Subacute Intestinal Obstruction Research Articles

2654 Metastatic Squamous Cell Carcinoma to the Small Bowel Masquerading as Crohn’s Disease: A Diagnostic Dilemma

INTRODUCTION: Head and neck squamous cell carcinoma (HNSCC) is the sixth most common type of cancer in the world. The presence of distant metastasis after the initial treatment of head and neck cancers is associated with a poor prognosis. The most frequent site for distant metastasis of HNSCC is lung, followed by mediastinal lymph nodes, bone and liver. Metastatic squamous cell carcinoma (SCC) to the small bowel is an extremely rare occurrence. We present a unique case of a patient with HNSCC who presented with small bowel obstruction and concern for Crohn’s disease (CD) but was ultimately diagnosed with metastatic SCC. CASE DESCRIPTION/METHODS: A 67 year old Caucasian male with a history of SCC of the left pinna and epiglottis on cisplatin chemotherapy and radiation therapy, presented with 2 weeks of intractable nausea, vomiting, and peri-umbilical abdominal pain. Lab work revealed leukocytosis with WBC 16,000. CT abdomen and pelvis was notable for dilated small bowel loops and a long segment thickening of the distal ileum causing a partial small bowel obstruction (Figure 1). His symptoms persisted despite nasogastric decompressiontube and antibiotics. An abdominal MRI showed similar findings of long discontinuous segments of diffuse distal small bowel thickening, luminal narrowing and mural enhancement with concern for small bowel CD. Given these findings, an empiric course of steroids was initiated. Patient’s symptoms improved and he was discharged from the hospital..To further evaluate the small bowel, he underwent a retrograde balloon enteroscopy, which showed subtle findings of multiple sub-centimeter distal ileal nodules (Figure 2), but no other abnormalities. Biopsies of the nodules returned as metastatic poorly differentiated squamous cell carcinoma (Figure 3). DISCUSSION: Small bowel metastasis represents less than 10% of malignant tumors of the small bowel. Small bowel metastasis from HNSCC is an unusually rare occurrence and to date, there is minimal literature on it’s occurrence. Clinical presentation is variable with acute or sub-acute intestinal obstruction, ileus, gastrointestinal hemorrhage or bowel perforation. Here, we present an unusual case of small bowel metastasis from HNSCC, which is unique given the initial radiologic findings suggestive of CD. Thus, clinicians must be cognizant of the metastatic potential of squamous cell cancer in order to prevent delayed diagnosis and avoid devastating consequences.

THE PATTERN OF ACUTE INTESTINAL OBSTRUCTION: A HOSPITAL BASED STUDY

BACKGROUND: Intestinal obstruction is a surgical emergency that causes confusion both in the diagnosis and the management. It is related by important disease and mortality. The goal of this study was to classify the etiology, to analyse the methods of performance of acute duodenal obstruction in different age groups, various therapeutic modalities of treatment, to accomplish operative management, anticipate the post-operative complications and outcomes of patients with acute intestinal obstruction. MATERIAL& METHODS: 82 patients of all age groups (except infants) presenting with acute intestinal obstruction were studied between June 2017 and December 2018 in a multispeciality hospital in Eastern India. Patients with history of subacute intestinal obstruction and paralytic ileus were excluded from this study. RESULTS: Males were found to be affected much more than females. Pain abdomen was the most common symptom found in 94% cases followed by distension and vomiting in 86.6% and 68.3% cases respectively. Most common etiology of intestinal obstruction was due to adhesion and bands (40.3%) followed by obstructed hernia (22%) and malignancy (17%). The most common procedure done in intestinal obstruction in present study was release of adhesions and bands (37.8%) followed by resection and anastomosis (26.8%). CONCLUSION: Bowel obstruction continues to be one of the most common abdominal problems faced by general surgeons. Success in the treatment of intestinal obstruction depends largely upon early diagnosis, skilful management and treating the pathological effects of the obstruction just as much as the cause itself.

THE PATTERN OF ACUTE INTESTINAL OBSTRUCTION: A HOSPITAL BASED. STUDY..

BACKGROUND: Intestinal obstruction is a surgical emergency that causes confusion both in the diagnosis and the management. It is related by important disease and mortality. The goal of this study was to classify the etiology, to analyse the methods of performance of acute duodenal obstruction in different age groups, various therapeutic modalities of treatment, to accomplish operative management, anticipate the post-operative complications and outcomes of patients with acute intestinal obstruction. MATERIAL& METHODS: 82 patients of all age groups (except infants) presenting with acute intestinal obstruction were studied between June 2017 and December 2018 in a multispeciality hospital in Eastern India. Patients with history of subacute intestinal obstruction and paralytic ileus were excluded from this study. RESULTS: Males were found to be affected much more than females. Pain abdomen was the most common symptom found in 94% cases followed by distension and vomiting in 86.6% and 68.3% cases respectively. Most common etiology of intestinal obstruction was due to adhesion and bands (40.3%) followed by obstructed hernia (22%) and malignancy (17%). The most common procedure done in intestinal obstruction in present study was release of adhesions and bands (37.8%) followed by resection and anastomosis (26.8%). CONCLUSION: Bowel obstruction continues to be one of the most common abdominal problems faced by general surgeons. Success in the treatment of intestinal obstruction depends largely upon early diagnosis, skilful management and treating the pathological effects of the obstruction just as much as the cause itself.

Colonoscopy: an inquiry into indications, findings and their correlation at a tertiary care hospital

Background: Though colonoscopy is widely performed, the statistical data regarding its indications, findings, and the diagnostic yield are not widely documented especially in developing countries. This study is an attempt to determine such data in a group of patients who underwent colonoscopy at our hospital.Methods: This was a hospital‑based retrospective study carried out at the Department of General Surgery, MMC&RI, Mysore. The subjects were a total of 286 patients who underwent colonoscopies in the year 2017. The relevant data from colonoscopy register were recorded and tabulated.Results: The major indications in our study group were bleeding per rectum (25%), unexplained diarrhoea or dysentery (16%), pain abdomen (15%) and suspected malignancy (13%). Other indications included suspected inflammatory bowel disease (IBD), subacute intestinal obstruction, anaemia, mass per abdomen and suspected irritable bowel syndrome (IBS). More than one third (35%) had normal colonoscopic studies. The most common pathology found was malignancy (24%) followed by the spectrum of proctocolitis (20%). The indications which produced high diagnostic yields included suspected carcinoma (97%), bleeding per rectum (82%) and suspected IBD (80%). Significant number of patients with per rectal bleeding was diagnosed with malignancy (21%). The indications which produced low yields included subacute intestinal obstruction (31%), anaemia (45%), non-specific pain abdomen (50%) and suspected irritable bowel syndrome (18%).Conclusions: Colonoscopy is highly rewarding among patients who are being evaluated for suspected malignancies, lower gastrointestinal bleeding and suspected IBD. As such, certain indications produce a higher diagnostic yield than others, suggesting that a stricter patient selection criterion may be employed for performing colonoscopy especially in resource poor settings.

Surgical Outcomes in Patients with Abdominal Cocoon: Series of 15 Patients.

Abdominal cocoon (AC) or sclerosing encapsulating peritonitis is an uncommon cause of intestinal obstruction. Surgical intervention is warranted in patients with persistent pain or intestinal obstruction. A retrospective analysis of patients operated for AC was performed. Clinical presentation, radiological data, postoperative outcomes (Ryles tube (RT) removal, duration of hospital stay, enterocutaneous fistula, requirement for re-exploration and mortality) were retrieved and analyzed. Fifteen patients of abdominal cocoon required surgical intervention for various indications. The mean age was 34.46years (13-60), and 11 (73.3%) were males. Intermittent abdominal pain was present in 14 (93.3%) followed by recurrent subacute intestinal obstruction (SAIO) in 11 (73.3%). Three patients presented with intestinal perforation. Of the 14 patients with preoperative computed tomography, radiological diagnosis was possible in five patients. The mean duration for surgery was 159min (60-360min). Membrane encasement was complete in 9/15 and partial in 6/15 patients. Adhesiolysis was done in all patients (complete-10/15 and partial-5/15). Mean duration for RT removal and hospital stay was 4.3 and 12.3days, respectively. Recurrence of SAIO was observed in three patients, and one patient needed re-exploration for the same. One patient developed postoperative enterocutaneous fistula requiring surgical intervention. Overall mortality in the study was 13.3% (2/15). Four patients had underlying tuberculosis, and the rest were idiopathic. Etiology of AC is not known in majority of patients. Persistent pain and recurrent SAIO are the most common indications for surgery. This morbidity associated with surgery can be reduced by meticulous dissection techniques and appropriate peri-operative care.

Study on Surgical Re-Admission in DMCH

Introduction: Re-admission of surgical patients following discharge from a surgical care unit to the same or different hospital is not uncommon. Underlying causes varied. Majority of re-admission are unplanned. Postoperative complications are mainly responsible for patients to seek re-admission. Post operative complications are the mainly liable for surgical re-admission.
 Methods: A prospective study was performed in General Surgical units of Dhaka Medical College Hospital, Dhaka for one year from August’2011 to July’2012. Amongst the patients admitted in surgical units, all re-admitted patients within the period had been studied. Purposive sampling was done. Rate, cause, avoidability etc. were studied according to criteria.
 Results: Among 4396 admitted patients 294 (7%) had history of previous admission in surgical department of different hospitals. 65% patients were male and 70.07% were middle aged (20-50yr). 67% re-admisssion occurred through emergency department of which 67.7% were unplanned. 58% re-admission were avoidable. Diagnosis at readmission contains quite a long list but notables were loop ileostomy (23.47%), enterocutaneous fistula (10.54%), incisional hernia (9.52%), mature colostomy (8.84%), wound infection (8.5%) and subacute intestinal obstruction (4.76%).
 Conclusion: Re-admission can be a contributing factor to assess quality and performance. It should be focused in audit and practice.
 J Bangladesh Coll Phys Surg 2019; 37(2): 54-59

A case of midgut malrotation in an adult male causing volvulus and subacute intestinal obstruction

Small bowel malrotation is a congenital disorder of midgut rotation usually encountered in paediatric age group. Here is a case report of small bowel sub-acute obstruction due to midgut volvulus precipitated by malrotation. The incidence of microtonal presentation in adults is 0.2%, making this case a rarity. This patient presented with chronic vague symptoms like dyspepsia, diffuse low-grade abdominal pain, non-projectile vomiting which were on and off for 4 to 5 years since he presented to us. Furthermore because of the remitting nature of his symptoms, these symptoms usually pointed out to a more benign ailment, so unless we do a more elaborate study like computed tomography, we might miss the diagnosis. This case report emphasis the wide range of presenting age for certain congenital disorders like malrotation of gut.

Prevalence of Intestinal Tuberculosis in Cases of Sub-Acute Intestinal Obstruction

Prevalence of Intestinal Tuberculosis in Cases of Sub-Acute Intestinal Obstruction

Role of CT scan in Diagnosis of Patients with Suspected Subacute Intestinal Obstruction

Background: Intestinal obstruction is defined as mechanical or functional obstruction of the intestines which prevents the normal passage of the products of digestion. Present study was performed to study the role of Computerized Tomography (CT) in Diagnosis of patients with suspected subacute intestinal obstruction (SAIO), to find out site & cause of obstruction and to diagnose complications of obstruction. Subjects and Methods: This study was conducted at Department of Radiodiagnosis, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat. Total number of 15 patients with SAIO having equivocal findings on USG was included in this study. All the statistical tests were performed in SPSS version 15 software. Results: Age of the patients in the study range between 14 to 70 years. Out of 15 were 8 male & 7 female patients. On CT scan all 15 patients were found to have obstruction with 12 patients having mechanical obstruction & 3 patients having pseudo obstruction secondary to appendicitis, jejunal perforation. CT scan correctly diagnosed intestinal obstruction with its cause in 14 out of 15 patients. Most common cause of SAIO was ileal stricture followed by intussusceptions. Conclusion: The findings of the study show that CT is a valuable diagnostic procedure in patients with subacute intestinal obstruction with high sensitivity. It is a problem-solving tool in equivocal cases.

Management of a Patient with Apical Hypertrophic Cardiomyopathy with Subacute Intestinal Obstruction

Management of a Patient with Apical Hypertrophic Cardiomyopathy with Subacute Intestinal Obstruction

Abdominal Cocoon Syndrome as a cause of Intestinal Obstruction: A Case Report

Abdominal cocoon syndrome is also known as sclerosing encapsulating peritonitis, characterized by small bowel encapsulation by a fibro-collagenous membrane or “cocoon”. It is a rare cause of intestinal obstruction and has been reported predominantly in adolescent girls living in tropical/subtropical region. The cause and pathogenesis of the condition have not been elucidated. Prolonged administration of practalol, meconium peritonitis, and tuberculous infection of the female genital tract have been incriminated as possible causes. Timely and accurate imaging and diagnosis is important to avoid morbidity and mortality. Preoperative diagnosis is difficult. It is usually diagnosed during surgery. Simple excision of the membrane and lysis of the adhesions produces optimal results. Breaking of adhesions needs to be done carefully; to prevent damage to serosal surface and perforation. This case report is of a 38yr old lady who presented with sub-acute intestinal obstruction that was secondary to an abdominal cocoon and was managed by Laparoscopic surgery in our hospital.

A prospective study of cases of intestinal obstruction and role of conservative expectant management

Background: Intestinal obstruction continues to be a common surgical emergency throughout the world and its management protocol has evolved over years. In our study we aimed to provide a complete epidemiological description of intestinal obstruction in adult age group patients in a tertiary care hospital in Northern India.Methods: This is a prospective study of patients belonging to age group more than 12 years admitted in our unit with clinical features suggestive of intestinal obstruction from September 2011 to December 2013 at R. N. T. Medical College, Udaipur. The study comprised of 134 patients.Results: Intestinal obstruction contributed to 6.5% of all surgical admissions. It was nearly twice more common in males. 43% patients presented with features of acute intestinal obstruction in comparison to 57% who presented with features of sub-acute intestinal obstruction. Most common cause observed was obstruction due to intra-abdominal adhesions followed by abdominal tuberculosis 48 and 29 percent respectively. Features of intestinal obstruction resolved in 60% patients with conservative management. Adhesions, abdominal tuberculosis and malignancy counted for majority of patients with sub-acute obstruction. Emergency surgery was done in 32% of patients and 36.5 % of patients were discharged non-operatively. Planned Surgery after successful expectant management was done in 24 % patients. Most frequently seen complication was wound site collection (72.5%) followed by respiratory tract infections (49%). Total mortality in our study was 12.6% of which 41% was post-operative mortality and 59% mortality seen in patients who expired during conservative management. Conclusions: This study demonstrates that intra-abdominal adhesions and abdominal tuberculosis account for most cases of intestinal obstruction in countries like India. A watchful expectant management can be tried in patients with prior operative history and those with history of tuberculosis.

A case of midgut malrotation presenting as subacute intestinal obstruction in an adult

A case of midgut malrotation presenting as subacute intestinal obstruction in an adult

MISDIAGNOSED ADVANCED INTERSTITIAL PREGNANCY - A CASE REPORT

Interstitial pregnancy is a rare and dangerous form of ectopic pregnancy that can be mistaken for a normal intrauterine pregnancy on ultrasonography leading to catastrophic results. Gynecologist should be aware of the potential for mistaking an interstitial pregnancy for intrauterine pregnancy. We present a case of 14 weeks interstitial pregnancy misdiagnosed on abdominal ultrasonography as intrauterine pregnancy with ascites. She was treated as sub-acute intestinal obstruction with severe anemia in pregnancy for 2 days. The correct diagnosis was first made at emergency laparotomy which showed hemoperitoneum and rent involving the right superolateral end of the uterus, with fetus and placenta lying in pouch of Douglas. Wedge resection of the right superolateral end of uterus along with repair done. Lack of suspicion and lack of expertise are a common cause for missing this rare ectopic pregnancy.

A rare case of carcinoma rectum with scalp metastasis: an unusual presentation

Colorectal cancer is the third most commonly diagnosed cancer and third leading cause of cancer death in both men and women in the world. Metastasis is common in case of carcinoma rectum due to the late arrival of the patient to the doctor. The common sites for metastasis are liver, lung or ovary. But metastasis to the scalp is very rare. A 65-year-old female patient who presented to the casualty with sub-acute intestinal obstruction of four days duration was managed conservatively. Incidentally the patient noticed a swelling over the scalp which was initially of size 1 × 1 cm which progressed to the size of 3 × 3 cm over a period of 2 weeks. FNAC from the swelling showed features of skin adnexal tumor. Excision of the swelling was done, and histopathological examination revealed features of metastatic adenocarcinoma. Colorectal carcinoma can be controlled or treated with frequent screening of any individual who has crossed 50 years with occult stool for blood or by colonoscopy. In this way metastasis can be controlled if we treat at the early stages.

Coinfection by Salmonella and Leptospira Presenting as Subacute Intestinal Obstruction with Colitis: A Diagnostic Dilemma

Coinfection by Salmonella and Leptospira Presenting as Subacute Intestinal Obstruction with Colitis: A Diagnostic Dilemma

Abdominal cocoon: Classic computed tomography images

Abdominal cocoon is an uncommon cause of acute or subacute intestinal obstruction mostly secondary to tuberculosis. This report highlights the classic imaging features on computed tomography in a case of ileocecal tuberculosis with secondary abdominal cocoon.

Case series: Two rare cases of primary jejunal adenocarcinoma with different clinical presentation

Small bowel tumors are rare, accounting for <5% of gastrointestinal neoplasms, 1%–2% of these being malignant. The most common histological subtype is adenocarcinoma. Small bowel adenocarcinoma (SBA) is challenging to diagnose, often presents at a late stage, and has a poor prognosis. Therefore, a high index of clinical suspicion is required to diagnose such patients, and a better outcome with early-stage detection is expected. We report here two cases of jejunal adenocarcinoma. (a) A 53-year-old male presenting with iron deficiency anemia. (b) An 81-year old-female presenting with subacute intestinal obstruction. Diagnosis of SBA remains a challenge. A physician's suspicion and awareness are crucial in such patients. The early diagnosis will affect overall survival and mortality rate. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome.

Small bowel obstruction due to ductal breast cancer metastasis

The most frequent sites of breast cancer metastasis are the bone, lung and liver. Metastasis to the gastrointestinal tract, central nervous system and adrenal glands are rare, the gastrointestinal tract more frequently with being affected by lobular breast cancer metastasis, and rarely by ductal breast cancer. The case reports a 52-year-old female patient, previously diagnosed with locally advanced ductal breast carcinoma - cT4N+M0, who received neoadjuvant chemotherapy, followed by modified radical mastectomy – ypT2N3aM0 – and adjuvant radiotherapy. During follow-up there were no signs of recurrence, but the patient experienced several episodes of sub-acute intestinal obstruction, which resolved with medical treatment. In 2017, January the patient had another intestinal obstruction, but this time a laparotomy was performed, and two small bowel metastasis were found, which were resected. The pathologic exam revealed metastasis from ductal breast cancer. In the article have we discussed the patterns of breast cancer metastasis, with special consideration for gastrointestinal tract.

Whipple's Pancreaticoduodenectomy in Pediatric Patients: An Experience from a Tertiary Care Center.

Purpose:Whipple's pancreaticoduodenectomy (WPD) is rarely required in children. However, WPD is the only option with pathologies involving the head of the pancreas requiring surgical excision. The objective of our study was to review our experience with WPD performed on children.Materials and Methods:A retrospective analysis of case records was conducted on all patients <18 years of age, who underwent WPD at our center over the last 20 years. Data regarding demographics, signs, and symptoms at presentation, diagnostic imaging and procedures, pathologic reports, surgical and medical treatment, and follow-up were collected to study the indications and safety and outcomes of WPD in children.Results:Five patients had been planned for a WPD during the study (1995–2015); but in one patient, the procedure was abandoned, the rest four patients formed the study group. Male to female ratio was 3:1. Median age at the time of surgery was 9 years (11 months–12 years). The most common presentation was obstructive jaundice (50%, 2/4). Radiological imaging was able to accurately predict the surgical procedure required in all except one case. The mean operating time was 205 min (180–240 min). There were no intraoperative complications. The mean intraoperative blood loss was 85 mL (20–150 mL). The youngest patient requiring WPD was an 11-month-old child. Oral feeding was established by the 7th postoperative day (range 5–7 days) in all cases. There were no cases of anastomotic leak or pancreatic or jejunal fistulae. One patient developed features of subacute intestinal obstruction after discharge and required re-exploration. There was no intra- or post-operative mortality.Conclusion:WPD is safe and efficacious procedure in a selected group of children. The overall efficacy of surgical treatment combined with the relatively low severity of complications leads us to recommend WPD in children when indicated.