A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep. 2017;19:28. [PMID: 28439845 DOI: 10.1007/s11894-017-0566-9]

Assessing the Modified Frailty Index and Post-Operative Outcomes in Adhesive Small Bowel Obstruction: A Retrospective Cohort Study

INTRODUCTION

Studies identifying predictors of postoperative outcomes in adhesive small bowel obstruction are limited. This study investigates the efficacy of the modified frailty index (mFI)to predict postoperative morbidity and mortality among patients undergoing surgery for adhesive small bowel obstruction.

METHODS

A multicentre retrospective cohort study including patients undergoing surgery for adhesive small bowel obstruction after failed trial of nonoperative management between January 2015 and December 2020 was performed. Impact of frailty status using the mFI, stratified as frail (≥0.27) and robust (<0.27), on postoperative morbidity, mortality, length of stay, and discharge destination was evaluated using multiple logistic regression.

RESULTS

Ninety-two robust patients (mean age 62.4 y, 68% female) and 41 frail patients (mean age 81.7 y, 63% female) were included. On simple stratification, frail patients had significantly increased 30-d morbidity (overall morbidity 80% versus 49%) and need for higher level of care on discharge (41% versus 9%). However, on multiple regression, functional dependence but not the mFI, was independently associated with worse 30-d overall morbidity (odds ratio [OR] 3.97, confidence interval [CI] 1.29-12.19) and lower likelihood of returning to preoperative disposition (OR 0.21, CI 0.05-0.91). The delay in operation beyond 5 d was independently associated with worse 30-d outcomes including overall morbidity and mortality (OR 7.54, CI 2.13-26.73) and decreased return to preoperative disposition (OR 0.14, CI 0.04-0.56).

CONCLUSIONS

The mFI, although promising, was not independently predictive of outcomes following surgery for adhesive small bowel obstruction. Further adequately powered studies are required.

Presentation, characteristics and management of obstructive intestinal conditions in cystic fibrosis

Objective

Constipation and distal intestinal obstruction syndrome (DIOS) are common gastrointestinal manifestations of cystic fibrosis (CF). The primary aim was to describe the characteristics of constipation and DIOS hospitalisations in a paediatric and adult CF service over a 12-year period. The secondary aims were to determine the proportion of constipation and DIOS presentations which met the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) CF Working Group definitions and to describe management strategies of both conditions.

Method

A retrospective study of children and adults with CF who were admitted with a primary diagnosis of constipation or DIOS between 1 January 2011 and 31 December 2022. ESPGHAN definitions for constipation and DIOS were retrospectively applied to all admissions to determine if the primary medical diagnosis met ESPGHAN criteria.

Results

During the 12-year study period, 42 hospitalisations for constipation were recorded in 19 patients, and 33 hospitalisations for DIOS were recorded in 23 patients. 88.10% of constipation episodes met ESPGHAN definitions, compared with 3.0% of DIOS episodes. Constipation and DIOS were primarily treated with polyethylene glycol (PEG). The use of sodium amidotrizoate meglumine enemas was significantly higher in the DIOS group (p=0.045). Those admitted with DIOS were significantly less likely to be recommended a weaning dose of PEG (p=0.018).

Conclusion

Children and adults with CF are more commonly admitted for the management of constipation than DIOS. There is considerable variation in diagnostic and therapeutic practice, and this study highlights the need to enhance the translation and adoption of existing best-practice guidelines.

Effect of modified gastrointestinal decompression under abdominal CT in patients with intestinal obstruction

INTRODUCTION

We aimed to evaluate the effect of continuous quality improvement on modified gastrointestinal decompression under abdominal computed tomography (CT) in patients with intestinal obstruction.

METHODS

The CT images of 74 patients with intestinal obstruction who underwent gastrointestinal decompression in our hospital from 1 January 2018 to 31 December 2019 were analysed retrospectively (Control group). Factors influencing unsatisfactory decompression effects were analysed, and corresponding improvement measures were formulated and implemented. A total of 77 patients from 1 January 2020 to 31 March 2022 were enrolled prospectively (Study group). The position of the nasogastric tube end, the amount of gastric drainage within 24h and the degree of abdominal distension relief were compared before and after the improvement.

RESULTS

After implementation of continuous quality improvement, the proportion of the end of the nasogastric tube reaching the antrum, the amount of gastric fluid drainage within 24h and the degree of abdominal distension relief were better than those before improvement (p<0.001, respectively). The execution rate and accuracy rate of CT interpretations by nurses reached 100% and 82%, respectively.

CONCLUSIONS

Modified gastrointestinal decompression based on abdominal CT scans can increase the success of gastrointestinal decompression and effectively reduce the discomfort of patients.

Ileocecal knotting as a rare cause of small bowel obstruction: a case report

Introduction

Ileocecal knot syndrome, a rare cause of small bowel obstruction where the ileum wraps around the cecum, poses a significant challenge for preoperative diagnosis. Prompt intervention is crucial due to the risk of rapid bowel deterioration and increased mortality.

Case presentation

A 45-year-old female presented with central abdominal pain associated with vomiting, abdominal distension, and obstipation. On examination, she was ill-looking with hypotension, tachycardia with a feeble pulse, direct and rebound abdominal tenderness, and absent bowel sounds. Aggressive fluid resuscitation was done. Based on the clinical presentation and abdominal radiograph suggestive of intestinal obstruction, an emergency exploratory laparotomy was done, which showed an ileocecal knot and 130 cm of gangrenous ileum. Peritoneal lavage followed by resection of non-viable ileum with double barrel ileostomy was done.

Discussion

Ileosigmoid, appendico-ileal, ileoileal, and ileocecal knotting are the various types of intestinal knotting, with very few cases of ileocecal knotting being reported. Intestinal knotting causes severe bowel obstruction, resulting in reduced mucosal perfusion, progressive ischemia, and peritonitis, leading to high mortality. X-ray findings of multiple air-fluid levels are non-specific, and for definitive diagnosis, laparotomy is required. Assessing bowel viability before definitive surgery is essential. Despite positive outcomes, extensive resection can lead to malabsorption and ileus, with potential risk for developing short bowel syndrome.

Conclusion

Despite its rarity, the possibility of ileocecal knotting should be considered in cases of small bowel obstruction due to its potential for rapid deterioration. Prompt resuscitation followed by emergency laparotomy is necessary to prevent mortality.

Portal vein gas is a sign of intestinal necrosis after pesticide poisoning: a case report

Portal vein gas accumulation and intestinal pneumatosis are uncommon signs indicating a high mortality risk in cases of intestinal ischemic necrosis. However, the widespread use of computed tomography has led to an increase in detection of benign lesions. We report a case of portal vein gas accumulation resulting from organophosphorus pesticide poisoning. A male patient was brought to the hospital in a comatose state with bilateral pupils that measured 1.0 mm, and he showed shortness of breath and wet rattles in the lungs. A cholinesterase concentration of 214 U/L was detected on an auxiliary examination. The patient was diagnosed with organophosphorus pesticide poisoning and underwent mechanical ventilation, hemoperfusion, and continuous renal replacement therapy according to the poisoning guidelines. On the fifth day, considerable abdominal distension was observed. An abdominal computed tomography scan revealed dilation of the small bowel and ascending colon with fluid and gas accumulation, as well as gas within the intestinal wall and hepatic veins. Although portal vein gas and intestinal pneumatosis are a sign of mortality requiring immediate surgical intervention, an increasing number of benign cases suggests potential benefits of conservative treatment approaches.

Management of small bowel obstruction in the third trimester

Small bowel obstruction (SBO) in pregnancy is exceedingly rare. Management of SBO in the third trimester may pose particular challenges, as clinicians must determine whether or not the delivery of the fetus is indicated. In this report, we review the case of a patient in her mid-20's with no prior surgical history who presented with nausea and vomiting at 34 weeks of gestation and was ultimately diagnosed with an SBO. Following expectant management during the initial 4 days of inpatient admission, the patient subsequently underwent an exploratory laparotomy at 35 weeks without concurrent delivery. She was monitored for the remainder of her pregnancy with non-stress tests to evaluate fetal status and eventually underwent induction of labour at 39 weeks, resulting in a successful vaginal delivery. Herein, we review the challenges related to the diagnosis and management of SBO in pregnancy, as well as the maternal-fetal outcomes in the setting of SBO in the third trimester.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Anaesthesia Management for Giant Intraabdominal Tumours: A Case Series Study

BACKGROUND

Due to a lack of randomised controlled trials and guidelines, and only case reports being available in the literature, there is no consensus on how to approach anaesthetic management in patients with giant intraabdominal tumours.

METHODS

This study aimed to evaluate the literature and explore the current status of evidence, by undertaking an observational research design with a descriptive account of characteristics observed in a case series referring to patients with giant intraabdominal tumours who underwent anaesthesia.

RESULTS

Twenty patients diagnosed with giant intraabdominal tumours were included in the study, most of them women, with the overall pathology being ovarian-related and sarcomas. Most of the patients were unable to lie supine and assumed a lateral decubitus position. Pulmonary function tests, chest X-rays, and thoracoabdominal CT were the most often performed preoperative evaluation methods, with the overall findings that there was no atelectasis or pleural effusion present, but there was bilateral diaphragm elevation. The removal of the intraabdominal tumour was performed under general anaesthesia in all cases. Awake fiberoptic intubation or awake videolaryngoscopy was performed in five cases, while the rest were performed with general anaesthesia with rapid sequence induction. Only one patient was ventilated with pressure support ventilation while maintaining spontaneous ventilation, while the rest were ventilated with controlled ventilation. Hypoxemia was the most reported respiratory complication during surgery. In more than 50% of cases, there was hypotension present during surgery, especially after the induction of anaesthesia and after tumour removal, which required vasopressor support. Most cases involved blood loss with subsequent transfusion requirements. The removal of the tumor requires prolonged surgical and anaesthesia times. Fluid drainage from cystic tumour ranged from 15.7 L to 107 L, with a fluid extraction rate of 0.5-2.5 L/min, and there was no re-expansion pulmonary oedema reported. Following surgery, all the patients required intensive care unit admission. One patient died during hospitalization.

CONCLUSIONS

This study contributes to the creation of a certain standard of care when dealing with patients presenting with giant intraabdominal tumour. More research is needed to define the proper way to administer anaesthesia and create practice guidelines.

Point of Care Abdominal Ultrasound

Abdominal pain is a common emergency department complaint, and point-of-care ultrasound (POCUS) of the abdomen is increasingly being utilized to evaluate clinical manifestations. It aids in accurate diagnoses and assists in procedures, particularly in emergency and critical care settings. Imaging is often required to confirm the etiology of abdominal pain. POCUS provides the benefit of avoiding radiation exposure and enables quicker diagnosis compared to computed tomography scans. There is growing evidence of the diagnostic accuracy for numerous abdominal POCUS applications, including appendicitis, intussusception, diverticulitis, gastric ultrasound and contrast-enhanced ultrasound.

Case report: Emergency management of unilateral herniation of bowel and a bilateral defect of the broad ligament in a resource limited setting

INTRODUCTION

Broad ligament herniation is a rare type of internal hernia, presenting as a diagnostic challenge. An exploratory laparotomy can be performed to definitively diagnose and treat the defect.

CASE PRESENTATION

A 36-year-old female, with no known comorbids and no significant past medical and surgical history presented with acute abdominal pain, multiple episodes of vomiting, and absolute constipation. After clinical and radiologic investigations, the diagnosis of an internal herniation of small bowel to the broad ligament was suspected. An emergent exploratory laparotomy was then performed. Intra-operatively it was found that she had a bilateral defect to the broad ligament and a unilateral broad ligament hernia (BLH). Postoperatively she remained vitally stable and was discharged home.

CLINICAL DISCUSSION

We report a rare case of a unilateral broad ligament hernia with a bilateral defect. Diagnosis of BLH is associated with diagnostic uncertainty mainly due to its rarity and nonspecific presentation.

CONCLUSION

Although broad ligament herniation is rare, it is a significant cause of intestinal obstruction and may result in complications if not attended to timely. Early diagnosis and management is necessary to minimize associated morbidity and mortality that can occur as a consequence of bowel ischemia and necrosis.

Automatic detection of ischemic necrotic sites in small intestinal tissue using hyperspectral imaging and transfer learning

Acquiring large amounts of hyperspectral data of small intestinal tissue with real labels in the clinic is difficult, and the data shows inter-patient variability. Building an automatic identification model using a small dataset presents a crucial challenge in obtaining a strong generalization of the model. This study aimed to explore the performance of hyperspectral imaging and transfer learning techniques in the automatic identification of normal and ischemic necrotic sites in small intestinal tissue. Hyperspectral data of small intestinal tissues were collected from eight white rabbit samples. The transfer component analysis (TCA) method was performed to transfer learning on hyperspectral data between different samples and the variability of data distribution between samples was reduced. The results showed that the TCA transfer learning method improved the accuracy of the classification model with less training data. This study provided a reliable method for single-sample modelling to detect necrotic sites in small intestinal tissue .

Primary small intestine angiosarcoma mimicking Crohn's disease

A man in his 40s presented to an emergency department after experiencing worsening abdominal pain for 2 days. Contrast-enhanced CT of the abdomen and pelvis revealed circumferential mural thickening and luminal narrowing of the distal ileum and upstream dilatation of the small intestine, indicating small intestine obstruction. This prompted emergency laparotomy, where two lesions in the distal ileum were identified as the source of his bowel obstruction and resected. Immunohistochemistry of the resected segment revealed a primary small intestine angiosarcoma acting positively for vascular markers ERG and CD31. A subsequent positron emission tomography (PET) scan revealed positive mediastinal metastatic lymphadenopathy without organ metastases.Following his surgery, the patient recovered well and was promptly referred to an oncology unit at a specialised health centre for further treatment. Primary small intestine angiosarcoma is a rare entity in which patients present with non-specific symptoms requiring prompt tissue diagnosis to facilitate multidisciplinary management.

Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study)

BACKGROUND

The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI).

METHODS

All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected.

RESULTS

AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied.

CONCLUSIONS

The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management.

TRIAL REGISTRATION

NCT05218863 (registered 19.01.2022).

Biocompatible Nanocomposites for Postoperative Adhesion: A State-of-the-Art Review

To reduce and prevent postsurgical adhesions, a variety of scientific approaches have been suggested and applied. This includes the use of advanced therapies like tissue-engineered (TE) biomaterials and scaffolds. Currently, biocompatible antiadhesive constructs play a pivotal role in managing postoperative adhesions and several biopolymer-based products, namely hyaluronic acid (HA) and polyethylene glycol (PEG), are available on the market in different forms (e.g., sprays, hydrogels). TE polymeric constructs are usually associated with critical limitations like poor biocompatibility and mechanical properties. Hence, biocompatible nanocomposites have emerged as an advanced therapy for postoperative adhesion treatment, with hydrogels and electrospun nanofibers among the most utilized antiadhesive nanocomposites for in vitro and in vivo experiments. Recent studies have revealed that nanocomposites can be engineered to generate smart three-dimensional (3D) scaffolds that can respond to different stimuli, such as pH changes. Additionally, nanocomposites can act as multifunctional materials for the prevention of adhesions and bacterial infections, as well as tissue healing acceleration. Still, more research is needed to reveal the clinical potential of nanocomposite constructs and the possible success of nanocomposite-based products in the biomedical market.

Gastric, Duodenal, and Small Bowel Emergencies

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

Hypothyroidism Presenting as Adynamic Ileus Mimicking a Mechanical Small Bowel Obstruction: A Diagnostic and Management Dilemma

Patients who present with nausea, vomiting, constipation, and abdominal pain typically undergo workups for small bowel obstruction (SBO). SBO is commonly caused by mechanical obstruction due to adhesions, inflammatory conditions, or malignancies. Hypothyroidism is primarily associated with decreased basal metabolic rate and rarely, in severe cases, gastrointestinal motility dysfunction. We report a case of a 44-year-old man who presented to the emergency department with abdominal pain, nausea, and vomiting. The workup, including computed tomography, showed a small bowel feces sign, highly suspicious for a mechanical SBO. His past medical history was significant for a poorly controlled hypothyroidism due to Hashimoto's thyroiditis with a markedly elevated thyroid stimulating hormone (TSH) level. He had no prior surgical history, and his family history was significant for a suspected inflammatory bowel disease (IBD) in his son. The patient failed initial resuscitative nonoperative management and underwent exploratory laparoscopy that revealed diffusely dilated small bowel loops with no obvious cause of mechanical obstruction. Inflammatory markers for IBD were found to be negative, and the patient's gastrointestinal motility gradually improved with daily intravenous levothyroxine.

Evaluation of Abdominal Emergencies

Early primary assessment and abdominal examination can often be enough to triage the patient with abdominal pain into those with less severe underlying pathologic condition from those with more acute findings. A focused history of the patient can then allow the clinician to develop their differential diagnosis. Once the differential diagnoses are determined, diagnostic imaging and laboratory findings can help confirm the diagnosis and allow for expeditious treatment and intervention.

Deep learning using computed tomography to identify high-risk patients for acute small bowel obstruction: development and validation of a prediction model : a retrospective cohort study

OBJECTIVE

To build a novel classifier using an optimized 3D-convolutional neural network for predicting high-grade small bowel obstruction (HGSBO).

SUMMARY BACKGROUND DATA

Acute SBO is one of the most common acute abdominal diseases requiring urgent surgery. While artificial intelligence and abdominal computed tomography (CT) have been used to determine surgical treatment, differentiating normal cases, HGSBO requiring emergency surgery, and low-grade SBO (LGSBO) or paralytic ileus is difficult.

METHODS

A deep learning classifier was used to predict high-risk acute SBO patients using CT images at a tertiary hospital. Images from three groups of subjects (normal, nonsurgical, and surgical) were extracted; the dataset used in the study included 578 cases from 250 normal subjects, with 209 HGSBO and 119 LGSBO patients; over 38 000 CT images were used. Data were analyzed from 1 June 2022 to 5 February 2023. The classification performance was assessed based on accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve.

RESULTS

After fivefold cross-validation, the WideResNet classifier using dual-branch architecture with depth retention pooling achieved an accuracy of 72.6%, an area under receiver operating characteristic of 0.90, a sensitivity of 72.6%, a specificity of 86.3%, a positive predictive value of 74.1%, and a negative predictive value of 86.6% on all the test sets.

CONCLUSIONS

These results show the satisfactory performance of the deep learning classifier in predicting HGSBO compared to the previous machine learning model. The novel 3D classifier with dual-branch architecture and depth retention pooling based on artificial intelligence algorithms could be a reliable screening and decision-support tool for high-risk patients with SBO.

Imaging of Strictures in Crohn's Disease

Crohn's disease (CD) is a chronic inflammation of the digestive tract, and it frequently affects young patients. It can involve any intestinal segment, even though it frequently affects the distal ileum. Up to 80% of patients with CD present with inflammatory behavior, and 5% to 28% develop stricturing disease. Based on the predominant mechanism causing them, strictures can be categorized as inflammatory, fibrotic, or mixed. Determining the relative amounts of inflammation and fibrosis in a stricture can influence treatment decisions. Imaging is an extremely useful tool in patients with small bowel stricturing CD to confirm the diagnosis and to evaluate disease characteristics, usually using CT or MRI. The aim of this paper is to describe how imaging can evaluate a patient with small bowel CD stricture.

Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy

A male patient in his 30s, with myotonic dystrophy (DM), presented to the emergency department with abdominal pain and vomiting. CT imaging revealed a soft tissue lesion in the terminal ileum causing small bowel obstruction (SBO). The patient underwent diagnostic laparoscopy which allowed identification and removal of the obstructing lesion. This was in the form of an intact, undigested potato, a phytobezoar. Bezoars are collections of undigested material found in the gastrointestinal (GI) tract, a phytobezoar is composed of plant material and is the most common form of bezoar. DM is a multisystem disorder characterised by skeletal muscle weakness, however it often presents with GI symptoms and the muscles of mastication are often affected. DM is a known risk factor for bezoar formation and should be considered as an important differential in DM patients presenting with SBO.

Accurately evaluating for a small bowel obstruction using an abdominal radiograph, by a new method: The Bowel-Spine Ratio

INTRODUCTION

A well-established method does not exist to rule out a small bowel obstruction using an abdominal xray series with significant accuracy. The hypothesis of the study is that the ratio of an average small bowel diameter to lumbar spine diameter over 0.5 is most likely a small bowel obstruction.

METHODS

An x-ray abdominal series measurement technique was applied to 41 subjects with a chief complaint of "abdominal pain" as part of a randomized retrospective case review to predict an obstruction v. non obstruction. A total number of 81 abdominal pain subjects with a mean age of 46.7 years were selected with 40 excluded due to normal small bowel gas pattern. The subject's medical information was unknown to the authors when reading their images. The measurement technique involved averaging the largest and smallest small bowel short axis diameters with comparison to the lowest clearly visible lumbar body width. The subjects' medical course as described in the medical chart or subsequent computed tomography scans were used as the referencing standard to determine presence of obstruction vs non-obstruction.

RESULTS

This method, called the Bowel-Spine Ratio (BSR), resulted in a sensitivity of 0.882 (0.622-0.979; 95% CI), specificity of 0.957 (0.760-0.998; 95% CI), accuracy of 94.7% (80.9%-99.1%; 95% CI) and a positive likelihood ratio of 21 for predicting a small bowel obstruction.

CONCLUSION

The abdominal series Bowel-Spine Ratio is a simple yet effective technique to screen for a small bowel obstruction using limited resources and to avoid unnecessary computed tomography scans with the potential to reduce health care costs.

IMPLICATIONS FOR PRACTICE

Clinicians could have increased confidence in utilizing abdominal radiographs to evaluate for small bowel obstruction.

When you hear hoofbeats, think horses before zebras - a case of recurrent small bowel obstructions with a twist

Mechanical small bowel obstructions (SBOs) account for a considerable proportion of hospital admissions for acute abdominal pain. SBOs are most frequently caused by adhesions; and very few SBOs are associated with intraperitoneal devices. An 84-year-old man was admitted to our tertiary institution with recurrent SBOs that were initially believed to be caused by his implantable cardioverter defibrillator which had undergone intraperitoneal migration. However, this was later found to be a misguided 'zebra'; as the cause was revealed to be a common 'horse' - adhesions. This article shares our key learnings from this diagnostic dilemma.

Association between clinical and surgical variables with postoperative outcomes in patients treated for intestinal obstruction for non-malignant conditions: a cross-sectional study

Intestinal obstruction is considered a frequent surgical pathology related to previous surgical procedures. Many different factors can lead to different outcomes when surgical management is needed. Therefore, we aim to describe the factors related to morbidity and mortality in surgical management of IO in a single-center experience. Retrospective observational study with a prospective database, in which we described patients who underwent surgical management due to intestinal obstruction between 2004 and 2015. Demographics, perioperative data, surgical outcomes, morbidity, and mortality were described. 366 patients were included. Female were 54.6%. Mean age was 61.26. Laparoscopic approach was done in 21.8% and the conversion rate was 17.2%. Intestinal resection was performed in 37.9% of the cases. Postoperative complications were observed in 18.85%. Reintervention and mortality were 9.5% and 4.1% respectively. Laparoscopic approach shows lesser time of intestinal transit (mean 28.67 vs. mean 41.95 h), and restart of oral intake after surgery (mean 96.06 vs. mean 119.65) compared with open approach. Increased heart rate and intensive care unit length of stay were related with mortality (p 0.01 and 0.000 respectively). For morbidity, laparotomy and need and duration of ICU stay were related with any complication statistically significant (p 0.02, 0.008, 0.000 respectively). Patients with increased heart rate in the emergency room, decreased amount of intravenous fluids, need and higher length of stay in the intensive care unit, and delay in resuming oral intake after surgery appear to have poor outcomes. Laparoscopic approach seems to be a safe and feasible approach for intestinal obstruction in selected patients.

Analysis of risk factors for recurrence and prognosis of adhesive small bowel obstruction

OBJECTIVE

The recurrence of adhesive small bowel obstruction (ASBO) limits the effectiveness of clinical treatments, making its significant clinical issues. Clinical features, perioperative parameters, and postoperative outcomes were retrospectively analyzed, to provide basis for screening the high risk factors in patients of recurrent ASBO.

METHODS

A review of medical records of patients with ASBO at Chongqing University Central Hospital, from 1 January 2015 to 31 December 2019 was conducted. We compared the clinical characteristics, intra-operative findings, and history surgery of ASBO "relapse-free" and relapsing patients. Logistic proportional hazard model was used to identify recurrence risks.

RESULTS

Based on specified inclusion and exclusion criteria, a total of 279 patients were included in this study. Participants' mean age was 63.0 (13.1) years; 49.4% (138 of 279) of them were male. Using multivariate Logistic regression analysis, the history of emergency abdominal surgery (hazard ratio, 0.241, p < 0.0001) was significantly associated with recurrence, as were multiple abdominal surgeries (hazard ratio, 0.250, p < 0.0001) and diabetes mellitus (hazard ratio, 0.182, p < 0.0001). Patients with recurrence, who underwent surgery had longer operative times, blood loss, and a higher incidence of wound complications than those without recurrence.

CONCLUSION

The history of emergency abdominal surgery, multiple abdominal surgeries, and diabetes mellitus independently increased the chances of ASBO recurrence. Patients with ASBO recurrence had a higher incidence of postoperative complications.

A gigantic Meckel's diverticulum: A case report of an exceptional cause of small bowel obstruction

INTRODUCTION

Meckel's diverticulum (MD) is the most common congenital malformation of the digestive tract, but the odds of stumbling on MD exceeding 10 cm are rare. Although obstruction is described in the literature, its occurrence due to an internal hernia caused by a fibrous band generated from a gigantic diverticulum is exceptional. This presentation aims to illustrate an exceptionally rare case of a gigantic MD responsible for a bowel obstruction due to the constriction caused by a fibrous band.

CASE PRESENTATION

A 45-year-old patient was admitted with symptoms of small bowel obstruction. On Examination, the abdomen was distended with rebound tenderness in the right iliac fossa. A CT scan showed a small bowel volvulus without signs of appendicitis. During emergency laparotomy, we found a 25 cm-long MD. The tip of the diverticulum was linked to the adjoining mesentery through a fibrous band, forming a narrow internal ring responsible for the strangulation of a part of the ileum, leading to gangrene.

DISCUSSION

Small bowel obstruction caused by a gigantic MD is rare. Diagnosis can be challenging due to its unspecific features. Management of complicated MD is surgical. Nevertheless, the management of asymptomatic MD continues to be a topic of significant disparity among authors, as there are no definitive guidelines that unequivocally dictate whether resection is warranted or not.

CONCLUSION

A gigantic MD causing small bowel obstruction is rare. Emergency doctors and surgeons should maintain a high index of suspicion for complicated MD in the preoperative phase to reduce morbidity and mortality.

Emergency laparoscopic intervention for fibrous band-induced intestinal obstruction and ischemia associated with Meckel's diverticulum: A case report

INTRODUCTION AND IMPORTANCE

Meckel's diverticulum (MD) is a common congenital malformation of the digestive tract, often asymptomatic but occasionally leading to complications such as bowel obstruction and ischemia. Timely recognition and treatment of these complications are crucial.

PRESENTATION OF CASE

We report the case of a 27-year-old male patient presenting with complete intestinal obstruction and ischemia of the ileum due to a fibrous band associated with MD. The patient presented with severe abdominal pain lasting for 10 h. Physical examination revealed a distended abdomen, antalgic position, and positive decompression. Laboratory tests showed leukocytosis and elevated lactic acid levels. Computed tomography revealed dilated small bowel loops with signs of intestinal ischemia. Emergency exploratory laparoscopy confirmed a complete ileum with ischemia and identified a fibrous band originating from the mesentery, strangulating the affected loop. The fibrous band was dissected and sectioned, confirming its association with the MD, which was resected with subsequent recovery of peristalsis and vascularization of the compromised segment. The patient had a favorable postoperative recovery without complications.

DISCUSSION

MD is a rare cause of bowel obstruction, requiring a high index of suspicion for diagnosis. Despite the challenges in preoperative identification, early surgical intervention is crucial to prevent adverse outcomes. This case emphasizes the importance of promptly recognizing and managing MD-related complications to optimize patient outcomes.

CONCLUSION

MD should be considered in cases of acute occlusive abdomen, despite its infrequent occurrence. Early diagnosis and timely surgical intervention are essential to minimize morbidity and mortality associated with MD-related complications.

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

OBJECTIVES

To investigate the diagnostic value of unenhanced CT in mechanical small bowel obstruction (SBO) with small bowel necrosis, and to establish a predictive model.

METHODS

From 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.

RESULTS

A 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.

CONCLUSION

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

BACKGROUND

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.

PATIENTS AND METHODS

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.

RESULTS

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 500 ml 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).

CONCLUSION

The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

Utility of Serum L-lactate in Identifying Ischemia in Acute Intestinal Obstruction: A Prospective Observational Study

Introduction In cases of intestinal obstruction, increasing luminal dilatation compromises bowel wall perfusion, eventually resulting in intestinal ischemia and bowel necrosis in advanced cases. Elevated L-lactate, as a biomarker of ischemia, may indicate the presence of bowel ischemia in cases of obstruction. The objective of this study was to evaluate the value of serum L-lactate measurement in predicting the presence of intraoperatively observed intestinal ischemia in patients with acute intestinal obstruction. Methods Patients diagnosed with acute intestinal obstruction were prospectively studied over an 18-month period. Serum L-lactate values were assayed twice: at the time of presentation and following appropriate fluid resuscitation. Receiver operating characteristic (ROC) curve analysis was applied to determine the predictive value of serum L-lactate in detecting intestinal ischemia. Results One hundred forty-four cases of intestinal obstruction were included in this study, of which 91 underwent operative intervention. Intestinal ischemia was identified in 52 cases and categorized intra-operatively as reversible (n = 33) and irreversible (n = 19). ROC analysis showed a good predictive value of serum L-lactate after fluid resuscitation for irreversible intestinal ischemia (area under the curve (AUC) = 0.884, 95% confidence interval (CI), 0.812-0.956). An L-lactate cut-off of 19.1 mg/dL following fluid resuscitation was determined to have a sensitivity of 89.5%, a specificity of 72.9%, a positive predictive value of 46.6%, and a negative predictive value of 96.3% for gangrenous bowel. Conclusion Serum L-lactate is a good predictive tool for identifying intestinal ischemia during the management of intestinal obstruction. Serum L-lactate after resuscitation showed better predictive value for ischemic bowel.

Perioperative Infusion Management for Adhesive Bowel Obstruction with Congenital Nephrogenic Diabetes Insipidus: A Case Report

Congenital nephrogenic diabetes insipidus (CNDI) is a rare disease that results in polyuria due to decreased responsiveness to the antidiuretic hormone in the collecting ducts of the kidney. Without compensation by drinking large amounts of water, dehydration and hypernatremia can rapidly develop. We present a case of a patient originally diagnosed with CNDI who required surgery and a fasting period due to adhesive bowel obstruction. The patient was a 46-year-old man who was originally diagnosed with CNDI. He was prescribed trichlormethiazide but self-discontinued treatment in the process. His normal urine output was about 7,000-8,000 mL/day. He underwent robot-assisted radical cystectomy and uretero-cutaneostomy for bladder cancer. Two years later, he was hospitalized due to adhesive bowel obstruction. A 5% glucose solution was infused, and the dose was adjusted according to the urine volume and electrolytes. An adhesiotomy was performed due to recurrent bowel obstruction in a short period of time. A 5% glucose solution was used as the main infusion during the perioperative period. Once drinking water was resumed after surgery, urinary output and electrolytes were easily controlled. In conclusion, patients with CNDI should be given a 5% glucose solution as the primary infusion, and the infusion volume should be adjusted by monitoring daily urine output, electrolytes, and blood glucose levels. Infusion management is easier if oral intake is initiated as early as possible.

Small bowel obstruction: what a gastroenterologist needs to know

PURPOSE OF REVIEW

Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment.

RECENT FINDINGS

Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery.

SUMMARY

Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.

Adhesive Small Bowel Obstruction: A Review

Adhesion is a leading cause of small bowel obstruction. Adhesive small bowel obstruction has significant challenges in diagnosis, treatment and prevention with considerable impact on morbidity and socioeconomic burden. Small bowel obstruction caused by adhesion or any other aetiology is clinically indistinguishable due to similar clinical presentation. Computed Tomography scans and water-soluble contrast studies are more specific in diagnosis and possess value in predicting the need for surgery. Surgical management is indicated only in complicated cases or failed conservative treatments with the majority resolving with non-operative management. However, there is no clear-cut consensus about the timing of operative intervention. Meticulous surgical practice is the keystone in preventing adhesion formation despite the availability of numerous pharmacological and surgical strategies. This review aims to update the current knowledge of the pathophysiology of adhesion formation, treatment options and various prevention modalities of adhesive small bowel obstruction.

KEYWORDS

diagnosis; laparotomy; prevention; surgery.

Small Bowel Obstruction as a Complication of Uterine Fibroids: A Case Report

Uterine fibroids are a common, benign gynecological smooth muscle neoplasm highly prevalent in women of reproductive age which can lead to multiple complications including small bowel obstruction. We report a case of a 31-year-old female, primigravida at 13 weeks gestation, a known case of uterine subserosal fibroids who presented to the emergency with complaints of dark red vaginal bleeding and cramping abdominal pain. On examination, her abdomen was 38 weeks in size. An abdominal ultrasound showed intrauterine retained products of conception measuring 5x5 cm. She was admitted as a case of incomplete miscarriage and underwent an evacuation of retained products of conception (ERPOC) immediately. A post-procedure computed tomography (CT) scan done showed the presence of multiple large uterine fibroids. The patient continued to worsen clinically with complaints of abdominal pain and diarrhea. Further laboratory tests revealed a continuous rise in inflammatory markers with positive stool clostridium toxins. She was hence shifted to the intensive care unit (ICU) as a case of sepsis. In the following days, she developed signs and symptoms of small bowel obstruction, and the diagnosis was supported by abdominal X-rays. Despite starting her on conservative management for the same, she deteriorated clinically, and a repeat CT abdomen showed new signs of small bowel obstruction. The gynecology team performed an exploratory laparotomy during which a myomectomy was done. The patient recovered well post-operatively and was discharged in a stable condition. In view of the presented case, small bowel obstruction should be considered as a complication of uterine fibroids in females with a history of large leiomyomas despite it being quite rare as it can cause considerable morbidity and mortality.

Comprehensively evaluate the short outcome of small bowel obstruction: A novel medical-economic score system

BACKGROUND

Small bowel obstruction (SBO) still imposes a substantial burden on the health care system. Traditional evaluation systems for SBO outcomes only focus on a single element. The comprehensive evaluation of outcomes for patients with SBO remains poorly studied. Early intensive clinical care would effectively improve the short-term outcomes for SBO, however, the full spectrum of the potential risk status regarding the high complication-cost burden is undetermined.

AIM

We aim to construct a novel system for the evaluation of SBO outcomes and the identification of potential risk status.

METHODS

Patients who were diagnosed with SBO were enrolled and stratified into the simple SBO (SiBO) group and the strangulated SBO (StBO) group. A principal component (PC) analysis was applied for data simplification and the extraction of patient characteristics, followed by separation of the high PC score group and the low PC score group. We identified independent risk status on admission via a binary logistic regression and then constructed predictive models for worsened management outcomes. Receiver operating characteristic curves were drawn, and the areas under the curve (AUCs) were calculated to assess the effectiveness of the predictive models.

RESULTS

Of the 281 patients, 45 patients (16.0%) were found to have StBO, whereas 236 patients (84.0%) had SiBO. Regarding standardized length of stay (LOS), total hospital cost and the presence of severe adverse events (SAEs), a novel principal component was extracted (PC score = 0.429 × LOS + 0.444 × total hospital cost + 0.291 × SAE). In the multivariate analysis, risk statuses related to poor results for SiBO patients, including a low lymphocyte to monocyte ratio (OR = 0.656), radiological features of a lack of small bowel feces signs (OR = 0.316) and mural thickening (OR = 1.338), were identified as risk factors. For the StBO group, higher BUN levels (OR = 1.478) and lower lymphocytes levels (OR = 0.071) were observed. The AUCs of the predictive models for poor outcomes were 0.715 (95%CI: 0.635-0.795) and 0.874 (95%CI: 0.762-0.986) for SiBO and StBO stratification, respectively.

CONCLUSION

The novel PC indicator provided a comprehensive scoring system for evaluating SBO outcomes on the foundation of complication-cost burden. According to the relative risk factors, early tailored intervention would improve the short-term outcomes.

High risk and low prevalence diseases: Mesenteric ischemia

INTRODUCTION

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

CONCLUSIONS

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature

Underlying cancer pain has heterogenous aetiologies and mechanisms. It requires detailed and comprehensive pain assessment, combined with personalized treatment. A multidisciplinary team is essential to providing the best management of cancer pain at every disease stage, improving the quality of life and outcomes in patients with cancer. This narrative literature review emphasizes the value of providing all patients with multidisciplinary pain management in their preferred care setting. Real-life experiences are also reported to witness the efforts of physicians to properly manage cancer pain. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.

Impact of gastric and bowel surgery on gastrointestinal drug delivery

General surgical procedures on the gastrointestinal tract are commonly performed worldwide. Surgical resections of the stomach, small intestine, or large intestine can have a significant impact on the anatomy and physiological environment of the gastrointestinal tract. These physiological changes can affect the effectiveness of orally administered formulations and drug absorption and, therefore, should be considered in rational drug formulation design for specific pathological conditions that are commonly associated with surgical intervention. For optimal drug delivery, it is important to understand how different surgical procedures affect the short-term and long-term functionality of the gastrointestinal tract. The significance of the surgical intervention is dependent on factors such as the specific region of resection, the degree of the resection, the adaptive and absorptive capacity of the remaining tissue, and the nature of the underlying disease. This review will focus on the common pathological conditions affecting the gastric and bowel regions that may require surgical intervention and the physiological impact of the surgery on gastrointestinal drug delivery. The pharmaceutical considerations for conventional and novel oral drug delivery approaches that may be impacted by general surgical procedures of the gastrointestinal tract will also be addressed.

Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not?

INTRODUCTION

Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra-abdominal surgery. However, recent studies have challenged this 'classic' approach describing success with conservative non-surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra-abdominal pathology in patients with SBO who have not undergone previous surgery.

METHODS

This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included.

RESULTS

Eighty-seven patients were included of whom 61(70.0%) were allocated to the 'therapeutic exploration' group and 26 (30.0%) to the 'non-therapeutic exploration' group. Forty-eight patients (55.0%) had adhesions, 17.2% had closed-loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups.

CONCLUSIONS

In this series, no variables were associated with intra-abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.

A rare complication of secondary pneumothorax following exploratory laparotomy for a small bowel obstruction: Case report

INTRODUCTION

Small bowel obstruction (SBO) is recognized as the most common surgical emergency following abdominal procedures. Moreover, a pneumothorax secondary to an SBO is an infrequent phenomenon less commonly reported in recent literature. Clinical presentation includes progressive dyspnea and fatigue. The diagnosis was made with imaging. In this case report, the authors present a rare case of concurrent surgical complications (pneumothorax, SBO, perforation of the stomach, and hiatal hernia).

CASE PRESENTATION

A 62 years-old African American patient who presented with severe sudden onset difficulty breathing two days following laparoscopic toupet fundoplication procedure. She was given oxygen via cannula and the underwent chest tube insertion. She was then transferred to different facility under care of a cardio thoracic surgeon.

CLINICAL DISCUSSION

Although SBO is most common emergency following an abdominal procedure, pneumothorax is rarely reported. This case report depicts a unique presentation of pneumothorax secondary to SBO and a discussion section conferring complication risk versus benefits of diverse management modalities (surgical or conservative), and a review of recent literature, further aiding healthcare professionals in the diagnosis and management of patients with SBO complications.

CONCLUSION

Review of this case and the literature show a rare presentation of secondary pneumothorax following exploratory laparotomy for SBO. Recognizing the clinical signs and even a small suspicion should prompt one to order imaging. Chest X-ray is inexpensive and can rapidly rule out pneumothorax. These complications have high mortality in patients above the age of 60 years, hence, timely management is of utmost importance.

Obstrucción intestinal por adherencias: un lienzo en blanco en el que el cirujano elige los colores

Introducción. La obstrucción intestinal es una patología de alta prevalencia. Su abordaje diagnóstico y terapéutico ha evolucionado acorde con el avance del conocimiento e implementación de la tecnología. El impacto de sus complicaciones obliga a redoblar esfuerzos en pro de lograr una mayor efectividad. Se hizo una aproximación reflexiva al problema, mediante una identificación de los puntos controversiales de interés para el cirujano general. Métodos. Se realizó una búsqueda sistemática de la literatura en varias bases de datos, utilizando dos ecuaciones de búsqueda que emplearon términos seleccionados a partir de los tesauros “Medical Subject Heading” (MeSH) y “Descriptores en Ciencias de la Salud” (DeCS). Resultados. Se recolectaron 43 artículos y a partir de ellos se construyó el texto de revisión. La identificación pronta de los posibles candidatos a cirugía, mediante un esquema diagnóstico y terapéutico, se constituye en una prioridad en el manejo de estos pacientes. De igual manera, se efectúan consideraciones en la toma de decisiones con respecto a la vía quirúrgica, así como recomendaciones técnicas operatorias producto de la experiencia y lo reportado en la literatura. Existen factores propios del cirujano, del contexto y del paciente, que inciden en la resolución del problema. Conclusión. La obstrucción intestinal y sus implicaciones clínicas obligan a una reevaluación constante de su estado del arte y avances en el manejo, tendiente a una búsqueda de oportunidades para impactar favorablemente en su curso clínico. Hay estrategias por implementar, inclusive el manejo laparoscópico en casos seleccionados.

Intestinal pseudo-obstruction caused byGiardia lambliainfection

A woman in her 40s presented with malaise, nausea, reduced appetite, abdominal distention, loose stools and weight loss. Symptoms had started 6 months earlier and worsened in the last 2 weeks. CT enterography showed hypotonic dilated small bowel loops in absence of any mechanical obstruction. Endoscopic examinations including capsule endoscopy did not reveal any obstructing lesion, but a delayed small bowel transit time of the capsule. Duodenal histology revealed Marsh 3a villous atrophy. Secondary causes of intestinal pseudo-obstruction and villous atrophy were investigated.Giardia lambliatrophozoites were found in the stools and in the duodenal biopsies. The patient’s symptoms quickly resolved after metronidazole treatment with complete normalisation of duodenal histology.

Analysis of Placement Priorities and Nursing Countermeasures of Transnasally Inserted Intestinal Obstruction Catheters in Patients with Acute Small Bowel Obstruction

Objective

To explore the placement priorities and analysis of nursing countermeasures of transnasally inserted intestinal obstruction catheters in patients with acute small bowel obstruction (ASBO).

Methods

One hundred and three patients with ASBO treated in our hospital from May 2016 to February 2022 were enrolled to this study. Patients who received individual nursing for transnasally inserted intestinal obstruction catheters were considered as the observation group (n = 59) and those who received traditional nursing were regarded as the control group (n = 44). The symptom relief time, daily gastrointestinal decompression, bowel sound recovery time, exhaust, defecation recovery time, and gas-liquid plane disappearance time were compared between both groups. The abdominal pain was evaluated by visual analogue scale (VAS), and the psychology of patients was evaluated by self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Patients' clinical efficacy and incidence of adverse effects were counted, and quality of life was assessed using the short form 36 (SF-36) health survey questionnaire.

Results

In the observation group, the improvement time of clinical symptoms and VAS, SAS, and SDS scores after intubation were lower than those of the control group, while the total clinical treatment efficiency was higher (P < 0.05). As to the adverse effects, the observation group was lower than the control group (P < 0.05). Also, the SF-36 scores were higher than those of the control group in all dimensions (P < 0.05).

Conclusion

The individual nursing strategy implemented for the transnasally inserted intestinal obstruction catheter can effectively shorten the recovery of ASBO patients and improve their treatment outcome and prognosis quality of life.

Use of Seprafilm in a Patient With Recurrent Small Bowel Obstruction: A Case Report

Small bowel obstruction (SBO) is an emergency that should be managed early to reduce the risk of bowel perforation, strangulation and subsequent life-threatening organ dysfunction caused by sepsis. A prompt diagnostic workup including imaging and lab studies is required to assess the severity of the obstruction and to establish if emergency surgery is required. We report the case of a 55-year-old male with a history of recurrent SBO, previous ventral hernia repair and indications of previous colonic tubular adenoma per colonoscopy findings. The patient underwent an exploratory laparotomy procedure and adhesiolysis to release the SBO. This case report emphasizes the safety and efficacy of Seprafilm placement intraoperatively in decreasing the occurrence of postoperative adhesions in abdominal laparotomy procedures.

Application of Laparoscopy Combined with Enhanced Recovery after Surgery (ERAS) in Acute Intestinal Obstruction and Analysis of Prognostic Factors: A Retrospective Cohort Study

Objective

A retrospective cohort study was carried out to research the effect of stent combined with laparoscopy combined with enhanced recovery after surgery (ERAS) in the operation of acute intestinal obstruction and to explore and analyze the prognostic factors.

Methods

During February 2019 to April 2021, sixty patients with acute intestinal obstruction cured in our hospital were enrolled. Randomly assigned control group patients (n = 50) were divided into the research group and control group patients. The control group accepted stent combined with laparoscopic therapeutic, and the research group accepted stent combined with laparoscopic therapeutic based on ERAS. The general data, operative index, Short Form 36 (SF-36) score, visual analogue scale (VAS) score, procalcitonin (PCT), CRP, prealbumin (PA) index, curative effect, and incidence of complications were investigated.

Results

No difference was found in age, gender, or type of disease among the general population (P > 0.05). A lower amount of blood was lost during the operation, less anal exhaustion was experienced by the research group, and a shorter hospital stay and lower hospitalization cost was experienced in the research group compared to the control group (P < 0.05). There exhibited no remarkable difference in SF-36 score and VAS score before operation, but after operation, the VAS score lessened, the SF-36 score augmented, while the VAS score was lower, and the SF-36 score in the research group was higher (P < 0.05). There exited no remarkable difference in the indexes of PCT, CRP, and PA before operation, but after operation, the levels of PCT and CRP lessened as well as the level of PA augmented, and the levels of PCT and CRP were lower, while the level of PA in the research group was higher. In terms of the clinical efficacy, the effective rate of the research group (98.00%) was higher compared to the control (86.00%) (P < 0.05). The main postoperative complications were pulmonary infection and incision infection. One case of incision infection occurred in the research group, and the probability of postoperative complications was 2.00%. In the control group, there were 3 cases of pulmonary infection, 0 cases of perforation, and 4 cases of incision infection, and the probability of postoperative complications was 14.00%. The prevalence in the research group was remarkably lower (P < 0.05).

Conclusion

Compared with the traditional concept of surgical therapeutic, it can more effectively reduce stress reaction, relieve postoperative pain, promote the recovery of postoperative gastrointestinal function as soon as possible, and reduce postoperative complications, which is worth to explore the application in the therapeutic of acute abdomen.

Impact of intravenous dexmedetomidine on gastrointestinal function recovery after laparoscopic hysteromyomectomy: a randomized clinical trial

Postoperative intestinal ileus is common after laparoscopic surgery, the incidence of those after hysterectomy was 9.2%. Anesthesia is one of the independent risk factors of postoperative ileus. Dexmedetomidine has been widely used in perioperative anesthesia and previous reports suggested that intraoperative dexmedetomidine may be associated with the improvement of gastrointestinal function recovery after abdominal surgery. We hypothesized that dexmedetomidine could improve gastrointestinal function recovery after laparoscopic hysteromyomectomy. Participants in elective laparoscopic hysteromyomectomy were enrolled with a single dose of 0.5 μg kg⁻¹ dexmedetomidine or the same volume of placebo intravenously administered for 15 min, followed by continuous pumping of 0.2 μg kg⁻¹ h⁻¹ of corresponding drugs until 30 min before the end of surgery. The primary outcome was the time to first flatus. Secondary outcomes were the time to first oral feeding and the first defecation, the occurrence of flatulence, pain score and postoperative nausea and vomiting until 48 h after the surgery. Eventually, 106 participants (54 in dexmedetomidine group and 52 in placebo group) were included for final analysis. The time to first flatus (SD, 25.83 [4.18] vs 27.67 [3.77], P = 0.019), oral feeding time (SD, 27.29 [4.40] vs 28.92 [3.82], P = 0.044), the time to first defecation (SD, 59.82 [10.49] vs 63.89 [7.71], P = 0.025), abdominal distension (n%, 12 (22.2) vs 21 (40.4), P = 0.044), PONV at 24 h (n%, 10 (18.5) vs 19 (36.5), P = 0.037), NRS 6 h (3.15(0.68) vs 3.46 (0.87), P = 0.043) and NRS 12 h (3.43 (0.88) vs 3.85 (0.85), P = 0.014) of dexmedetomidine group were significantly shorter than those of the placebo group. Intraoperative dexmedetomidine reduced the time to first flatus, first oral feeding, and first defecation. These results suggested that this treatment may be a feasible strategy for improving postoperative gastrointestinal function recovery in patients undergoing laparoscopic hysteromyomectomy.

Atypical Small Bowel Obstruction Caused by Perforated Cecum: A Case Report

Acute onset of abdominal pain with emesis and lack of stool or flatus is an alarming presentation for possible small bowel obstruction (SBO). SBO should be high on the differential diagnosis due to concomitant signs and symptoms that are highly sensitive in diagnosing SBO. These include diffuse tenderness on palpation of the abdomen, abdominal distention, hypotension, vomiting, and lack of flatus or stool. In this report, we present a 67-year-old African American male, who presented to the emergency department with the above-mentioned signs and symptoms and decreased oral intake for four days, ultimately undergoing surgical exploration to relieve the SBO caused by an idiopathic cecal perforation. This case report calls attention to the decision-making, standard protocol, and surgical intervention of a patient with SBO.