation is even rarer. Case Report We report a case of a 64-year-old hypertensive, diabetic and cardiac patient who came to surgical emergency department with generalized abdominal pain and vomiting for 3 days. She was tachycardiac, tachypneic and hypotensive at the initial presentation. Abdominal examination revealed tense, rigid abdomen with absent bowel sounds. Bilateral air under diaphragm was seen on an erect abdominal radiograph. Laboratory workup showed leukocytosis and metabolic acidosis. Laparotomy was performed after resuscitating the patient. Operative findings revealed gross contamination and gangrenous small bowel starting from about 8 feet distal to DJ flexure till 15 cm proximal to ICJ. There was a 2 x 2 cm perforation about 8.5 feet distal to DJ flexure secondary to obstructed seed bezoar (1 each of apricot, peach, and mango pickle seeds and 4 java plum seeds). Gangrenous small bowel was resected, and loop ileostomy was fashioned. She underwent cardioversion for ventricular tachyarrhythmias during the surgery. Post-operatively, she remained on ventilatory support in ITU but could not survive due to cardiac arrhythmias. Conclusion Although intestinal obstruction and perforation occur rarely due to phytobezoars, this should always be considered in the differential diagnosis, and early therapeutic intervention should be considered in morbid patients.

Vaginal vault dehiscence with small bowel evisceration, bowel necrosis, and intra-abdominal haemorrhage: a case report

Abstract Vaginal vault dehiscence with evisceration is a rare but a potentially life-threatening complication of total hysterectomy that requires prompt recognition, diagnosis, and management. The overall incidence of vaginal vault dehiscence is 0.53%. The mortality rate increases to 5.6% when bowel evisceration is present. We report a case of vaginal vault dehiscence with small bowel evisceration complicated by bowel necrosis and intra-abdominal haemorrhage in a 48-year-old woman following her first sexual intercourse 4 months after her total abdominal hysterectomy.

Two cases of small bowel necrosis due to intussusception secondary to abnormal proliferation of intestinal Peyer’s patches in infants after MMR vaccination

BackgroundIntussusception is one of the most common acute abdominal conditions in pediatric patients, and if left untreated, it may result in intestinal necrosis and even death. The etiology of the disease is unknown and may be related to a variety of factors, and there are only limited reports of small bowel necrosis secondary to abnormal Peyer’s node hyperplasia after MMR vaccination.Case presentationIn this report, we present two infants who had an abnormal proliferation of Peyer’s nodes secondary to intussusception eventually leading to small bowel necrosis after MMR vaccination.ConclusionsIntestinal necrosis and infectious shock are the most common causes of infant mortality, and early detection and management are critical.

Ileo-ileal knot causing acute gangrenous small bowel obstruction: a case report

BackgroundIleo-ileal knotting is a very rare cause of small bowel obstruction, and only a few reports have been published. Small bowel obstruction (SBO) is one of the most common emergency surgical conditions that require urgent evaluation and treatment and is one of the leading causes of emergency surgical admission. There are many causes of SBO that are known in general surgical practice, and these causes are different in the developing and developed worlds.Clinical presentationIn this article, we present a case of acute gangrenous SBO secondary to ileo-ileal knotting in a 37-year-old Ethiopian female patient after she presented with severe abdominal cramp, vomiting, and abdominal distension of 4 hours duration. The patient was operated on intraoperatively; she had gangrenous small bowel obstruction caused by ileo-ileal knotting. Later, the patient was discharged and improved after 12 days of hospital stay.ConclusionIleo-ileal knotting should always be considered in the differential diagnosis of acute small-bowel obstruction. The diagnostic difficulty and the need for urgent treatment of this condition to yield optimal results are discussed.

Uncommon presentation of complicated internal hernia through the appendices epiploicae ring of adhesion: a clinical case study.

Internal hernias are infrequent, yet serious, medical conditions with potentially severe consequences. An internal hernia resulting from an Appendices epiploicae (AE) ring is an especially rare cause, with a mere nine documented instances worldwide. This report presents the case of a 58-year-old male who suffered from an internal hernia originating from an AE ring. The condition led to a gangrenous small bowel, which was treated by laparotomy and resection of the affected segment, followed by primary anastomosis. The post-operative recovery was favorable. Internal hernias, although rare, warrant immediate attention and early intervention to preclude detrimental outcomes, as illustrated in this particular case.

Unenhanced CT-based predictive model to identify small bowel necrosis in patients with mechanical small bowel obstruction

ObjectivesTo investigate the diagnostic value of unenhanced CT in mechanical small bowel obstruction (SBO) with small bowel necrosis, and to establish a predictive model.MethodsFrom May 2017 to December 2021, the patients with mechanical SBO admitted to our hospital were retrospectively collected. Taking pathology-confirmed small bowel necrosis as the gold standard, the experimental group was composed of patients with small bowel necrosis confirmed by pathology, and the control group was composed of patients with no intestinal necrosis confirmed by surgery or successful conservative treatment with no recurrence of intestinal obstruction during 1-month followed-up.ResultsA total of 182 patients were enrolled in this study, 157 patients underwent surgery, of which 35 patients were accompanied with small bowel necrosis and 122 patients were not (33 patients with ischemic findings at surgery without necrosis). Finally, there were 35 patients in the experimental group and 147 patients in the control group. Multivariable logistic regression showed that increased attenuation of small bowel wall (P = 0.002), diffuse mesenteric haziness (P = 0.010), difference of CT value between mesenteric vessel and aorta (P = 0.025) and U-/C-shaped small bowel loop (P = 0.010) were independent risk factors for the diagnosis of mechanical SBO with small bowel necrosis. Through internal verification, the area under curve (AUC) of the predictive model reached 0.886 (95%CI: 0.824–0.947), and the calibration result was moderate.ConclusionMultiple features (increased attenuation of small bowel wall; difference of CT values between mesenteric vessel and aorta; diffuse mesenteric haziness; and U-/C-shaped small bowel loop) of unenhanced CT have clinical value in the diagnosis of mechanical SBO with small bowel necrosis. The predictive model based on these four features could achieve satisfactory efficiency.

A rare case of small bowel gangrene and perforation following high voltage electrical injury

This case is a 42-year-old male with an alleged history of electric shock. About 8 h after the insult, an ulcer in the right iliac fossa increased in size with fecal matter coming out. Contrast-enhanced computed tomography of the abdomen revealed a full thickness anterior abdominal wall defect with prolapse of a segment of the distal ileal loop, showing discontinuous wall and no wall enhancement suggestive of evisceration and perforation of bowel with gangrene.

A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

Idiopathic Small Bowel Volvulus: A Case Report

Idiopathic small bowel volvulus is a rare cause of acute intestinal obstruction by strangulation in adults and is defined by the twisting of a segment of the small bowel around its mesenteric axis with no obvious underlying congenital or acquired cause.
 This article reports the case of a 56-year-old patient, chronic smoker and cannabis user, who was admitted with febrile occlusive syndrome and generalized abdominal contracture.
 The abdominal CT scan showed a distension of the small intestines upstream of a probable small bowel volvulus, associated with signs of digestive distress.
 Surgical exploration revealed a large peritoneal effusion of distressed fluid, with a volvulus of the distal small bowel causing 1.80 m of small bowel and coecum necrosis from 2.20 ADJ without rotational abnormality or docking defect.

Surgical management of necrotising enterocolitis in Sweden: A national cohort study.

Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis.

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Potential for intestinal transplantation after acute mesenteric ischemia in patients aged less than 70 years: A population-based study.

Acute mesenteric ischemia (AMI) has a high mortality rate due to the development of bowel necrosis. Patients are often ruled outside active care if a large proportion of small bowel is necrotic. With the development of treatment for short bowel syndrome (SBS) and intestinal transplantation methods, long-term survival is possible even after extensive small bowel resections. This study aims to assess the incidence of SBS and potentially suitable candidates for intestinal transplantation among patients treated for AMI. This population-based retrospective study comprised patients aged less than 70 years and diagnosed with AMI between January 2006 and October 2020 in Helsinki and Uusimaa health care district, Finland. Altogether, AMI was diagnosed in 711 patients, of whom 133 (19%) were aged below 70. An intervention was performed in 110 (83%) patients. Of these 133 patients, 16 (12%) were ruled outside active treatment due to extensive small bowel necrosis at exploratory laparotomy, of whom 6 (5%) were potentially suitable for intestinal transplantation. Two patients were considered as potential candidates for intestinal transplantation at bowel resection but died of AMI. Nine (7%) patients needed parenteral nutrition after resection, and two of them (2%) developed SBS. Only one patient needed long-term parenteral nutrition after hospital discharge. This patient remained dependent on parenteral nutrition but died before evaluation of intestinal transplantation could be carried out while the other patient was able to return to enteral nutrition. A small number of patients with AMI below 70 years of age are potentially eligible for intestinal transplantation.

Small bowel necrosis after esophagectomy.

The study aimed to fully understand small bowel necrosis, a rare but fatal complication after esophagectomy. Patients who underwent esophagectomy for esophageal cancer at the Fudan University Shanghai Cancer Center from January 2013 to December 2021 were retrospectively reviewed. Clinical information on the demographics, presenting features, and outcomes of the cases were collected. Of the 6607 patients during the study period, 11 (0.2%) underwent reoperation due to bowel necrosis, including nine males (81.8%) and two females (18.2%). Among them, eight cases (72.7%) had hypertension and seven (63.6%) suffered from lower thoracic esophageal cancer. Eight (72.7%) and three (27.3%) patients underwent the Ivor-Lewis and McKewon procedures, respectively. Jejunostomy was performed in nine patients (81.8%). The first signs of bowel necrosis appeared within 5 days after esophagectomy. Abdominal distension and deteriorating renal function were observed in seven patients (63.6%). There was no evidence of mesenteric vascular occlusion in any of the 11 cases, except for the hepatic portal venous gas found in seven patients on the computed tomography (CT) scan. Eight (72.7%) of the 11 patients underwent reoperation within 24 h due to the onset of the first symptoms. Eight (72.7%) had ileal necrosis, and three (27.3%) died. Close attention should be paid to patients with abdominal distension, renal function damage, and portal hepatic venous gas after esophagectomy. These patients may suffer from small bowel necrosis, which may result in rapid disease progression. Exploratory laparotomy and bowel resection are effective treatments for such patients.

OGC P18 Feeding jejunostomy complications after oesophagectomy: a quality improvement project at a tertiary referral centre

Abstract Background A feeding jejunostomy is one method to provide adequate nutrition after oesophagectomy. This bypasses the anastomosis allowing healing before oral feeding resumes. However, routinely using feeding jejunostomies may not be appropriate for patients within an Enhanced Recovery After Surgery protocol due to complications. Feeding jejunostomies have 3–61% morbidity, with mechanical (i.e tube dislodgement) and non-mechanical (i.e. site infection) complications plus associated increased length of stay. The local standard after oesophagectomy is routine feeding jejunostomy placement. However, selective, rather than routine feeding jejunostomy placement may therefore be warranted. Aim Conduct a quality improvement project addressing the local feeding jejunostomy complication rate after oesophagectomy. Methods Cycle 1: A review of oesophagectomies between 2018–2021 assessing complications using the Clavien-Dindo classification. An existing database of oesophagectomies was screened for patients undergoing concurrent feeding jejunostomy insertion. Patients ≥18 were included, whilst any indication for oesophagectomy was included. Patients lacking information on type and bore of jejunostomy tube inserted were excluded. Demographics, jejunstomy tube type and bore, complication and Clavien-Dindo grade of complication were recorded. The Charlson comorbidity score of each patient was determined to help find a population at risk. Intervention: Findings to be presented at a departmental audit meeting, with patient risk stratification to identify a cohort at risk. Cycle 2: re-audit (July 2022 - July 2023) as per cycle 1 after presentation. Improvement = fewer jejunostomy-specific complications. Results 110 patients were included, with a median age of 65.5 (IQR 61.0–72.0). 81.8% patients (n=90) sustained a complication, mostly Clavien-Dindo grade II. Jejunostomy-specific complications occurred in 21.8% patients (n=24), with the commonest jejunostomy-specific complication being a leak (44.8%). 4 ‘major’ (Clavien-Dindo ≥III) jejunostomy-specific complications were reported. No ischaemic small bowel necrosis was reported, significantly less than a prior audit (0.0% vs. 3.74%, p=0.029). Demographics/ Charlson comorbidity score, jejunostomy type inserted (JJ tube, 15F or 9F) and jejunostomy insertion method (open/ laparoscopic) did not impact overall or major feeding jejunostomy-specific complication rate. Conclusions This first cycle agrees with the reported complication rate in the literature. Though a population at risk could not be determined, reviewing local non-specialist centres may aid this, to reduce future complications. The literature would support a more selective approach to feeding jejunostomy insertion and as such this should be taken to reduce post-insertion complications. Continued prominent advice regarding inotropes may prevent ischaemic bowel. We aim to introduce clear warnings to the local ERAS protocol over the concurrent use of jejunostomy feed and inotropes, whilst electronic warnings flagging concurrent jejunostomy feed and inotrope prescribing are being worked upon. Moreover, poor hospital coding of jejunostomies may have limited the cohort, preventing determining a cohort at risk of feeding jejunostomy insertion.

Superior mesenteric venous thrombosis presenting with hematemesis: a case report

The superior mesenteric vein (SMV) is one of the two tributaries to the portal vein, which is the main pre- hepatic drainage channel of the splanchnic circulation. Venous thrombosis in the SMV is one of the rare causes of splanchnic ischemic syndrome. Clinical presentation is often vague abdominal symptoms. It seldom presents with hematemesis, which may further confound diagnosis, thereby increasing the risk of poor outcomes. This case highlights an otherwise healthy 31-year-old woman, who presenting at a tertiary hospital in Nairobi with a 2-day history of epigastric pain and copious hematemesis. She had been treated for Helicobacter pylori gastritis 2 months prior. Common differentials were considered. However, with normal esophagogastroduodenoscopy findings and dark- colored fluid sequestered in the upper gastrointestinal tract, mesenteric venous congestion with associated small bowel ischemia was suspected. Three-phase abdominal computed tomography angiogram confirmed proximal superior mesenteric venous thrombosis extending into the portal vein confluence. Associated small bowel necrosis was suspected, and surgery involving resection and primary ileo-jejunal anastomosis was performed. Post-operative 2-week parenteral nutrition and anticoagulation were administered. The patient was discharged after 3 weeks of hospitalization and remains in excellent condition.

Assessment of Outcome of and Factors Associated with Gangrenous Small Bowel Obstruction

1.1. Background: small bowel obstructions account for 15% of hospital admissions for acute abdominal complaints and up to 30% of these patients will require operative intervention. Ethiopia is one of the countries where intestinal obstruction is a major cause of morbidity and mortality. 1.2. Objectives: To assess outcomeand factors associated with gangrenous small bowel obstruction among patients admitted to surgical ward of Hiwot Fana Specialized University Hospital from January 1, 2016-December 31, 2020. 1.3. Methods: A retrospective cross-sectional study was conducted on all patients with gangrenous small bowel obstruction admitted to surgical ward of Hiwot Fana Specialized University Hospital from January1, 2016-December 31,2020. For this study, a customized data abstraction form was developed for data capturing from medical records of the patients. The captured data was coded, entered to EpiINFo and exported to statistical package for social sciences software, version 22.0. for analysis. To summarize demographic and clinical characteristics of the patients considered for this study, descriptive statistics such as percent and frequency was employed. All variables with P-value < 0.3, during bi-variable analyses were considered for multivariable logistic regression analyses. Odds ratio along with 95% Confidence interval were estimated to measure the strength of the association. Level of statistical significance was declared at p value less or equal to 0.05. 1.4. Results: A total of 91patiens were included and finally analyzed in this study. From these 52 (57.1%) patients have un favorable surgical outcomes of gangrenous Small bowel obstruction. Of the 52 patients with unfavorable outcome, the most common postoperative complication occurred was anastomotic leak (29.5) followed by surgical site infection (25.5%) and pneumonia (23.6%) . A total of 15 postoperative deaths were also documented as unfavorable surgical management outcomes of gangrenous Small bowel obstruction. Three factors including duration of illness before surgery, length of hospital stay after surgery and shock at presentation were significantly associated withthe surgical management outcome of gangrenous Small Bowel Obstruction. 1.5. Conclusion: In this study, the majority of patients had unfavorable surgical management outcomes of gangrenous Small Bowel Obstruction, however the proportion of patients with favorable outcomes was considerable. Thus, designing a strategy that address the factors associated with unfavorable outcomes could be helpful to further increase the likelihood of favorable surgical management outcomes of gangrenous Small Bowel Obstruction.

Precise diagnosis of acute mesenteric ischemia using indocyanine green imaging prevents small bowel resection: A case report.

IntroductionAcute mesenteric ischemia (AMI) is a rare life-threatening condition that causes intestinal necrosis. Prompt intervention is essential to mitigate high mortality. In this report, we describe a case of AMI where precise diagnosis using indocyanine green (ICG) imaging to confirm sufficient bowel perfusion and viability, helped in preventing intestinal resection.Presentation of caseA 91-year-old male was diagnosed with AMI associated with superior mesenteric artery thrombosis using computed tomography and underwent exploratory laparotomy. Under white light, there was no outward evidence of small-bowel necrosis. Hence, ICG was used to confirm adequate bowel perfusion and viability. The operation was terminated without resection of the small intestine. When anticoagulation therapy was initiated postoperatively, the thrombus subsided. Although the patient had no subsequent recurrence, he died of dysphagic pneumonia two months after the surgery.DiscussionPhysicians often choose to perform trial laparotomy to diagnose intestinal ischemia due to AMI.However, it was difficult to assess the viability of the entire intestinal tract using white light alone, and the introduction of ICG in the evaluation of intestinal perfusion will facilitate the identification and objective evaluation of the intestinal ischemic zone. There have been few reports on application of fluorescent-guided determination of the viable zone of the small intestine, which will help surgeons to make precise diagnosis.ConclusionThis case demonstrates ICG fluorescence imaging as a useful method for objectively assessing bowel viability.

Severe small intestinal bacterial overgrowth syndrome after jejunal feeding requiring surgical intervention: a case report and review of the literature

BackgroundSmall intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention.Case presentationA 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO.ConclusionsPresentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.