Subacute Intestinal Obstruction Research Articles

DISSEMINATED TUBERCULOSIS PRESENTING AS AN ACUTE ABDOMEN

Mycobacterium tuberculosis is a widespread infection in developing countries like India. Tuberculosis is primarily a chronic condition but can present with acute and unusual manifestations. Disseminated tuberculosis is defined as having two or more non-contiguous sites resulting from lymphohematogenous dissemination of mycobacterium tuberculosis ex.: Miliary TB. Before COVID-19, tuberculosis was the worlds leading cause of death due to a single infectious agent. Especially in India because India accounts for one-quarter of the global burden and prevalence, the incidence rate of Latent TB Infection (LTBI) and active tuberculosis is 33% & 36% respectively in India which is quite high, therefore it is important to consider tuberculosis as an etiological agent if symptom indicates and subsequent work up consideration. Here we are reporting a rare presentation of disseminated tuberculosis in an emergency department at a tertiary care center with sub-acute intestinal obstruction to emphasize the importance of clinical examination and history to evaluate for the cause, for the management of patients even in acute settings like emergency.

Clinical Profile and Outcome of Sub Acute Intestinal Obstruction. A Descriptive Cross-Sectional Study

Introduction: Sub-acute intestinal obstruction (SAIO) is a partial blockage of the intestines causing abdominal pain, nausea, vomiting and obstipation. Diagnosing SAIO can be difficult, and CT scans are more accurate than plain X-rays. Treatment involves conservative measure initially, but surgery may be necessary if symptoms persist after 24-48 hours. This study aimed to assess the clinical profile and outcome of patients with SAIO. Methods: This was a descriptive cross-sectional study conducted in department of surgery at KIST Medical College and Teaching Hospital from 2022 to 2023 after getting ethical clearance. Fifty patients admitted with clinical feature suggestive of SAIO were enrolled for study. Predesigned proforma was used to record information that assessed demographic, clinical and treatment profile. SPSS version 26 was used for data analysis to generate descriptive statistical findings. Results: Abdominal pain was the most prevalent symptom observed in 39 (78%) patients while exaggerated bowel sound was most common clinical findings that was observed in 31 (62%). Pervious abdominal surgeries were present among 30 (60%) patients. Plain X-Ray showed feature suggestive of SAIO in 49 (98%) patients. Majority patients 35 (70%) were managed successfully with conservative treatment. Conclusion : In SAIO, abdominal pain was the most prevalent symptom while alteration in bowel sound is important clinical finding that is consistent with intestinal obstruction. Previous abdominal surgeries are an important risk factor to be considered for intestinal obstruction. Plain x-ray findings play important role to make diagnosis of intestinal obstruction. Conservative treatment resolves obstruction in majority of patients.

Unveiling the Hidden Peril: A Rare Case of Gossypiboma in an Elderly Woman

Background: Revolutionary developments in the surgical field have led to a comparative reduction in surgeryassociated complications than in the past. However, some complications, which directly indicate surgeon’s negligence, should not be underestimated. Gossypibomas, a rare but horrifying complication of surgeries, occur when cotton foreign bodies are retained in the patient and are only discovered after long periods of time.
 Methods: A 46-year-old diabetic anemic female, with a previous history of operative management for cancer of the cervix (stage IA2), presented with features suggesting sub-acute intestinal obstruction.
 Results: Contrast Enhanced Computed Tomography (CECT) of the abdomen revealed a linear hyper-attenuating string-like structure in the distal bowel loop, suggesting a Retained Foreign Body. The patient was immediately taken up for exploratory laparotomy, and the retained foreign body was removed.
 Conclusions: Although the diagnosis of Gossypibomas can be challenging at times, it is imperative to manage patients with this rare complication swiftly and precisely to prevent permanent future disabilities. Young surgeons should be made aware of the legal consequences of such a dreaded complication and should anticipate the diagnosis in bizarre surgical circumstances.

An obstructed inguinal hernia with maldescended testis as content in an adult male: A case report

Abstract A long-standing direct inguinal hernia may manifest as an acute or subacute intestinal obstruction. An obstructed direct inguinal hernia with testis as content is extremely uncommon, and up to date, no such case has been reported. Direct inguinal hernias are much less common than indirect ones in terms of incarceration and even strangulation. Obstructed direct inguinal hernias requiring surgery are very rare. Such hernias are exceedingly challenging to diagnose clinically and are diagnosed intraoperatively. According to the literature, individuals with direct inguinal hernias on the left side are more likely to develop such sequelae. Herein, we report the case of a 26-year-old male who presented with an obstructed inguinal hernia of the left side with the testis as content, taking into consideration the rarity and possible consequences of such hernias.

Foreign Body Causing Diagnostic Dilemma in Koch’s Abdomen Patient Presenting with Acute Intestinal Obstruction: A Case Report

The ileocaecal region is the most commonly affected region in Koch’s abdomen; however, it can involve any part of the Gastrointestinal Tract (GIT). Patients usually present late with either features of acute or subacute intestinal obstruction or with features of perforation peritonitis. Early diagnosis of abdominal Tuberculosis (TB) is still challenging due to the vague and non specific symptomatology of the disease. Hereby, the authors present a case report of 11-year-old boy who was on Antitubercular Treatment (ATT) for suspected abdominal TB, presented with features of subacute intestinal obstruction which subsequently had to be operated for acute obstruction. However, the cause of obstruction was not due to the complications of abdominal TB but due to the mechanical obstruction caused by the seeds of bayberry, which got obstructed in the relatively narrowed part of the ileocaecal region due to thickening of the bowel wall. No similar case reports have been found in the literature earlier. Hence, the present case is being reported.

117 Double Trouble: Rapunzel Syndrome Presenting with Closed-Loop Intestinal Obstruction Between Two Synchronous Trichobezoars

Abstract Background Trichobezoar formation is a rare phenomenon associated with certain psychiatric conditions like trichophagia and is more frequent in young women. Rapunzel Syndrome denotes a gastric trichobezoar which extends into the duodenum. We report a rare case of dual isolated trichobezoars, a gastric and an ileal trichobezoar, causing sub-acute closed-loop intestinal obstruction between the two bezoars. Case presentation A 15-years old girl presented to the emergency department with history of generalized abdominal pain and distention for two days. She had nausea, loss of appetite, absolute constipation followed by vomiting.She was tachycardiac, had abdominal distention with an ill-defined upper abdominal mass and absent bowel sounds. CT-scan abdomen revealed a giant trichobezor in stomach tailing into duodenum and a separate small rounded mass in ileum with dilated bowel loops. Mid-line laparotomy was done. Per-operatively a giant gastric trichobezoar(22x8cms) was extracted after gastrostomy, which completely occupied the stomach and extended into the duodenum. Another large ileal trichobezoar(6x5cms) was also removed via enterotomy at 2 feet proximal to the ileo-cecal junction. Hence a markedly distended closed loop was formed between the two obstructing trichobezoars. Enterotomies were closed using vicyrl2.0. Feeding was started on post-operative day-3 & she was discharged on day-5. She developed complete wound dehiscence after 2 weeks which was surgically closed. Patient was consulted for nutritional and psychiatric evaluation and for management of trichophagia. Conclusion Trichobezoars usually present with vague abdominal symptoms and can rarely cause intestinal obstruction. Invasive intervention such as laparoscopy or laparotomy becomes necessary for such large obstructing trichobezoars. Psychiatric follow-up and management are crucial to prevent its recurrence.

307 Intraluminal Migration of Gossypiboma and rectal expulsion an unusual Case- Case Report

Abstract Background Gossypiboma refers to foreign body retained in the body at the end of operation and can be in the form of gauze, sponge or any form of textile resulting in grave consequences for both the patient and the surgeon. Case Summary A 23-year-old female presented with complain of generalized abdominal pain along with non-bilious vomiting since 10 days. She also had relative constipation since four days. Her past surgical history was unremarkable except for three elective lower segment caesarean sections at another hospital. Upon abdominal examination, she had a scar of pfannenstiel incision along with 3x4 cm swelling in umbilical region with positive cough impulse. Her bowel sounds were exaggerated. DRE was unyielding. Clinical diagnosis of subacute intestinal obstruction was made and she was managed conservatively. Ultrasound abdomen showed dilated gut loops with hyperperistalsis. It also revealed a defect measuring 8.5 cm in the supraumbilical region of anterior abdominal wall through which fat content was seen protruding. She was advised contrast enhanced CT abdomen, developed diarrhoea and later on expelled the surgical sponge per rectally. After passage of surgical sponge, condition of patient improved and symptoms resolved. Discussion Diligent efforts are required to prevent this human error by ensuring meticulous sponge count, use of radio-opaque sponges, adjunctive use of WHO safety checklist and introduction of new advancements like tagging system in our healthcare system. Conclusion Gossypiboma is under-reported due to reluctance of institutions to report it to governing body. Reporting of such dreadful complications of surgery and analysis of their root cause should be done to prevent such events from happening.

Giant cell arteritis causing mesenteric ischemia without cranial manifestations: Report of an unusual case.

Giant cell arteritis is a medium to large vessel vasculitis involving most commonly temporal arteries, vertebral and ophthalmic arteries. Giant cell arteritis causing mesenteric ischemia is not so frequent, more so if it occurs without cranial manifestations. Here we present an unusual case of a 26-year-old male patient presenting with subacute intestinal obstruction due to giant cell arteritis leading to mesenteric ischemia.

Case report on laparoscopic management of congenital peritoneal encapsulation: A rare cause of small bowel obstruction.

Peritoneal encapsulation (PE) is a rare congenital disorder described as an accessory peritoneal lining covering a part or whole of the small bowel. Some theorise the encapsulation is due to the formation of adhesion between the physiological hernia and the caudal duodenum. While others have stated it is a defect in the reduction of the physiological hernia. Patients usually present at different stages of intestinal obstruction at any point of time during life. There are also reports on post-humous diagnosis on autopsy. PE is a rare surgical entity, hence not much evidences are available on how to tackle this condition by minimally invasive approach. Here, we report a case of PE in a 43-year-old male who presented with features of intermittent sub-acute intestinal obstruction and was managed by laparoscopic surgery at our institute.

Post-myomectomy omental infarction: a case report

BackgroundOmental Infarction (OI) is uncommon and mimics common causes of acute abdomen. It is important to differentiate it from other abdominal conditions that require emergency management. It was first reported in literature in 1896 and about 400 cases have been reported till date.Case presentationWe reported on a 41 year-old Para 0+0 Ibo house wife who presented with 10 years history of supra-pubic mass and five months history of excessive menstrual flow. After physical examination, a diagnosis of symptomatic uterine fibroid was made. She had myomectomy and the raw surface created after the excision of the myomas was covered with omentum. Wound infection developed on the 8th post-operative day leading to a wound breakdown and later partial extrusion of infarcted omental tissue through the dehisced wound. During re-exploration, the infarcted omental tissue was extracted and the residual abdominal abscess was drained. Surgical site wound infection occurred on the 3rd day after re-operation and a sub-acute intestinal obstruction developed on the 4th day thereafter which responded to conservative management.ConclusionCareful surgical technique is imperative when utilizing the omentum for reconstructive abdominal surgery. Torsion of the omentum and creation of excess tension while using the omentum for reconstructive procedures should be avoided and increase awareness of this uncommon disease condition by the surgeon is also important. This case is to report a rare finding of omental infarction following myomectomy.

Management of complicated colorectal cancer in Benghazi hospitals

Introduction: Colorectal cancer (CRC) is the third most frequent malignant disease in men and second most frequent in women. The treatment of emergency cases of CRC presented with complication is different than elective controlled cases. Aim: of this study is to find the best way to treat a patient admitted as an emergency case of complicated colorectal cancer. Methods: The medical data of 102 patients was retrospectively evaluated for those who were admitted as emergency cases with acute or subacute intestinal obstruction, perforation or bleeding colorectal cancer to Al-Jalla Hospital, Benghazi Libya. Three different emergency treatment methods were received as follow: · Tumor resection, · Damage control procedure with elective or semi elective resection, and · No radical treatment. Primary endpoints were 6 months mortality and morbidity. Secondary endpoints were length of hospital stay, number of lymph nodes, rate of radical R0 resections, and the number of patients who had received chemo-radiotherapy. Results: 55 patients had immediate resection and colostomy. 33 patients were inoperable because the cancer was too advanced or they were too ill to tolerate an operation. 10 had damage control followed by elective resection. There was no statistically proven significant difference between immediate resections and 2-stage treatment. The patients who underwent staged treatment had a higher possibility of receiving a laparoscopic resection. Conclusion: This study couldn't determine which treatment is better, even with using staging resection.

Mesenteric Panniculitis in A Patient with Dengue Fever

Mesenteric panniculitis or sclerosing panniculitis is a chronic nonspecific inflammation of mesentery adipose tissue ofsmall intestine and colon. It can also rarely involve retroperitoneal, pelvic and peripancreatic fat. No specific etiologyhas been found behind this rare disease. It is most commonly associated with abdominal surgery, autoimmune diseaseand malignancy. Here we present a case of a middle-aged man with history of abdominal surgery and he was presentedto us with dengue fever. His hospital course was complicated with sudden, severe abdominal pain with clinical featuresof subacute intestinal obstruction, and mesenteric panniculitis was diagnosed during further evaluation. It was a greatchallenge for us not only to diagnose such a disease of rare spectrum, but also to manage this patient who was alreadysuffering from another agonizing disease, dengue fever
 Bangladesh Crit Care J March 2023; 11 (1): 61-64

Endometriosis : A Rare Etiology for Small Bowel Obstruction

Endometriosis affecting gastrointestinal tract has been reported in 3-37% of menstruating women. It is seen in the recto-sigmoid, caecum, small bowel and the appendix in decreasing frequency. Involvement of the ileum by endometriosis is quite rare ,1-7% cases have been documented..Endometriosis of ileal segment of gastrointestinal tract leading to intestinal obstruction ranges from 7% to 23%.We report a 40 year. old female who presented with complete intestinal obstruction ten days with history of recurrent subacute intestinal obstruction for one year. She was previously treated with empirical Antitubercular drug to which she did not respond. Now histology of the resected specimen showed endometriosis in muscular propria and submucosa , leading to fibrosis and stricture formation.

A RARE CASE OF MULTIPLE INTESTINAL TRICHOBEZOAR CAUSING INTESTINAL OBSTRUCTION IN A YOUNG FEMALE PATIENT

A trichobezoar is an accumulation of hair inside the gastrointestinal tract. It's usually seen in patients of trichotillomania. Case Report: A-17 year old girl with features of subacute intestinal obstruction was operated in civil hospital ahmedabad and was found to have multiple hairballs inside of her small bowel. Enterotomy done and hairballs were extracted, ileoileal exteriorisation was done. Trichobezoar is a rare disorder which can often pres Conclusion: ent as a surgical emergency.

Inflammatory Myofibroblastic Tumor in a Child Presented as Subacute Intestinal Obstruction Associated with Pancreatitis.

Inflammatory Myofibroblastic Tumor in a Child Presented as Subacute Intestinal Obstruction Associated with Pancreatitis.

Pneumatosis Cystoides Intestinalis: A rare cause of intestinal obstruction

There are many well-known causes of acute or sub-acute intestinal obstruction. But Pneumatosis cystoides intestinalis (PCI) is a rare cause and can easily be misdiagnosed. PCI refers to presence of air within the wall of small or large intestine. This benign disease having both idiopathic and secondary causes with different contributing pathogenic factors that confuses many doctors. In most of the time it is asymptomatic, but clinical signs and imaging impressions may mimic true abdominal visceral perforation or soft tissue stranding leads to mechanical obstruction. PCI is sometimes incidentally found during radiological evaluation, endoscopic procedure or laparotomy. Surgery is not recommended for PCI if there was no intestinal obstruction, because of high operative risk. So correct diagnosis is imperative as treatment of PCI is generally conservative. We are presenting a case of intestinal obstruction who underwent to laparotomy followed by the histopathological diagnosis as a case of PCI. KYAMC Journal Vol. 13, No. 03, October 2022: 177-180

A rare case of jejunal diverticula with bone causing sub-acute intestinal obstruction

Jejunal diverticula is a rare condition, usually remains asymptomatic though sometimes presents as vague abdominal pain and in the rare case may present as a life-threatening gastrointestinal (GI) bleed. In this case, the patient presented with features of subacute intestinal obstruction and contrast enhanced computed tomography (CECT) abdomen suggested intraluminal obstruction due to impacted bone in the small bowel. The patient underwent exploratory laparotomy, there were jejunal diverticula with bone as a foreign body, and a was ileal stricture causing an obstruction. Jejunal diverticula with bone as a foreign body is a rare case, requiring high suspicion index and relevant investigations for reaching a diagnosis.

UTILITY OF SURGICAL APGAR SCORE TO PREDICTPOSTOPERATIVE MORBIDITY AND MORTALITY IN LAPAROTOMY PATIENTS - A PROSPECTIVE STUDY

Background:This Ten-point Surgical Apgar Score also known as the SAS score predicts postoperative mortality and morbidity in patients undergoing laparotomy. Method:50 patients undergoing laparotomy surgery were enrolled. 42 of these were emergency surgeries forintestinal obstruction,perforationperitonitis, subacute intestinal obstruction,penetrating injury,blunt injury to abdomen, ovarian cyst rest.8 cases were elective surgeries. The Surgical Apgar Score (SAS) was calculated intra-operatively based on estimated blood loss, lowest mean arterial pressure and lowest heart rate. Post-operative complications and mortality were recorded. Results:In our study 10 out of 12 patients in the high-risk group developed complications. In other words, 83.34%developed complications.7 out of18 patients belonging to the medium-risk group developed complications which is 38.8%.Only 5 out of 20 patients in the low-risk group suffered from complications. 75% of the patients in the low-risk groups did not have any major complications following the surgery. This was statistically significant with a p-value of 0.04. Conclusions:In our situation, laparotomy is still considerably high related with morbidity and mortality. The Surgical Apgar Score is excellent at classifying the postoperative risk of major complication following laparotomyusing straightforward and highly varying intraoperative measurements. The SAS score alarms the surgeon and empowers him to take proactive action19.

S2643 Rare Gastrointestinal Bleeding in a Patient With Severe Plasmodium Falciparum Malaria

Introduction: Malaria clinically presents as a systemic febrile illness; the most severe form is caused by Plasmodium Falciparum. In addition to hematologic manifestations such as severe anemia, thrombocytopenia, and coagulopathy, malaria patients uncommonly experience gastrointestinal complications such as GI bleeds, splenic rupture and subacute intestinal obstruction. We report a severe case of P. falciparum malaria complicated by a GI bleed. Case Description/Methods: A 66-year-old male with recent travel to Nigeria and a medical history of hypertension was brought to the ER with altered mental status, abdominal pain and a 25lb weight loss in the last month. In the ED he spiked a fever to 102F, prompting a thorough infectious workup. An LP was remarkable for many RBCs, glucose 81 and protein 47. CSF was negative for meningitis/encephalitis; he did not have EBV, CMV or HIV. Blood and fungal cultures were negative. Due to his recent travel history, our patient had a 5-thin and 2-thick malarial smear which showed P. falciparum malaria ring forms. He was started on cefepime, vancomycin, metronidazole, atovaquone/proguanil. Over the next 12-hours, the patient rapidly deteriorated with a large coffee ground emesis, a hemoglobin drop from 12.1 to 8.6, and a thrombocytopenia from 135 to 15. Hemolysis labs were positive: haptoglobin < 30, LDH 607, reticulocyte 14.6%, fibrinogen 112. Upper endoscopy showed Grade-C esophagitis, an oozing duodenal ulcer and hematin all throughout the stomach wall. Abdominal ultrasound and CT showed no acute intra-abdominal pathologies. With new ongoing hematemesis and melena, he went into progressive septic vs hemorrhagic shock and required vasopressors and stress-dose steroids. Discussion: The hematologic manifestations often seen in malaria rarely lead to massive GI bleeds. Our patient did not use NSAIDS, he was not tested for H. Pylori, and despite the stress of his acute severe illness, he had no other risk factors for duodenal ulceration. High levels of free oxygen radicals and tumor necrosis factor may have played a role in the etiology of his peptic ulcer formation. Malarial hemolysis results from the release of cytokines, macrophage recruitment, causing a cytokine storm and activation of endothelial adhesion molecule type 1, E-selectin, enhancing cytoadherence of parasitized cells, mediating lactic acidemia, shock, gut mucosal damage and increased permeability. Despite aggressive measures, our patient ultimately developed shock and died.

P8.031: Outcome of Simultaneous Pancreas Kidney Transplantation A Single Center Experience

Introduction: Simultaneous simultaneous pancreas-kidney (SPK) transplantation is one of the treatment options for type 1 diabetes mellitus (T1DM) patients with chronic kidney disease stage 5. The SPKT outcomes are reported to be excellent with a 5 year patient, kidney and pancreas graft survival of 88%, 77% and 69% respectively. Here, we present data regarding outcome of the SPKT done at our institution. Method: We studied patients who underwent SPKT in our institution. 11 T1DM patients who were CKD-5 underwent SPKT from 2014 to 2022. Their graft function and complications were analysed. Results: A total of 12 patients were studied. 50 % were males and 50% were females. Mean age at diagnosis was 14 ± 4 years. Mean age at transplantation was 32 ± 6 years. Mean hemodialysis (HD) vintage was 22 ± 14 months. Mean age of donor was 31 ± 10 years. Induction was with Basiliximab in 1 patient, Alemtuzumab in 5 patients and ATG in 6 patients. Maintenance immunosuppression was tacrolimus and mycophenolate in 8 patients; and, tacrolimus, mycophenolate and everolimus in 2 patients Mean duration of hospital stay was 30 ± 18 days. Mean graft kidney function at 1 month was 1.38 ± 0.48 mg/dl. Mean graft kidney function at 6 months was 1.30 ± 0.47 mg/dl. At 1 year, one patient had severe renal graft dysfunction requiring HD. Among the other 10 patients who completed one year, mean kidney graft function at 1 year was 1.25 ± 0.23 mg/dl. Three (25%) patients had renal allograft loss with need for initiation of HD after 30, 21 and 6 months. Two patients with renal allograft loss required insulin after 19 and 25 months. Three (25%) patients had delayed graft function. Five (41.7%) patients had renal allograft rejection at 1 month. Among the five, three had another episode of rejection at 17, 11 and 4 months. Three (25%) patients had suspected pancreatic graft rejection at POD 13, 13 and 14, which resolved with intravenous steroids. Eight (66.6%) patients had infections in the first year following transplant which included urosepsis, LRTI, tuberculosis, varicella, CMV, cellulitis, periodontal abscess, dental caries and esophagial candidiasis. Seven (58.3%) had surgical complications including pseudo aneurysm of graft pancreas, urinoma, perinephric hematoma, abdominal bleed and DIC, jejujno-jejunal anastomotic site bleed, kinked renal vein requiring re-exploration, graft pancreas fat necrosis with impending GB rupture and peritonitis, and splenic vein thrombosis requiring re-exploration. Other complications noted were incisional hernia, subacute intestinal obstruction, bilateral femoral head avascular necrosis and acute myeloid leukemia. Conclusion: The graft survival and outcomes in our institution is comparable to that of international standards. Surgical complications were noted to be higher compared to renal transplantation. SPK remains to be treatment of choice in T1DM patients with ESRD.