Small Bowel Necrosis Research Articles

Biliary Stone Small Bowel Obstruction and Gangrene Post ERCP

Biliary Stone Small Bowel Obstruction and Gangrene Post ERCP

Hybrid revascularization of the superior mesenteric artery in a patient with acute mesenteric ischemia and an occluded aorta

A 60-year-old man with a history of chronic mesenteric ischemia and chronic aortic occlusion presented with diffuse abdominal pain. On admission he was hypotensive and acidotic. A computed tomography angiogram revealed occlusion of his entire infrarenal aorta to the femoral arteries, an occluded celiac trunk and inferior mesenteric artery (previously stented), and severe stenosis of his superior mesenteric artery (SMA; A). He underwent explorative laparotomy, during which three segments of gangrenous small bowel were resected. The rest of the small bowel appeared ischemic but viable. Endovascular attempts to recanalize the SMA were unsuccessful. Owing to his hemodynamic instability and metabolic status, we performed a hybrid procedure. Under fluoroscopy, the thrombosed aorta was punctured. A wire and catheter were introduced into the thoracic aorta. After intraluminal position was confirmed, a 14F peel-away sheath was placed. A 6-mm hybrid vascular graft (W. L. Gore and Associates, Flagstaff, Ariz) was introduced (10-cm nitinol reinforced section and a 50-cm nonringed graft). The sheath was removed and the visible end of the nitinol section, which protruded through the aorta, was secured with stitches to the aortic wall. (model, B) An 8-mm ringed polytetrafluoroethylene graft was placed over the 6-mm graft to prevent kinking and the graft was anastomosed to the SMA. The remaining bowel improved immediately. Postoperative computed tomography angiography showed the hybrid graft was patent, with filling of the SMA (C and D/Cover).

A Case of Curative Resection of Massive Small Bowel Gangrene at Gandaki Medical College Teaching Hospital, Pokhara, Nepal

A Case of Curative Resection of Massive Small Bowel Gangrene at Gandaki Medical College Teaching Hospital, Pokhara, Nepal

PTH-237 Differing risk of small bowel necrosis in patients undergoing oesophagectomy and total gastrfectomy with feeding jejunostomy placement: Abstract PTH-237 Table 1

Introduction Placement of feeding jejunostomy at the time of oesophagectomy or total gastrectomy has become standard of care at most UK centres. Review of the literature reveals isolated reports of small bowel necrosis, although the frequency of this problem is unclear. Further, it is unclear whether the risk of small bowel problems is similar for patients after gastrectomy as those after oesophagectomy. The aim of this study was to ascertain the frequency of small bowel problems in a cohort of patients undergoing oesophagogastric surgery. Method Retrospective review of patients undergoing oesophagogastric resection for cancer during the years 2009–2014. Results The study population comprised 325 patients undergoing oesophagogastric resection with jejunostomy placement (255 oesophagectomy, 70 total gastrectomy). Five patients undergoing total gastrectomy developed small bowel necrosis (5/70, 7%), while this was not observed in any patient undergoing oesophagectomy (0/255, 0%). The table details the time of this complication and the associated factors. All five patients developed small bowel necrosis after initial discharge from intensive care unit to the surgical ward. All patients required laparotomy with small bowel resection with double barrel stoma formation, parenteral nutrition and subsequent reconstruction (6–8 weeks later). Only one patient had a leukocytosis on the day of diagnosis. No laboratory abnormalities were identified in the preceding 24 hr in the other four patients. One patient dies from multi-organ failure, the remaining four were discharged home. Conclusion Small bowel necrosis and perforation is a serious and life threatening complication of feeding jejunostomy. In our cohort, it was observed exclusively in patients who had undergone total gastrectomy. There were very few antecedent signs of a problem. All patients required laparotomy and small bowel resection. Disclosure of interest None Declared.

WITHDRAWN: An interesting case of retrocaecal internal herniation causing small bowel obstruction

Herein, we report a case of an elderly woman with multiple co-morbidities who presented with clinical findings indicative of small bowel obstruction (SBO), which was confirmed on a CT scan. She underwent a laparotomy, which demonstrated herniation of small bowel into a retrocaecal position. Gangrenous small bowel was resected and primary anastomosis performed. After a brief period on the High Dependency Unit (HDU), she returned to the ward and was discharged back to the community.

MP79-08 SURGICAL MANAGEMENT OF RENAL ARTERY STENOSIS DUE TO TAKAYASU'S AORTOARTERITIS:RESULTS FROM A TERTIARY CARE CENTER IN SOUTH INDIA

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-08 SURGICAL MANAGEMENT OF RENAL ARTERY STENOSIS DUE TO TAKAYASU'S AORTOARTERITIS:RESULTS FROM A TERTIARY CARE CENTER IN SOUTH INDIA John S. Banerji, Antony Devasia, Nitin S. Kekre, Ninan K. Chacko, and Ganesh Gopalakrishnan John S. BanerjiJohn S. Banerji More articles by this author , Antony DevasiaAntony Devasia More articles by this author , Nitin S. KekreNitin S. Kekre More articles by this author , Ninan K. ChackoNinan K. Chacko More articles by this author , and Ganesh GopalakrishnanGanesh Gopalakrishnan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2865AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Takayasu's arteritis is a rare disease with significant morbidity amongst young patients, with a predilection to involve renal vasculature. As literature regarding long term outcome is sparse, we decided to elucidate our experience with treatment for renal artery stenosis in this group. METHODS After institutional review board clearance, electronic records were reviewed retrospectively. Patients with renal artery stenosis, secondary to Takayasu's arteritis, as diagnosed by American College of Rheumatology criteria (1990) were included, over a 10 year period (2000- 2010). Data on presentation, antihypertensive usage, renal function and intra and post operative complications were described. RESULTS There were 48 patients with renal artery stenosis, during the 10 year period, with a female preponderance (F: M =7:1). Mean ages were 27 years in female patients and 33.7 years in males. Unilateral renal artery stenosis was present in 8 subjects; the rest had bilateral disease. All had hypertension, and 72% (35/48) presented with headache as the predominant symptom. More than half (54%; 26/48) had fever. Clinically audible renal bruit was present in less than 10% (4/48). At presentation, 6 patients had creatinine levels more than 2 mg % (Range 2-4.5 mg %). Inflammatory markers viz. Erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) were elevated in 79% (38/48) and 91% (32/35) respectively. Angiogram revealed aortic arch involvement in 88% (37/42), with aorta and renal vessels involved in isolation in 5. Prior angioplasty with stenting was performed in 8 patients, with 2 failures. 10 patients underwent nephrectomy. 38 underwent renal auto transplantation, with bench surgery in 4 who had multiple vessels and technically demanding renal vasculature. The mean renal size was 8.8 cm. Perioperative complications included post op haemorrhage (5/48), and thrombosis of graft in 1 patient, leading to graft loss. One patient developed abdominal compartment syndrome leading to small bowel gangrene and death. Follow up was available for 38 of the 48 patients. The average follow up was 48 months. In the group with elevated creatinine (>2 mg %), all but one had a significant fall in creatinine. Inflammatory markers returned to normal in a majority of the patients. There was a decreased need for antihypertensive in 78% (30/38). CONCLUSIONS Renal revascularization helps in preserving renal function in patients with Aortoarteritis. There is an appreciable decrease in the use of antihypertensives with revascularization. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1013 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information John S. Banerji More articles by this author Antony Devasia More articles by this author Nitin S. Kekre More articles by this author Ninan K. Chacko More articles by this author Ganesh Gopalakrishnan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

TRANSOMENTAL HERNIATION CAUSING ACUTE INTESTINAL OBSTRUCTION

Internal Herniation is an unusual cause of intestinal obstruction 1 first described by Steinke 2 in 1932 The incidence of Internal Hernia amongst Acute Intestinal Obstruction in the adult population has been reported as around 0.6-5.8% 3 and amongst these, transomental hernias account for about 1- 8.9%. 4,5 They can be congenital or acquired (Trauma, inflammation, age related atrophy.2,6) There are multiple sites where herniation can occur. There are no specific investigations to rule out internal hernias and should be considered a possibility in cases of acute intestinal obstruction. This patient was operated on early after presentation of acute symptoms and so recovered without any immediate or late post-operative complications. CASE REPORT : A 55 years old male was received in the casualty with the complaints of abdominal pain, distension with nausea and vomiting since 2 days. He had not passed stools since 2 days and flatus since the previous evening. He is a known Hypertensive on irregular treatment. Physical Examination revealed mild abdominal distension, palpable small bowel loops and a collapsed rectum with faecal matter. Bowel sounds were hyperactive with Borborygmi sounds. Patient was afebrile, Pulse rate - 64/ min B.P - 170/100 mm hg. Serum creatinine levels were raised. The first plain abdominal X-ray revealed only intestinal gas with distended bowel loops in upper left quadrant. A Ryles tube was inserted which drained around 500 ml of bilious fluid after which abdominal girth deceased from 73 to 67 cm. Plain CT abdomen revealed pneumomediastinum, an over distended stomach with the tip of the Ryles tube in the Left Iliac fossa, multiple dilated small bowel loops with a segmental collapse in the Ileum. There was a thin rim of air under the Left dome of the diaphragm but there were no clinical signs of hollow viscous perforation, only subacute intestinal obstruction. The patient was kept under observation and was conservatively managed for 2 days in which period, the vitals were stable, there was maintenance of saturation, there was no abdominal guarding or rigidity and no increase in abdominal girth. After 2 days, repeat X-ray and CT abdomen still showed dilated small bowel loops with multiple air fluid levels and signs of impending small bowel gangrene and was thus shifted for an Emergency Open Explorative Laparotomy. There was an internal herniation of distal end of stomach, gastrocolic omentum, gastroduodenum and Rt. 2/3 rds of the transverse colon which appeared to be abnormally pulled subhepatically, but could not be reduced. The C-loop of the duodenum with the head of pancreas was in fact an S-loop, with pancreas occupying one convexity. The DJ flexure was in the normal position. The caecum was in the Rt. Iliac fossa ruling out malrotation. About 10 cm of the jejunum, the entire ileum was occupying the Rt. Side of the abdominal cavity and irreducible. Part of the ileal segment was congested. There were no signs of gangrene. The duodenum was kocherised and reduced through the lesser omentum where

English

Superior mesenteric venous thrombosis is a rare & life threatening condition. We report a case of 18 years old boy presented to emergency department with pain abdomen, fever, Melena for almost week duration. Bowel sounds were absent since two days. With a preoperative diagnosis of peritonitis Patient was taken up for emergency laparotomy. Resection of gangrenous small bowel and end to end anastomosis was done. Intra operatively thrombus in SMV was found. Coagulation profile was normal except for elevated homocystine levels. Early postoperative period was stormy. Patient was started on LMV Heparin from day -1. Pregangrenous changes were seen in contrast CT abdomen on Day-4. We managed conservatively with anticoagulation therapy in the postoperative period. Pregangrenous changes disappeared with conservative management. Patient was shifted to oral warfarin and discharged on 3rd week. Follow up Doppler USG abdomen revealed a portal vein of normal size & caliber with no evidence of thrombus. On postoperative follow up for one year, patient is doing well. Hyperhomocycteinemia is an independent predisposing factor to superior mesenteric venous thrombus.

Unusual case of right iliac fossa pain: A case report

Right iliac fossa pain does not always mean acute appendicitis even though it is the most common etiology. We report a rare case where on clinical grounds patient was diagnosed to have acute appendicitis which on diagnostic laparoscopy turned out to be gangrenous small bowel secondary to a band causing constriction and compression.

Physiologic changes with abdominal wall reconstruction in a porcine abdominal compartment syndrome model.

Abdominal compartment syndrome (ACS) is a severe complication of ventral hernia repair. The aims of this study were to investigate the effects of intra-abdominal pressure on the physiologic changes of abdominal wall reconstruction and component separation in a porcine model. Ventral hernia repair (VHR) was simulated by abdominal fascial imbrication of a 10 × 15 cm defect in 45 Yorkshire pigs assigned to five experimental groups. ACS was simulated by a Stryker endoscopy insufflator with intra-abdominal pressure elevated to 20 mmHg in two groups. Component separation was performed in one of these groups and in one group without ACS. Physiological parameters were measured before and after the procedures and monitored for 4 h. The animals were euthanized for histologic analysis of organ damage. VHR led to an increase in intra-abdominal pressure, bladder pressure, and central venous pressure by an average of 14.89, 13.93, and 14.69 mmHg (p < 0.001) in all animals. Component separation was performed in 25 animals and the three pressures reduced by 9.11, 8.00, 7.89 mmHg (p < 0.001). ACS correlated with higher percentages of large and small bowel necrosis compared to groups without abdominal compartment syndrome. The results confirm that primary repair of large abdominal wall defects leads to increased intra-abdominal pressure, which can be reduced with component separation. In animals with ACS, component separation may reduce the risk of organ damage. Central venous pressure, bladder pressure, and other physiologic parameters accurately correlated with elevated intra-abdominal pressure and may have utility as markers for diagnosis of ACS.

The length of necrosis and renal insufficiency predict the outcome of acute mesenteric ischemia

Acute mesenteric ischemia (AMI) is a potentially life-threatening condition because of its diagnostic difficulty, operative challenges, and comorbidities a patient may have. The aim of this study was to identify factors associated with adverse outcomes in patients with AMI. The hospital records and clinical data of all patients with AMI were reviewed for a recent 4-year period. Clinical outcomes and factors influencing mortality were analyzed. Included in the study were 104 patients (46 females and 58 males) with an overall mean age of 66 ± 13.4 years. The cause of AMI was arterial pathology in 74 (71%) patients, venous thrombosis in 15 (14%) patients, and nonocclusive ischemia in 12 (12%) patients. Abdominal pain was the most common presenting symptom (97% of patients). The 30-day mortality rate was 66%. Univariate analysis showed that mortality was associated with renal insufficiency (p = 0.004), an age greater than 70 years (p = 0.02), the presence of comorbidities (p = 0.001), a leukocyte count greater than 18,000/mL (p = 0.04), and small bowel necrosis of more than 100 cm (p < 0.0001). Logistic regression analysis showed that independent predictors of mortality were small bowel necrosis of more than 100 cm (p = 0.002) and a serum creatinine level greater than 2 mg/dL (p = 0.04). The length of the necrosis and renal insufficiency are the primary factors that result in a poor outcome in AMI patients. Prompt diagnostic evaluation and early therapeutic interventions may help to prevent the development of these fatal predictors.

A sudden death of a prisoner: A rare case of adult presentation of Bochdalec hernia

Mostly diaphragmatic hernias are due to congenital or secondary to a traumatic rupture of the diaphragm. From this the incidence of congenital diaphragmatic hernias varies from 1: 2000 to 1: 5000 live births. Bochdalec hernia which is the commonest type, accounts for 75-85% of it. This condition is diagnosed antenatally or neonatally, only 5% are presented after neonatal period. We report a rare case of asymptomatic congenital Bochdalec hernia in an adult male prisoner who had died in the prison cell. A 26 year old male was brought dead to a tertiary care hospital where the prison officers stated that the deceased had a sudden attack of respiratory distress and collapsed. Post mortem examination revealed a left sided diaphragmatic hernia with collapsed left lung, mediastinal shift to the right and gangrenous small bowel in the chest cavity. Cause of death was ascertained as acute respiratory distress due to mediastinal shift due to strangulated diaphragmatic hernia. Congenital diaphragmatic hernia in an adult is a diagnostic challenge. The diagnosis should be considered in patients presenting with acute chest or abdominal pain or with chronic vague inconsistent cardio respiratory and abdominal symptoms. DOI: http://dx.doi.org/10.4038/mljsl.v1i1.7276 Medico-Legal Journal of Sri Lanka 2011; 1(1), Jan-April : 49-51

Spontaneous intra-abdominal bleed following oral anticoagulant therapy

With expanding avenues of oral anti-coagulant (OAC) use, the complications associated with it are also increasing. The incidence of hemorrhagic complications following oral anticoagulation varies between 3 and 48%.1,2 Spontaneous intra-abdominal hemorrhage associated with oral anticoagulant may present as an acute abdominal condition. The earliest such case was reported in 1953.3 Bleeding may occur into the lumen, wall or mesentery of the bowel, retroperitoneum, into or from solid viscera and into abdominal wall.4 We report a case of spontaneous mesenteric hematoma with adjacent small bowel gangrene in a patient on oral anticoagulation.

English

INTRODUCTION: Gall Bladder perforation with superior mesenteric artery thrombosis causing midgut gangrene are two different pathologies occurring in a patient at same time presenting as an acute abdomen is a rare case. There is no such case reported in the literature of these two different diseases occurring together at a time in a patient. Incidence of isolated Gall Bladder perforation is reported as 3 % in cases of acute cholecystitis with mortality ranging from 12 to 16%1. Superior mesenteric artery ischemia is due to sudden hypoperfusion of small intestine leading eventually to small bowel gangrene. Acute mesenteric ischemia is a lethal disease due to delay in diagnosis by virtue of its nonspecific clinical presentation. Incidence of both the pathologies in a single patient has not been documented till date, however awareness of condition with high index of suspicion and early intervention is needed as emphasized in our case.

A spontaneous strangulated transomental hernia: Prospective and retrospective multi-detector computed tomography findings

Transomental hernias are among the rarest type of all internal hernias which overall account for less than 6% of small bowel obstructions. Most transomental hernias occurring in adults are either iatrogenic or post-traumatic. More rarely, a spontaneous herniation of small bowel loops may result from senile atrophy of the omentum. We report a case of an 86-year-old male who presented with signs and symptoms of small bowel obstruction but had no past surgical or traumatic abdominal history. At contrast-enhanced multi-detector row computed tomography (CT), a cluster of fluid-filled dilated small bowel loops could be appreciated in the left flank, with associated signs of bowel wall ischemia. Swirling of the mesenteric vessels could also be appreciated and CT findings were prospectively considered consistent with a strangulated small bowel volvulus. At laparotomy, no derotation had to be performed but up to 100 cm of gangrenous small bowel loops had to be resected because of a transomental hernia through a small defect in the left part of the greater omentum. Retrospective reading of CT images was performed and findings suggestive of transomental herniation could then be appreciated.

Superior Mesenteric Vein Thrombosis as a complication following Jejunal lymphoma resection: A Case Report

We report a 65 year old female who presented with Left iliac fossa mass for three months with pain for ten days. Ultrasound and CT scans have revealed a lymphoma involving the descending colon. Colonoscopy was normal. At mini laparotomy, the mass was found to be arising from jejunum, with impending obstruction. A Jejunal resection was carried out. Following stable first three post-operative days, the patient developed septicemia. Review CT scan revealed, non-perfused, gangrenous bowel. At relook laparotomy, there was extensive small bowel gangrene along the drainage territories of Superior mesenteric vein. Patient succumbed to septic shock on fourth post-operative day.

Mean platelet volume as a potential prognostic marker in patients with acute mesenteric ischemia–retrospective study

IntroductionWe investigated prognostic parameters of patients who underwent surgical intervention for acute mesenteric ischemia by evaluating demographic characteristics and laboratory data on admission.MethodsThe hospital records of 30 patients who underwent surgical interventions due to acute mesenteric ischemia between January 2008 and December 2012, were reviewed retrospectively. The records were investigated with regard to demographic data, the presence of co-morbid diseases, presenting complaints, time elapsed between symptom onset and hospital admission, laboratory findings at admission, findings at surgical exploration, surgical methods used, and treatment outcomes. The patients were divided into two groups, according to death (Group 1) or survival (Group 2), and the two groups were compared in terms of the specified parameters.ResultsOf the patients, 15 were male (50%) and 15 female (50%); their mean age was 71.4 (29–94) years. Abdominal pain was the chief complaint in all patients (100%) and mean time from pain onset to hospital admission was 21 (1–72) h. In abdominal exploration, total small bowel (SB) ischemia and necrosis was found in 6 (20%) patients and other patients had subtotal SB, segmental SB, segmental SB with colon, or isolated colon ischemia. Treatment in 15 patients (50%) ended in mortality. Mean age (p = 0.038), urea (p = 0.002), AST (p < 0.001), ALT (p < 0.001), mean platelet volume (MPV; p = 0.002), and amylase (p = 0.022) levels in Group 1 were significantly higher versus Group 2, whereas Ca (p = 0.024) and albumin (p = 0.002) levels were significantly lower.ConclusionsIn this study, unlike other parameters that have been shown to be of prognostic significance in mesenteric ischemia, MPV values at presentation were higher among non-survivors than survivors.

Gastroenteropatic neuroendocrine tumors: Multidisciplinary approach in therapy and influence of tailored therapy for prognosis of patients

Introduction: Gastroenteropancreatic neuroendocrine tumors (GEP-NET) are classified on the basis of hormonal activity of tumor cells to functional and non-functional tumors. Therapy of well differentiated NETs includes surgical procedures, debulking of tumor mass, biotherapy and peptide receptor radionuclide therapy. Multidisciplinary approach in diagnostic and therapy leads to prolongation of survival. Aim of the study: Analysis of therapeutic modalities in group of patients with well differentiated gastroenteropatic neuroendocrine tumors and influence of tailored therapy for prognosis of patients. Characteristics of patients: In our department we followed up in period from 1.1.2007 to 31.3.2013 65 pts (21 men/44 women) with well differentiated GEP neuroendocrine tumors. Primary localisation was: stomach — 6 times, pancreas — 9×, duodenum — 1×, jejunum — 4×, appendix — 8×, ileum — 26×, rectum — 7×, unknown primary — 4×. On the base of histomorphological diagnosis 47 patients belonged to WHO I. group — very well differentiated neuroendocrine tumors, and 18 pts to WHO II. group — well differentiated neuroendocrine carcinomas. Metastatic disease was affirmed in 36 patients in time of diagnosis. In all patients chromogranin A, urine level of 5-HIAA, hormonal analysis were examined. Besides ultrasound, endoscopy, computer tomography also Octreoscan was performed. Carcinoid syndrome was present in 27 patients: in 23 pts primary tumors were localised in midgut, in 4 pts we did not find the primary tumor. In our group 9 patients had neuroendocrine tumor of pancreas, 4 of them were functional: 2× overproduction of calcitonine, 1× of gastrin,1× of insulin. Therapy: A. Surgical treatment: Resection of primary tumor and debulking of metastases was performed in 56 pts, in 5 pts with pancreatic tumor resection was not possible due to invasion of tumor mass to surrounding tissue and vessels. In 4 patients with unknown primary surgical treatment was not performed. B. Biological treatment with long acting somatostatin analogues was indicated in 37 pts, 4 pts are treated also with m-tor inhibitors. Biotherapy with somatostatin analogues reduced symptoms of hormonal activity (decrease of 5-HIAA in urine) and brought on stabilisation of disease in most of patients. C. Peptide receptor radionuclide therapy (PRRT) was indicated in 8 pts, 4 of them with nonresectable neuroendocrine carcinoma of pancreas. In 6 of patients PRRT with 90 Ytrium–DOTA-octreotid and in 2 patients with 123 I-MIBG. Reduction of tumor volume was noticed. In period of follow up 8 patients died. Reasons of death: in 2 pts right side heart failure due to fibrosis of endocardium, in 1 patient — small bowel necrosis due to desmoplastic reaction of mesenterium, in 4 patient — malignant cachexia, in 1 patient — carcinoid crisis. Conclusion: Patients with GEP-NETs demand on multidisciplinary approach in therapy. Surgical procedure, biological therapy with somatostatin analogues, m-tor inhibitors and PRRT in patients with well differentiated neuroendocrine tumors markedly contribute to prolongation of survival of patients and also to enhancement quality of their life. We supposed that early combination treatment has high influence for best survival of patients with metastatic disease.

English

Lymphangiomas are rare tumours of lymphatic vessels, most commonly found in children. We present the unusual case of small bowel obstruction caused by benign lymphangioma of Jejunal mesentery in a young man. KEY WORD: Lymphangioma: Jejunal mesentery. INTRODUCTION: Lymphangiomas are no longer considered to be truly neoplastic but rather may be the result of developmental failure of the original lymphatico-venous system. Three forms of lymphangioma are described: (i) Capillary lymphangioma, (ii) Cavernous lymphangioma, (iii) Cystic lymphangioma. They consist of numerous small or large, thin walled lymphatic spaces. Approximately 50% of the lesions have an associated haemangiomatous element. Lymphangioma are rare benign tumors. They are preferentially located in head, neck and axilla in children. However lymphangiomas in the peritoneal cavity are extremely rare, particularly in adults. This report describes a case of an adult with a large lymphangioma of the jejunal mesentery. CASE REPORT: A 22 year old man was admitted to hospital with small bowel obstruction. On examination - The Abdomen was distended, with a palpable vague lump .It was presumed that his condition was caused by obstruction. X-ray F.P.A.-showed multiple air fluid levels. USG Abdomen-showed a large multilocular solid mass with obscure margins. CECT/MRI of Abdomen was advised, which were not done. Emergency Exploratory Laparotomy was performed. At operation he was found to have a large multiloculated cystic cum solid mass measuring 20cm x 15cm in the mesentery of the small bowel approximately 3 feet from the duodeno-jejunal flexure. The mesentery had undergone torsion through 180 around the mass resulting in obstruction and gangrene of the small bowel. The torsion was reduced and the gangrenous small bowel (upto Ileo-Caecal Junction), and mesenteric lesion were resected (Figure). An Ileo transverse anastomosis was done. Histology showed this to be a benign lymphangioma of the small bowel mesentery with complete excision of the tumour. The tumour consisted of multiple cysts measuring up to 5 cm in diameter separated by fibrous or fibro muscular walls. The lymphangioma extended into the bowel wall, with increased lymphangiomatous spaces particularly prominent in the submucosa.

Outcomes following “rescue” superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients

Therapeutic angioembolization is a relatively new "rescue treatment" modality for gastrointestinal hemorrhage (GIH) for unstable patients who fail primary treatment approaches; however, the effectiveness of this treatment and the incidence of ischemic necrosis following embolization for acute GIH are poorly described. The purpose of this study was to evaluate the effectiveness and safety of "rescue" transcatheter superselective angioembolization (SSAE) for the treatment of hemodynamically unstable patients with GIH. A 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure < 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. All patients with evidence of active contrast extravasation were included. Data were collected on demographics, comorbidities, clinical presentation, and type of intravascular angioembolic agent used. Outcomes included technical success (cessation of extravasation), clinical success (no rebleeding requiring intervention within 30 days), and incidence of ischemic complications. Ninety-eight patients underwent SSAE for GIH during the study period; 47 were excluded owing to lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority underwent embolization with a permanent agent (71%), while the remaining patients received either a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections. Only one patient had an ischemic complication (small bowel necrosis) requiring resection. SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications are extremely rare. Therapeutic study, level IV.