Gastrointestinal involvement in STEC-associated hemolytic uremic syndrome: 10 years in a pediatric center

BACKGROUND

The gastrointestinal (GI) tract represents one of the main targets of typical hemolytic uremic syndrome (HUS) in children. In this observational study, we tried to establish (1) the main features of GI complications during STEC-HUS and (2) the relationship between Escherichia coli serotypes and Shiga toxin (Stx) variants with hepatopancreatic involvement.

METHODS

A total of 79 STEC-HUS patients were admitted to our pediatric nephrology department between January 2012 and June 2021. Evidence of intestinal, hepatobiliary, and pancreatic involvements was reported for each patient, alongside demographic, clinical, and laboratory features. Frequency of gastrointestinal complications across groups of patients infected by specific E. coli serotypes and Stx gene variants was evaluated.

RESULTS

Six patients developed a bowel complication: two developed rectal prolapse, and four developed bowel perforation which resulted in death for three of them and in bowel stenosis in one patient. Acute pancreatitis was diagnosed in 13 patients. An isolated increase in pancreatic enzymes and/or liver transaminases was observed in 41 and 15 patients, respectively. Biliary sludge was detected in three, cholelithiasis in one. Forty-seven patients developed direct hyperbilirubinemia. Neither E. coli serotypes nor Shiga toxin variants correlated with hepatic or pancreatic involvement.

CONCLUSIONS

During STEC-HUS, GI complications are common, ranging from self-limited elevation of laboratory markers to bowel perforation, a severe complication with a relevant impact on morbidity and mortality. Hepatopancreatic involvement is frequent, but usually short-lasting and self-limiting.

Previously undiagnosed Morgagni hernia with bowel perforation detected during repeat screening colonoscopy: A case report

BACKGROUND

Morgagni hernia (MH) is a form of congenital diaphragmatic hernia (CDH) characterized by an incomplete formation of diaphragm, resulting in the protrusion of abdominal organs into the thoracic cavity. The estimated incidence of CDH is between 1 in 2000 and 1 in 5000 live births, although the true incidence is unknown. MH typically presents in childhood and can be diagnosed either prenatally or postnatally. However, it can also be asymptomatic and carry the risk of developing into a life-threatening condition in adulthood.

CASE SUMMARY

A 76-year-old female with no history of prior abdominal surgeries presented for an elective colonoscopy for polyp surveillance. During the procedure, when approaching the hepatic flexure, the scope could not be advanced further despite multiple attempts. The patient experienced mild abdominal discomfort, leading to the abortion of the procedure. While in the recovery area, she developed increasing abdominal pains and hypotension. Urgent abdominal imaging revealed herniation of the proximal transverse colon through a MH into the chest with evidence of perforation. The patient underwent laparoscopic urgent colonic resection and primary hernia repair and was discharged uneventfully 2 d later.

CONCLUSION

A MH is a rare condition in adults that can present as a life-threatening complication of colonoscopy, even in patients with a history of uneventful colonoscopies. This case highlights the importance of considering congenital and internal hernias when faced with sudden and unexplained difficulties during colonoscopy. If there is a suspicion of MH, the endoscopist should halt the procedure and immediately obtain abdominal imaging to confirm the diagnosis.

Primary sclerosing encapsulating peritonitis

Sclerosing encapsulating peritonitis also known as cocoon abdomen is a rare chronic inflammatory condition of the peritoneum in which the bowel loops are encircled by a membrane (cocoon formation) within the peritoneal cavity leading to intestinal obstruction. It can be primary (idiopathic) or secondary (chemotherapy, beta-blockers, peritoneal dialysis, shunts, tuberculosis, systemic lupus erythematosus, etc.). The symptomatology report includes recurrent episodes of abdominal pain and vomiting. We present here a case of a 32-year-old male who presented with complaints of being unable to pass stools, vomiting (3-4 times), and abdomen pain for 4 days. This case is considered worth mentioning due to its rarity, lack of identification of secondary causes, and diminutive mention of histopathological aspect.

Characteristics, treatment, and outcome of patients with bowel perforation after immune checkpoint inhibitor exposure

PURPOSE

Exposure to immune checkpoint inhibitors (ICIs) can predispose to immune-related adverse events (irAEs) involving the gastrointestinal tract. The association between ICIs and bowel perforation has not been well studied. We aimed to describe the clinical course, complications, treatment, and outcomes of patients experiencing bowel perforation during or after ICI treatment.

METHODS

This retrospective, single-center study included adult cancer patients with bowel perforation that occurred between the first dose of ICI treatment and up to 1 year thereafter between 1/1/2010 and 4/30/2021. Patients' clinical course, imaging, treatment, and outcomes related to bowel perforation were collected and analyzed.

RESULTS

Of the 13,991 patients who received ICIs during the study period, 90 (0.6%) met the inclusion criteria. A majority were male (54.4%), the most common cancer type was melanoma (23.3%), and most patients had received PD-1/L1 inhibitor treatment (58.8%). Onset of perforation occurred after a median of four ICI treatment cycles. The most common symptom was abdominal pain (95.5%). The colon was the most common location for the perforation (37.7%). Evidence of diverticulitis, enterocolitis, or appendicitis was seen in 32 (35.6%) patients, and 6 (6.6%) patients had luminal cancer involvement at the time of perforation. The overall hospitalization rate related to perforation was 95.5%, with mortality of 15.5% during the same admission. Antibiotics were given in 95% of our sample; 37.8% of patients also required surgical/interventional radiology intervention. Forty-six patients (51.1%) had perforation-related complications (e.g., sepsis, fistula, abscess), which were associated with a higher mortality rate (30%).

CONCLUSION

Our findings suggest a low incidence of bowel perforation after ICI treatment (0.6%), with 40% of patients having coexisting bowel inflammation as a potential contributing factor. Patients with bowel perforation had an aggressive disease course and high rates of hospitalization, complications, and mortality. Early recognition and prompt intervention is critical to improve patient outcomes. Future studies are warranted to further investigate the cause, predictive markers, and optimal treatment for this patient population.

Surgical complications of oncological treatments: A narrative review

Gastrointestinal complications are common in patients undergoing various forms of cancer treatments, including chemotherapy, radiation therapy, and molecular-targeted therapies. Surgical complications of oncologic therapies can occur in the upper gastrointestinal tract, small bowel, colon, and rectum. The mechanisms of action of these therapies are different. Chemotherapy includes cytotoxic drugs, which block the activity of cancer cells by targeting intracellular DNA, RNA, or proteins. Gastrointestinal symptoms are very common during chemotherapy, due to a direct effect on the intestinal mucosa resulting in edema, inflammation, ulceration, and stricture. Serious adverse events have been described as complications of molecular targeted therapies, including bowel perforation, bleeding, and pneumatosis intestinalis, which may require surgical evaluation. Radiotherapy is a local anti-cancer therapy, which uses ionizing radiation to cause inhibition of cell division and ultimately lead to cell death. Complications related to radiotherapy can be both acute and chronic. Ablative therapies, including radiofrequency, laser, microwave, cryoablation, and chemical ablation with acetic acid or ethanol, can cause thermal or chemical injuries to the nearby structures. Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication. Furthermore, it is important to know the stage and prognosis of the disease, and a multidisciplinary approach is necessary to personalize the surgical treatment. The purpose of this narrative review is to describe complications related to different oncologic therapies that may require surgical interventions.

Misdiagnosis of food-borne foreign bodies outside of the digestive tract on magnetic resonance imaging: Two case reports

BACKGROUND

Patients with foreign bodies in the digestive tract are often encountered, but complete penetration of a foreign body through the gastrointestinal tract is rare, and the choice of imaging method is very important. Improper selection may lead to missed diagnosis or misdiagnosis.

CASE SUMMARY

An 81-year-old man was diagnosed as having a liver malignancy after he took magnetic resonance imaging and positron emission tomography/computed tomography (CT) examinations. The pain improved after the patient accepted gamma knife treatment. However, he was admitted to our hospital 2 mo later due to fever and abdominal pain. This time, he received a contrast-enhanced CT scan, which showed fish-boon-like foreign bodies in the liver with peripheral abscess formation, then he went to the superior hospital for surgery. It lasted for more than 2 mo from the onset of the disease to the surgical treatment. A 43-year-old woman with a 1 mo history of a perianal mass with no obvious pain or discomfort was diagnosed as having an anal fistula with the formation of a local small abscess cavity. Clinical perianal abscess surgery was performed, and fish bone foreign body was found in perianal soft tissue during the operation.

CONCLUSION

For patients with pain symptoms, the possibility of foreign body perforation should be considered. Magnetic resonance imaging is not comprehensive and that a plain computed tomography scan of the pain area is necessary.

Sigmoid colon perforation secondary to blunt abdominal trauma from cow hoof

INTRODUCTION

Abdominal discomfort is one of the most prevalent complaints presented to the emergency department. When making a clinical diagnosis, blunt trauma with substantial visceral injuries requires a high index of suspicion.

CASE PRESENTATION

The patient went to the emergency room after experiencing lower abdomen discomfort and a fever for two days. He was 40 years old. He says he was injured two days earlier when a cow foot landed on his stomach, causing mild blunt injuries. When examined, he is delicate all the way down in his lower belly. Results from the lab indicated a higher-than-normal total leucocyte count. Echogenic bowel thickening is seen on point-of-care ultrasonography (PoCUS) of the lower abdomen. Abdominal CT with contrast revealed oedema, heterogeneous enhancement, and a focal stretch of thickened circumferential mural including the sigmoid colon and peri-colonic fat stranding. Biopsy results from a sigmoidoscopy revealed significant sigmoid colon constriction and localized areas of active inflammation. Stricture development after a Sigmoid hole caused by a cow foot injury is an extremely unusual occurrence.

DISCUSSION

This case emphasizes the need of a thorough history and physical examination, especially in a high-pressure emergency scenario, and the value of using ultrasonography at the bedside to make a definitive diagnosis and improve patient care.

CONCLUSION

Regardless of the severity of abdominal damage caused by cattle collision, early imaging should be explored since delaying action might result in poor results.

Postpartum Multiple Colon Perforation after Cesarean Section in COVID-19 Patients: A Case Series

Introduction

Gastrointestinal symptoms are present in 50% of polymerase chain reaction (PCR)-positive COVID-19 patients. In addition, bowel abnormalities are a common finding of COVID-19, and bowel-wall disorder is reported in 31% of computed tomography images of COVID-19 patients.

Case History

We report three postpartum cases with colon perforation after Cesarean section and positive PCR for SARS-CoV-2-RNA and during the main peak of COVID-19 pandemic, who were managed by early detection, laparotomy, and effective treatment and were discharged and followed up.

Conclusion

A colonic perforation could be considered as one of the causes of abdominal pain especially in women with a past surgical history as well as patients with infectious diseases such as COVID-19. Therefore, abdominal and pelvic ultrasound or x-ray was strongly recommended for postpartum women with abnormal abdominal distension, gastrointestinal symptoms, and pain to prevent possible fetal complications.

Enterococcus gallinarum group meningitis after transanal migration of the ventriculoperitoneal shunt: a pediatric case report

In the literature, only 11 Enterococcus gallinarum group meningitis has been reported so far. The Enterococcus gallinarum group was shown for the first time in a pediatric patient presenting with meningitis after bowel perforation, a complication of a ventriculoperitoneal shunt. A 30-month-old male patient presented with vomiting and fever, with the ventriculoperitoneal shunt distal catheter protruding from the anal orifice. The patient was diagnosed with intestinal perforation and meningitis. Enterococcus gallinarum group bacterial yield in cerebrospinal fluid culture. A total of 6 weeks of intravenous antibiotic treatment was given in the hospital. After the treatment, the patient was re-ventriculoperitoneal shunt and was discharged. Among the shunt complications, meningitis with intestinal perforation is rare. It should be kept in mind that meningitis in such patients may be caused by very rare microbiological factors such as Enterococcus gallinarum group. Antibiotherapy should be given according to the culture result. Then planning should be made for a permanent shunt.

Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report

BACKGROUND

In patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure.

CASE PRESENTATION

We report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen.

CONCLUSIONS

The patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.

Hypereosinophilic syndrome presenting as coagulopathy

Background

Hypereosinophilic syndrome (HES) is an extremely uncommon group of disorders. It rarely presents with coagulopathy without cardiac involvement.

Case presentation

A 33-year-old previously healthy male with no history of atopic disease presented with abdominal pain, hematochezia, peripheral eosinophilia as high as 10,000 eos/µL, right and left portal vein, mesenteric, and splenic vein thrombi with ischemic colitis resulting in hemicolectomy and small bowel resection. Despite an extensive workup for primary and secondary etiologies of hypereosinophilia by hematology/oncology, infectious disease, rheumatology and allergy/immunology, no other clear causes were identified, and the patient was diagnosed with idiopathic HES. His eosinophilia was successfully treated with high-dose oral corticosteroids (OCS) and subsequently transitioned to anti-IL-5-receptor therapy with benralizumab. He has continued this treatment for over a year with no recurrence of eosinophilia or thrombosis while on benralizumab.

Conclusion

In patients with an unexplained coagulopathy and eosinophilia, eosinophilic disorders such as HES should be considered. Corticosteroid-sparing agents, such as benralizumab show promise for successfully treating these patients.

Percutaneous peritoneal drain placement: A pilot study of pediatric surgery simulation-based training for general surgery residents

INTRODUCTION

General surgery residents often feel unprepared to perform pediatric surgery procedures since case volume and experience may be low. Previously, we successfully implemented a simulation-based training (SBT) module for placement of a silastic silo for gastroschisis. Therefore, we designed a single institution pilot study to assess whether SBT for placement of a percutaneous peritoneal drain for perforated necrotizing enterocolitis (NEC) was feasible and lead to skill acquisition and increased confidence.

METHODS

Our newly created NEC module within our pediatric surgery SBT curriculum for general surgery residents was used. Residents completed two simulation sessions three months apart with confidence testing before and after each session. Skill acquisition and performance were assessed using a standardized case scenario and procedure checklist. Changes in residents' confidence and performance were determined using Wilcoxon Signed-Rank Tests.

RESULTS

Nine post-graduate-year three general surgery residents completed this curriculum. Following completion, residents reported improved confidence completing each step of the procedure initially (p = 0.005) and at 3 months (p = 0.008) with improved technical scores (p = 0.011). The number of residents deemed proficient significantly improved (p = 0.031).

CONCLUSION

Implementation of SBT module for perforated NEC was feasible and improved residents' confidence and proficiency completing the procedure.

Gastrointestinal complications (gangrene or perforation) after corona virus disease 2019 - A series of ten patients

During the recent second wave of corona virus disease 2019 (COVID-19) pandemic in India, we managed a series of gastrointestinal complications in patients with COVID-19. We aim to highlight the key presentation and clinical course and emphasize the lessons we learnt from our series of such patients. A case review of ten consecutive patients with either bowel gangrene or perforation who were managed at our centre from March 20, 2021 to June 10, 2021. Clinical-demographic details, possible etiology, radiological findings, management and outcomes have been described. Of the 10 patients, 2 presented with bowel gangrene and 8 with perforation. In our series, all these patients were diagnosed with the help of computed tomography (CT) abdomen during the 3rd week after diagnosis of COVID-19. All had received steroid medication. Both patients with bowel gangrene and 4 of 8 patients with perforation underwent surgery, while 4 were managed non-operatively. Barring one patient, all the operated patients succumbed within 5 days of surgery after rapid clinical deterioration. Non-operative management in selected patients with perforation including placement of percutaneous drains, bowel rest and antibiotics was successful. Emergency surgery for COVID-19 related intestinal gangrene or perforation was associated with high mortality in our series. Non-operative management which avoids the added stress of a major emergency surgery particularly in patients just recovering from COVID-19 may be considered in stable patients in whom perforation appears to be contained.

Clinical features and outcomes of bowel perforation in primary pediatric gastrointestinal lymphoma

Background

Whether surgery can improve the prognosis of patients with primary pediatric gastrointestinal lymphoma (PPGL) who experienced bowel perforation remains controversial. This study aimed to evaluate the prognosis of such patients.

Methods

Nine patients pathologically diagnosed with PPGL who experienced perforation at our center between January 2010 and December 2020 were enrolled and divided into two groups: those with perforation during (n = 4) and before (n = 5) chemotherapy. Their medical records were reviewed, and long-term follow-up was conducted by telephone in February 2021.

Results

All patients with perforation during chemotherapy were diagnosed with PPGL in the outpatient department. The mean time from outpatient visit to chemotherapy was 17.3 ± 6.1 days. Two patients experienced perforation during the first chemotherapy regimen and received conservative treatment, while the others developed perforation after multiple chemotherapy regimens and underwent surgery. All of the patients received regular chemotherapy and survived for a mean follow-up time of 3.8 ± 1.9 years. No patient with perforation before chemotherapy had a definite diagnosis in the outpatient department. Among these patients, 4 experienced perforation and underwent surgery, of whom 3 developed perforation-related complications and died; the other recurred after chemotherapy. Only the patient who received conservative treatment was diagnosed with PPGL before chemotherapy, received regular chemotherapy, and survived without a recurrence for 1.0 year.

Conclusion

Prompt diagnosis and chemotherapy improve the prognosis of PPGL. Surgery does not affect the prognosis of patients with perforation during chemotherapy but may accelerate disease progression in patients with perforation before chemotherapy.

[Severe bowel complications in SARS-CoV-2 patients receiving protocolized care]

Introduction and aims

A case series of ten patients that received protocolized care for SARS-CoV-2 infection and developed severe gastrointestinal complications, is presented. The aim of our study was to contribute to the ongoing discussion regarding gastrointestinal complications related to SARS-CoV-2 infection. After reviewing the current literature, ours appears to be the first detailed case series on the topic.

Materials and methods

A retrospective filtered search of all patients admitted to our hospital for SARS-CoV-2 infection, who developed severe gastrointestinal complications, was performed. All relevant data on hospital patient management, before and after surgery, were collected from the medical records.

Results

Of the 905 patients admitted to our hospital due to SARS-CoV-2 infection, as of August 26, 2020, ten of them developed severe gastrointestinal complications. Seven of those patients were men. There were four cases of perforation of the proximal jejunum, three cases of perforations of the ascending colon, one case of concomitant perforation of the sigmoid colon and terminal ileum, one case of massive intestinal necrosis, and one preoperative death. Three right colectomies, four intestinal resections, one Hartmann's procedure with bowel resection, and one primary repair of the small bowel were performed. The mortality rate of the patients analyzed was 50%.

Conclusion

Spontaneous bowel perforations and acute mesenteric ischemia are emerging as severe, life-threatening complications in hospitalized SARS-CoV-2 patients. More evidence is needed to identify risk factors, establish preventive measures, and analyze possible adverse effects of the current treatment protocols.

Large intestinal perforation secondary to COVID-19: A case report

Introduction

COVID-19 infection is generally characterized by the presence of respiratory symptoms. However, a small percentage of these patients also have gastrointestinal symptoms and complications that are associated with high morbidity and mortality.

Presentation of case

A 50-year-old male patient with COVID-19 infection was being treated for COVID-19 and pneumonia in the ICU. He presented with gastrointestinal symptoms, and the computed tomography (CT) scan revealed a hollow viscus perforation. Ultimately, the patient was taken to surgery, where a spontaneous perforation was found in the right colon. The defect was sutured with separate stitches. There were no complications postoperatively.

Discussion

Although respiratory symptoms are the most common presentation of COVID-19, about 18% of these patients may present with gastrointestinal symptoms. However, an even smaller percentage of critically ill patients may develop serious gastrointestinal complications such as perforation of the large intestine. This unusual complication requires immediate diagnosis and surgical management.

Conclusion

At the time of the COVID-19 pandemic, physicians must recognize COVID-19 in patients presenting gastrointestinal symptoms. A high degree of clinical suspicion enables timely diagnosis and management, thereby preventing major complications.

•

Bowel perforation is an uncommon complication of COVID-19. It has been rarely reported in the literature.

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Patients with severe COVID-19 have an increased risk of gastrointestinal complications, including bowel perforation.

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Bowel perforation secondary to COVID-19 in critically ill patients has a nonspecific presentation; thus, it only confers a high degree of suspicion.

Bowel obstruction and perforation during pregnancy: Case report and literature review

OBJECTIVE

Bowel perforation during pregnancy is a rare but life-threatening situation, and the management remained uncertain. We presented a case in our hospital and reviewed literatures to provide a guidance to deal with this challenging situation.

CASE REPORT

A case at gestational age 26 weeks and 4 days, who had bowel perforation over previous ileo-colonic anastomosis site. The fetus was delivered via cesarean section after 1 week of operation and both were discharged without major complication at 35 days after delivery. We searched Pubmed and reviewed 15 English literatures and make a discussion.

CONCLUSION

A simultaneous cesarean section could be considered if the gestational age was large enough to avoid the comorbidity of preterm birth or the maternal risk of sepsis outweigh the risk of preterm birth. Otherwise, tocolysis should be used in an attempt to delay delivery until the antenatal corticosteroids have worked.

Severe bowel complications in SARS-CoV-2 patients receiving protocolized care

INTRODUCTION AND AIMS

A case series of ten patients that received protocolized care for SARS-CoV-2 infection and developed severe gastrointestinal complications, is presented. The aim of our study was to contribute to the ongoing discussion regarding gastrointestinal complications related to SARS-CoV-2 infection. After reviewing the current literature, ours appears to be the first detailed case series on the topic.

MATERIALS AND METHODS

A retrospective filtered search of all patients admitted to our hospital for SARS-CoV-2 infection, who developed severe gastrointestinal complications, was performed. All relevant data on hospital patient management, before and after surgery, were collected from the medical records.

RESULTS

Of the 905 patients admitted to our hospital due to SARS-CoV-2 infection, as of August 26, 2020, ten of them developed severe gastrointestinal complications. Seven of those patients were men. There were four cases of perforation of the proximal jejunum, three cases of perforations of the ascending colon, one case of concomitant perforation of the sigmoid colon and terminal ileum, one case of massive intestinal necrosis, and one preoperative death. Three right colectomies, four intestinal resections, one Hartmann's procedure with bowel resection, and one primary repair of the small bowel were performed. The mortality rate of the patients analyzed was 50%.

CONCLUSION

Spontaneous bowel perforations and acute mesenteric ischemia are emerging as severe, life-threatening complications in hospitalized SARS-CoV-2 patients. More evidence is needed to identify risk factors, establish preventive measures, and analyze possible adverse effects of the current treatment protocols.

Comparison of risk factors and treatments for intestinal perforation after colonoscopic treatment

BACKGROUND

In recent years, colonoscopy, as the most important tool for the diagnosis and treatment of colorectal diseases, has been widely used in clinical practice, but it is somewhat invasive and may lead to a series of serious complications such as gastrointestinal bleeding and perforation. Among them, gastrointestinal perforation, if not detected and treated timely, can cause septic shock, and even endanger life.

AIM

To analyze the risk factors that may lead to colonoscopy-related perforation and explore the reasonable treatment for patients with perforation.

METHODS

A total of 41642 patients who underwent electronic colonoscopy at our hospital from January 2012 to December 2020 were statistically analyzed. The general information of the patients (gender, age, past history, body mass index, anesthesia, intestinal cleanliness, operating time, perforation site, etc.) was reviewed, and the risk factors for colonoscopy-related perforation were analyzed. The clinical efficacy and prognosis were compared between laparoscopic surgery (LS) and open surgery (OS).

RESULTS

Intestinal perforation occurred in 21 (0.05%) patients, including 13 cases of perforation caused by colonoscopy and 8 cases caused by treatment (including entrapment polypectomy, endoscopic mucosal resection, balloon dilation, and other invasive procedures). The most common perforation sites were the sigmoid colon (47.6%) and rectum (28.6%). Laparoscopic surgery was performed in 13 cases, open surgery in 7, conservative treatment in 1, and enterostomy in 3. Logistic regression analysis indicated that intestinal cleanliness, anesthesia, and abdominal operation history were the risk factors for colonoscopy-related perforation (P < 0.05), while gender, age, body mass index, examination, and treatment were not (P < 0.05).The postoperative length of stay, postoperative pain score, wound infection rate, and hospitalization cost in the LS group were significantly different from those in the OS group.

CONCLUSION

Colonoscopy-related perforation more commonly occurs in the sigmoid colon and rectum. Roughness of operation, weak local intestinal wall, and abnormal anatomical structure are three important factors leading to intestinal perforation. Poor intestinal cleanliness and previous history of abdominal surgery are high risk factors for perforation, while early detection and active surgery are the basic principles for the treatment of intestinal perforation, and laparoscopic perforation repair is the first choice. If bowel preparation is ready, it is safe and feasible to avoid a prophylactic enterostomy in most patients with colonoscopy perforation.

Gastric perforation by fish bone with hepatic abscess formation presenting as prolonged fever

A 70-year-old woman presented to the emergency department with a 3-week history of prolonged fever, asthenia and anorexia, denying other symptoms. Physical examination was unremarkable and the patient admitted for further investigation. Initial laboratory testing showed leucocytosis, elevated C-reactive protein and cholestasis, without hyperbilirubinemia or cytolysis. Abdominal ultrasonography found no abnormalities. Viral serologies, autoimmune tests and blood cultures were collected for further investigation of causes of prolonged fever with hepatic involvement. After two days, Citrobacter koseri was isolated in blood cultures and intravenous (IV) piperacillin-tazobactam initiated. Computed tomography (CT) scan of the abdomen showed a left lobe hepatic abscess with gas and a linear hyperdense image, possibly a foreign body, piercing through the gastric antrum into the abscess. Surgical exploration was done for source control. The abscess was drained and the foreign body, a 3.5 cm long fishbone, was removed. The patient's condition rapidly improved. Gastrointestinal perforation due to the ingestion of sharp and elongated foreign bodies usually occur in ileal loops, where the intestinal wall is thinner, causing extravasation of fluids and air into the peritoneum and typically presents with an acute abdomen. The uncommon location of perforation masked these symptoms leading to the unusual presentation with prolonged fever.

Early postoperative colonic ventriculoperitoneal shunt migration with trans-anal protrusion: A unique case report

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Early post-operative trans-anal shunt protrusion is a rare presentation.

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Patients may be asymptomatic.

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With concomitant bowel surgery, it may indicate intraoperative occult bowel injury.

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Early post-operative follow up shunt imaging is recommended in this group.

Introduction and importance

Colonic ventriculoperitoneal shunt (VPS) migration with trans-anal protrusion remains uncommon. Patients may be asymptomatic, and diagnosis may only be made on visualization of the prolapsed catheter from the anus. This unique case of early post-operative trans-anal shunt protrusion highlight the possibility of this rare complication specially when shunt revision accompanies bowel surgery.

Case presentation

The authors present a case of early postoperative colonic shunt migration in a thirteen-year-old female with who underwent Malone Antegrade Continence Enema (MACE) with concomitant revision of the distal part of the peritoneal catheter. She presented two weeks post operatively with shunt catheter protruding from the anus. This was noticed by her carer and she was asymptomatic on her presentation.

Clinical discussion

Delayed post-operative shunt related bowel perforation and trans-anal shunt protrusion is an uncommon complication after ventriculoperitoneal shunting. Most cases present months after surgery and majority are asymptomatic on presentation. The exact pathophysiology is not established, and mechanisms have been proposed. Early post -operative trans-anal shunt protrusion is rare and suggests inadvertent occult bowel injury especially when shunt placement or revision accompanies extensive bowel surgery.

Conclusion

The authors recommended shunt imaging within the first two to three weeks after shunt revision in patient who undergo concomitant bowel surgery with risk of inadvertent bowel injury to identify early colonic migration and avoid its potentially fatal sequelae.

Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: a case report

BACKGROUND

Diaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious.

CASE PRESENTATION

A 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7-10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3-9 on the left side.

CONCLUSION

This is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.

Lethal multiple colon necrosis and perforation due to fulminant amoebic colitis: a surgical case report and literature review

Background

Amoebiasis caused by the protozoan species Entamoeba histolytica rarely develops into fulminant amoebic colitis (FAC), but when it does, it shows an aggressive clinical course including colonic perforation, necrotizing colitis, and high mortality. Surgical treatment for FAC patients should be carried out urgently. However, even after surgery, the mortality rate can be 40–50%. Although FAC is one of the most unfavorable surgical diseases with a poor prognosis, there are a few reports on the perioperative diagnosis and management of FAC based on autopsy findings. We herein report the surgical case of a 64-year-old man who developed multiple colon necrosis and perforation due to FAC. A detailed autopsy revealed FAC as the cause of death. Additionally, we reviewed the existing literature on FAC patients who underwent surgery and followed their perioperative diagnosis and management.

Case presentation

A 64-year-old man presented with anorexia, diarrhea, and altered consciousness on arrival to our hospital. Computed tomography revealed a large mass in the upper right lobe of his lung, and the patient was admitted for close investigation. Bloody diarrhea, lower abdominal pain, and hypotension were observed soon after admission. Urgent abdominal contrast-enhanced computed tomography scan revealed extensive intestinal ischemia, intestinal pneumatosis, and free intra-abdominal gas. The preoperative diagnosis was bowel necrosis and perforation with intussusception of the small intestinal tumor. Emergency subtotal colectomy and enterectomy were performed soon after the contrast-enhanced computed tomography. He was taken to an intensive care unit after surgery. However, he could not recover from sepsis and died with disseminated intravascular coagulation and multiple organ failure on the 10th-day post-surgery. A histopathological examination of the resected colon showed transmural necrosis and massive amoebae invasion. He was diagnosed with FAC. An autopsy revealed that he had developed pulmonary large cell carcinoma with small intestinal metastasis. The death was caused by intestinal ischemia, necrosis and the perforation of the residual bowel caused by amoebae invasion.

Conclusions

Since FAC is a lethal disease with a high mortality rate and antibiotic therapies except metronidazole are ineffective, preoperative serological testing and perioperative metronidazole therapy in FAC patients can dramatically improve their survival rates.

Paclitaxel-Induced Bowel Perforation: A Rare Cause of Acute Abdomen

Paclitaxel, a chemotherapeutic agent, is routinely administered for the treatment of various solid organ malignancies. In rare instances, patients receiving infusions of paclitaxel may present with signs of an acute abdomen. Ischemia and necrosis of the bowel wall from chemotherapy-induced neutropenia and direct toxic effects of the drug have been implicated as the cause. We present a case of necrotizing small and large bowel perforation in a patient with breast cancer, 2 weeks after paclitaxel administration.

Multiple intestinal perforations due to primary mediastinal B-cell lymphoma: A case with an infrequent extra-nodal presentation

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Primary mediastinal large B-cell lymphoma (PMBCL) is confined to the mediastinum or contiguous nodal areas in most cases.

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PMBCL is characterized by a rapidly growing mediastinal mass, frequently accompanied by local invasiveness.

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Gastrointestinal involvement of PMBCL may cause serious complications such as intestinal perforation.

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PET-CT increases the sensitivity of staging by detecting unusual sites of disease localization.

Introduction

Primary mediastinal B-cell lymphoma (PMBCL) is an uncommon subtype of non-Hodgkin lymphoma (2–3%), predominantly occurring in female young adults. Extrathoracic involvement is found in 10–20%. It can affect the kidneys, pancreas, stomach, adrenal glands, liver, and infrequently the central nervous system (6–9%). There is currently only one reported case of ileum dissemination with a single perforation.

Presentation of case

A 51-year-old woman with a history of PMBCL, hospitalized by a superior vena cava syndrome. PET-CT showed numerous lesions in the small intestine, pancreas, adrenal glands, and left kidney. During chemotherapy she presented abdominal symptoms, requiring an emergency laparotomy. On examination, six perforation sites were found in the small intestine. The pathology report revealed lesions compatible with PMBCL spread.

Discussion

There are few case series with reports of dissemination in the gastrointestinal tract, with the main location in the stomach. Knowing the visceral location of the PMBCL would allow us to plan a strict follow-up during the first phases of chemotherapy treatment, as well as the early diagnosis of unexpected complications, such as intestinal perforation.

Conclusion

The PMBCL is a rare entity. Visceral involvement should be suspected in these patients since intestinal perforation represents a complication with high morbidity and mortality. This is the first case reported with numerous intestinal locations and multiple post-chemotherapy perforations.

Case report: Colon ischemia and perforation as a result of Norovirus infection

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Atypical Norovirus infection symptoms and course.

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Unusual diagnostics with CT findings: ischemia, pneumatosis intestinalis and perforation.

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Surgical Procedure: Resection with good surgical outcome.

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First case of its kind in Germany, first recommendations of how to approach atypical Norovirus infection.

Introduction

Norovirus (NoV) gastroenteritis has been documented as the worldwide leading cause of the majority of acute cases of viral gastroenteritis. Here, we present a Case of NoV that progressed into colon perforation.

Presentation of case

A 47-year-old woman was admitted via the emergency unit with diarrhoea, lower abdominal pain, vomiting and fever. The virological testing of her stool revealed a NoV infection. The abdominal CT scan showed massive pneumatosis intestinalis. Following the scan findings, the patient was admitted for a diagnostic laparotomy the same day. A side-to-side ileosigmoidostomy was performed. We performed two clinical re-evaluations of the patient, the first one took place 2 weeks after we discharged the patient and another one-year later. The patient is in perfect health.

Discussion

To the best of our knowledge and following a thorough bibliographical search, this is the first case report in Germany and the first case report of colon perforation due to NoV infection in adults in the European Union.

Conclusion

A NoV infection could, along with the typical symptoms, indicate a life-threatening bowel ischemia and/or necrosis.

Gastrointestinal mucormycosis due to Rhizopus microsporus following Streptococcus pyogenes toxic shock syndrome in an HIV patient: a case report

Background

Gastrointestinal (GI) mucormycosis is a rare and often deadly form of mucormycosis. Delayed diagnosis can lead to an increased risk of death. Here, we report a case of GI mucormycosis following streptococcal toxic shock syndrome in a virologically suppressed HIV-infected patient.

Case presentation

A 25-year-old Thai woman with a well-controlled HIV infection and Grave’s disease was admitted to a private hospital with a high-grade fever, vomiting, abdominal pain, and multiple episodes of mucous diarrhea for 3 days. On day 3 of that admission, the patient developed multiorgan failure and multiple hemorrhagic blebs were observed on all extremities. A diagnosis of streptococcal toxic shock was made before referral to Siriraj Hospital – Thailand’s largest national tertiary referral center. On day 10 of her admission at our center, she developed feeding intolerance and bloody diarrhea due to bowel ischemia and perforation. Bowel resection was performed, and histopathologic analysis of the resected bowel revealed acute suppurative transmural necrosis and vascular invasion with numerous broad irregular branching non-septate hyphae, both of which are consistent with GI mucormycosis. Peritoneal fluid fungal culture grew a grayish cottony colony of large non-septate hyphae and spherical sporangia containing ovoidal sporangiospores. A complete ITS1–5.8S-ITS2 region DNA sequence analysis revealed 100% homology with Rhizopus microsporus strains in GenBank (GenBank accession numbers KU729104 and AY803934). As a result, she was treated with liposomal amphotericin B. However and in spite of receiving appropriate treatment, our patient developed recurrent massive upper GI bleeding from Dieulafoy’s lesion and succumbed to her disease on day 33 of her admission.

Conclusion

Diagnosis of gastrointestinal mucormycosis can be delayed due to a lack of well-established predisposing factors and non-specific presenting symptoms. Further studies in risk factors for abdominal mucormycosis are needed.

Abdominal wall reconstruction after emergent surgery for fistulizing incarcerated ventral wall hernia in morbidly obese patient

Incarcerated abdominal wall hernias may have a variety of manifestations and the most dreaded consequence is strangulation leading to obstruction and perforation of hollow viscus. Very rarely, such a perforation presents with fistulization into the abdominal wall and skin, which is often not considered but may complicate the management approach. &lt;br/&gt;Case presentation: We reported on presentation and management of a 56-year-old morbidly obese male with a fistulizing incarcerated ventral wall hernia and postoperative abdominal wall necrosis. &lt;br/&gt;Discussion: Contained bowel perforations caused by ventral hernia incarceration are a rare and not well recognized problem and are confined to a handful of case reports in the surgical literature. &lt;br/&gt;Conclusion: The most recognized complications of ventral hernias are incarceration and strangulation leading to obstruction and consequent perforation; however, as the case described below reveals, intestinal perforation and bowel-skin fistulization may occur as unusual incident. Management should involve operative reduction, resection of the involved bowel and staged repair of abdominal wall defect.

Bowel perforation from malignant atrophic papulosis treated with eculizumab

We present the case of a 57-year-old man with known cutaneous manifestations of malignant atrophic papulosis, also known as Köhlmeier-Degos disease, who developed an almost-fatal small bowel perforation following a parathyroidectomy. He required two surgical interventions during his initial hospitalization and was started on eculizumab. Despite these therapies, the patient developed recurrent bowel perforations and ultimately died.

Colorectal surgery obesity-related morbidity during COVID-19

Tocilizumab, a monoclonal antiinterluekin-6 receptor antibody, has been empirically used in the treatment of cytokine release syndrome associated with severe coronavirus disease 2019 infections. The efficacy and safety of these medications for these patients is unknown. The purpose of this report was to present a case of acute large bowel perforation in a morbidly obese patient with coronavirus disease 2019 pneumonia who received empiric Tocilizumab. This case report analyzes the risks of acute large bowel perforation after using this medication empirically and discusses the appropriate management of this adverse event.

Jejunal perforation during peritoneal dialysis catheter placement: A case report

Introduction

Bowel perforation is a rare but serious complication after peritoneal dialysis (PD) catheter insertion, which significantly increases mortality. Currently, there is no recommendation for preferring catheter insertion technique, since neither open surgical or percutaneous technique demonstrate superior outcome.

Presentation of case

This is a 78-year-old man who developed jejunal perforation during PD catheter placement, presenting with initial clear and satisfying PD fluid drainage. Bowel perforation was recognized after long dwell of PD fluid returned in yellowish color. Operative finding revealed a through and through jejunal wall perforation.

Conclusion

Satisfying dialysate flow and tip catheter location could not exclude accidental bowel perforation after PD catheter placement. Carefully patient monitoring is crucial in detecting postoperative complication.

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Satisfying dialysate flow and tip catheter location could not exclude bowel perforation after PD catheter placement.

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Long dwell of peritoneal dialysate increase sensitivity for detecting bowel injury after PD catheter insertion.

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Early detection and treatment of bowel injury after PD catheter placement is crucial to minimize the patient morbidity.

An international comparison of the utilisation of and outcomes from minimal access surgery for the treatment of common abdominal surgical emergencies

BACKGROUND

Minimal access surgery (MAS) has suggested improvements in clinical outcomes compared to open surgery in several abdominal elective and emergency surgeries. The aims of this study were to compare England with the United States in the utilisation of MAS and mortality from four common abdominal surgical emergencies.

METHODS

Between 2006 and 2012, the rate of MAS and in-hospital mortality for appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel and peptic ulcer perforation were compared between England and the United States. Univariate and multivariate analyses were performed to adjust for differences in baseline patient demographics.

RESULTS

132,364 admissions in England were compared to an estimated 1,811,136 admissions in the United States. Minimal access surgery was used less commonly in England for appendicitis (odds ratio (OR) 0.27, 95% CI 0.267-0.278), abdominal hernia (OR 0.16, 95% CI 0.15-0.17), small or large bowel perforation (OR 0.33, 95% CI 0.32-0.35) and peptic ulcer perforation (OR 0.93, 95% CI 0.87-0.99). In-hospital mortality was increased in England compared to the United States for all four conditions: appendicitis (OR 2.11, 95% CI 1.66-2.68), abdominal hernia (OR 3.25, 95% CI 3.10-3.40), small or large bowel perforation (OR 3.88, 95% CI 3.76-3.99) and peptic ulcer perforation (OR 3.09, 95% CI 2.94-3.25). In England, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for abdominal hernia (OR 1.80, 95% CI 1.26-2.71), small or large bowel perforation (OR 1.59, 95% CI 1.37-1.87) and peptic ulcer perforation (OR 2.31, 95% CI 1.91-2.82).

CONCLUSIONS

Minimal access surgery was performed less commonly and in-hospital mortality was increased in England compared to the United States for common abdominal surgical conditions. Therefore, strategies to enhance adoption of MAS in emergency conditions in England need to be optimised and include appropriate patient selection and improved surgeon MAS training.

Delayed Bowel Perforation after Routine Distal Loopogram Prior to Ileostomy Closure

Ultra-low anterior resection for low rectal cancer is usually done with a covering ileostomy as a safety measure to reduce the consequences of distal anastomotic failure. In many centres, distal loopogram is performed routinely, prior to the closure of the loop ileostomy, to assess the integrity of anastomosis. Distal loopogram is generally considered a safe procedure with very low complication rates, especially when water-soluble contrast is used. We report two cases of delayed bowel perforation which led to severe sepsis and generalized peritonitis after distal loopogram prior to ileostomy closure. Our cases highlight the potential dangers of distal loopogram. Therefore, the routine usage of this procedure should be scrutinized and the patient needs to be properly counselled prior to the procedure.

A case report of a sub-clinical necrotising lower limb infection secondary to pelvic anastomotic leak and chronic corticosteroid use

Anabolic steroids have attracted attention from the media with regard to misuse, but overuse of medically prescribed steroids also has a propensity to cause harm. Gluteal necrotising soft tissue infections are an uncommon presentation for plastic surgeons, and therefore, abdominal sources may be overlooked. We report a rare case of a 57-year-old male who presented with a necrotising lower limb infection on a background of long-term corticosteroid overuse and recurrent pelvic anastomotic leaks.

Transoral Protrusion of a Ventriculoperitoneal Catheter Caused by Jejunal Perforation in an Adult: Rare Case Report and Review of the Literature

BACKGROUND

Although several complications after ventriculoperitoneal shunting (VPS) have been reported, transoral protrusion of a peritoneal catheter is a rare event. In the few reported cases from the literature, it is more common in pediatric patients. This case report describes the first adult in the literature with a transoral VPS protrusion after jejunal perforation.

CASE DESCRIPTION

A 58-year-old man with posttraumatic hydrocephalus was noted with the distal tubing of the VPS protruding from his mouth after he vomited. Radiologic imaging showed jejunal perforation of the distal part of the VPS. The VPS was initially externalized, and then removed. The patient remained stable.

CONCLUSIONS

We present a rare case of transoral protrusion of a peritoneal catheter 11 months after a VPS procedure and review of the literature through this article.

Sonographic assessment of infectious diseases of the gastrointestinal tract: from scanning to diagnosis

BACKGROUND

Sonography of the gastrointestinal (GI) tract is a practical, safe, inexpensive, and reproducible diagnostic tool for the evaluation, diagnosis, and follow-up of infectious bowel disease. The modality is rapidly gaining prominence among clinicians on a global scale. In the United States, however, ultrasound of the bowel remains underutilized primarily due to insufficient experience among radiologists and sonographers in performing sonographic bowel assessment. This lack of experience and knowledge results in misinterpretations, missed diagnoses, and underutilization of this modality in patients with acute abdomen, with the majority of GI pathology on sonography discovered incidentally.

OBJECTIVES

This article aims to demonstrate the characteristic sonographic findings associated with GI infectious processes as well as provide dedicated ultrasound protocols for evaluation of the GI tract.

CONCLUSION

This article serves a twofold purpose, raising awareness of the utility of this imaging modality within the radiology community and also providing practical teaching points for sonographic evaluation of infectious disorders of the GI tract.

Mesenchymal Stem Cell-injected Omental Patch More Effective Promoting Wound Healing in Bowel Perforation Animal Model

Introduction:

Bowel perforation (BP) occurs as the complication of many gastrointestinal problems. Omental patch (OP) is one of the methods to place omentum flaps in the perforated area. Mesenchymal stem cells (MSCs) may increase regeneration process in all tissues.

Aim:

to demonstrate the role of MSC in accelerating of wound healing process by analyzing fibroblast and collagen appearance in perforated bowel conditions.

Methods:

Using a BP rabbit model, 18 rabbit were randomly assigned into three groups: combination of umbilical cord (UC)-MSCs injection and OP (T1), OP only (T2) and vehicle control (Veh). Hematoxylin-eosin staining and Masson’s trichrome staining were performed to analyze the level of fibroblast and collagen. Wound length were measured using standardized caliper.

Results:

The study showed a significant (P<0.05) increase of fibroblast and collagen amount on T1 and T2, in which T1 was higher than T2. This result was also followed by the decrease of wound length.

Conclusion:

The combination of MSCs and OP-sutured in perforated bowel are better to accelerate wound healing than OP only in BP cases.

Bowel perforation in a Covid-19 patient: case report

INTRODUCTION

Since the outbreak of novel coronavirus (2019-nCoV), it became evident that a proportion of patients may present with gastrointestinal symptoms.

CASE

We report the case of a Covid-19-infected patient who, during recovery from the pulmonary pneumonia, had gastrointestinal symptoms followed by a diastasic right colon perforation due to acute over distension of the bowel.

CONCLUSION

This case highlights the importance of paying attention to initial gastrointestinal symptoms in order to prevent possible complications.

A unique strategy for large-bowel perforation with ventriculoperitoneal shunt: Conversion to ventriculoatrial shunt: A case report

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Large-bowel perforation can lead to critical sepsis, and urgent intervention including surgery is indispensable to control systemic infection.

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We describe a strategy for large-bowel perforation using a ventriculoperitoneal shunt that was converted to a ventriculoatrial shunt and discuss its utility based on the literature.

Introduction

Large-bowel perforation can lead to critical sepsis, and urgent intervention including surgery is indispensable to control systemic infection. Here, we describe a strategy for large-bowel perforation using a ventriculoperitoneal shunt.

Case presentation

A 74-year-old Japanese female with a history of cerebral aneurysm clipping and ventriculoperitoneal shunting due to aneurysmal subarachnoid hemorrhage presented with lower abdominal pain, fever, and disturbed consciousness. Clinical findings indicated a diagnosis of large-bowel perforation and ventriculoperitoneal shunt-transmitted bacterial meningitis. Thus, sigmoidectomy and shunt externalization were performed, and the ventriculoperitoneal shunt was converted to a ventriculoatrial one.

Conclusion

Based on our experience and the literature, we successfully discuss bowel perforation management with respect to the ventriculoperitoneal shunt, including the utility of the ventriculoatrial shunt as an alternative.

Rectal foreign body causing perforation: Case report and literature review

Background

Clinicians must maintain an index of suspicion to diagnose an anorectal foreign body (FB). The patient may not be forthcoming with information secondary to embarrassment or possibly psychiatric issues. Providers must express empathy and compassion while maintaining nonjudgmental composure. Despite accounts of anal FB insertion, this pathology is lacking level one evidence-based surgical algorithms.

Case presentation

A 46-year-old male psychiatric patient presented in septic shock, complaining of lower abdominal/pelvic pain starting 1 week prior. His past medical history was significant for schizophrenia, bipolar disorder, and noncompliance with medications. CT of the abdomen/pelvis revealed a rectal perforation with free air and a FB which appeared to be a screwdriver. Fluid resuscitation and broad-spectrum antibiotics were administered. In the operating room, after unsuccessful transrectal removal, an exploratory laparotomy was performed. The metallic end of the screwdriver had perforated the rectosigmoid. Resection of the perforated rectum with removal of the screwdriver, incision and drainage of a large right buttock abscess and colostomy was performed. The patient recovered and was discharged to behavioral health. At 2 weeks follow-up the patient was doing well with a functioning colostomy and reversal was planned for later this year.

Conclusion

This case highlights the importance of maintaining a high index of suspicion when encountering psychiatric patients with nonspecific lower abdominal or anorectal pain with inconsistent presentations. Controversy exists regarding the type of surgical treatment in case of anorectal perforation. More research is needed to provide surgeons with evidence-based standardized methods for dealing with these rare pathologies.

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Maintaining a high index of suspicion when encountering patients with nonspecific lower abdominal and/or rectal pain.

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Despite the numerous reports of anal FB trauma there are no cases documenting a unique incident with a screwdriver being inserted through the anus.

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Controversy exists regarding the type of surgical treatment.

Multiple colonic and ileal perforations due to unsuspected intestinal amoebiasis-Case report and review

Amoebiasis, caused by the intestinal protozoan Entamoeba histolytica, though a relatively common parasitic disease in the tropical and subtropical regions, is uncommon in the developed countries. In these countries, as amoebic colitis shares similar clinical symptoms and endoscopic features with inflammatory bowel disease (IBD), these cases can be easily unrecognized and misdiagnosed. In this case report, we discuss the case of an adult patient with invasive intestinal amoebiasis, who was initially managed as Crohn's disease on corticosteroid treatment and subsequently rapidly deteriorated and developed multiple perforations in the colon and ileum. Despite total colectomy followed by resection of the small bowel, he died of multiple organ failure and sepsis within two months of his initial clinical presentation of diarrhea with abdominal pain. The learning point of this case is that invasive intestinal amoebiasis should be considered as a differential diagnosis at the first clinical adult presentation of IBD-like symptoms despite suggestive endoscopic findings of Crohn's like ulcers. Regardless of negative endoscopic biopsies, due to the low sensitivity of microscopic examination, serology test for antibody and molecular test for Entamoeba DNA are recommended for accurate detection and identification of Entamoeba species, especially in the high risk populations with recent travel to endemic zones and for patients with immunosuppression and comorbidities such as diabetes mellitus, tuberculosis, alcoholism, HIV/AIDS and in pregnant women. Amoebiasis should be completely ruled out prior to corticosteroid administration, to avoid severe complications such as fulminant intestinal amoebiasis which is associated with an inherently high mortality.

Case report: reinitiating pembrolizumab treatment after small bowel perforation

BACKGROUND

Immune checkpoint inhibitors (ICIs) have emerged as paradigm shifting treatment options for a number of cancers. Six antibodies targeting the immune checkpoint proteins programmed cell death 1 (PD-1), programmed cell death 1 ligand 1 (PD-L1) or cytotoxic T-lymphocyte associated protein 4 (CTLA4) have been approved. In some cases, response rates have been impressive, but not uniformly so and not consistently; similarly, toxicity to this class of therapeutic is often unpredictable and can be life threatening. Predicting treatment response and toxicity are two main obstacles to truly individualize treatment with ICIs. One of the most severe and life-threatening adverse events is colitis induced colonic perforation, estimated to occur in 1.0 to 1.5% of patients treated with ICIs. An important question to address is, under what circumstances is it appropriate to reinitiate ICI treatment post-bowel perforation?

CASE PRESENTATION

The patient is a 62-year-old woman, who presented with stage IV lung cancer. Immunohistochemical staining indicated that 80% of the patient's tumor cells expressed PD-L1. The patient was started on a three-week cycle of pembrolizumab. Subsequent reducing in tumor burden was observed within ten weeks. Initially, pembrolizumab was tolerated fairly well, with the exception of immunotherapy related hypothyroidism. However, the patient experienced a second, more serious immune-related adverse event (irAE), in the form of enteritis, which led to small bowel perforation and necessitated exploratory laparotomy. The concerning part of the small bowel was resected, and a primary anastomosis was created. Based on the pathological and surgical findings, the patient was diagnosed with pembrolizumab-associated small bowel perforation. The patient recovered well from surgery and, considering the patient's remarkable response to treatment, a collective decision was made to reinitiate pembrolizumab on post-operative day twenty-eight. The patient is continuing her immunotherapy with ongoing partial response and is able to continue her full-time job.

CONCLUSIONS

This case report highlights the challenges of identifying patients likely to respond to ICIs and those that are likely to experience irAEs and it discusses the impressive work that has been done to start to address these challenges. Lastly, the topic of reinitiating pembrolizumab treatment even after colonic perforation is discussed.

When traditions become dangerous: Intestinal perforation from unusual foreign body-Case report and short literature review

Gastrointestinal perforation (GI) is a common cause of acute abdomen in the emergency department that needs a prompt surgery intervention. Nowadays, CT examinations represent the method of choice to image patients with acute abdominal pain in emergency. GI perforations by foreign bodies ingested is rare and only <1% of ingested foreign bodies are believed to cause perforation of GI. MDCT is to be considered the best imaging method for identifying foreign bodies, the perforation site and the surgical treatment to be planned reliably. We presente a case of 70-year-old lady presented to our Emergency Department with acute abdominal pain.

Blunt abdominal aortic injury may accompany bowel transection

Blunt abdominal aortic injury is an extremely rare condition. In the past, when blunt abdominal aortic injury was managed with open surgery, intra-abdominal injury was identified more easily, while in the era of endovascular surgery, intra-abdominal injury might potentially be found after vascular reconstruction. We present a case of blunt abdominal aortic injury treated using a parallel graft-stent and simultaneous laparoscopy which revealed an occult bowel perforation.

Lymphangiomatosis of the ileum with perforation: A case report and review of the literature

Lymphangiomatosis is a benign proliferation of lymph vessels. Lymphatic diseases can vary from small lymphangioma to generalized lymphangiomatosis, which is a rare condition and can have several clinical manifestations. The gastrointestinal tract may be affected, but the incidence in the intestinal wall is very low. We propose in our study a case of ileal lymphangiomatosis presenting with perforation, in which the diagnosis was made after the pathological analysis of the resected intestinal tract. Although rare and not described in the literature, intestinal lymphangiomatosis could manifest itself with acute abdomen and could be a surgical urgency. This disease should be considered when intestinal perforation is observed.

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Lymphangiomatosis is a multisystemic disorder.

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The GI tract may be affected, but the incidence of lymphangioma of the intestinal wall is very low.

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Lymphangiomatosis of the small bowel is a rare disease, so it is easy for a clinician to make a misdiagnosis.

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Intestinal lymphangiomatosis could manifest itself with an acute abdomen and surgical urgency.

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The pathologist should keep it in mind in the differential diagnosis, when he analyses a case of perforation.

Perforated small bowel GIST in an immunocompromised male

Gastrointestinal (GI) stromal tumor is a relatively rare tumor of the GI tract, with estimated prevalence of 2%, which arises from the interstitial cells of Cajal. Common presentations range from asymptomatic to abdominal pain, bloating, GI bleeding, and anemia. Less-common signs include obstruction and peritonitis. In this case, a young immunocompromised patient experienced a changing symptomatic spectrum with an enlarging abdominal mass, which ultimately perforated, leading to acute peritonitis.

Pneumatosis Intestinalis After Molecular-Targeted Therapy

BACKGROUND

Pneumoperitoneum after surgical manipulation of the abdomen implies a perforation. Rare cases of nonoperated cancer patients, largely with gastrointestinal or genitourinary cancers, have been noted to have radiologic findings of pneumatosis intestinalis and/or pneumoperitoneum as a complication of molecular-targeted therapy (MTT) without confounding factors for perforation. We present a patient with a cranial malignancy treated with bevacizumab who subsequently manifested with pneumatosis intestinalis.

CASE DESCRIPTION

A 67-year-old man with metastatic melanoma, non-small cell lung cancer, and recurrent cerebellar subependymoma was initiated on bevacizumab treatment for subependymoma recurrence. He subsequently underwent an uncomplicated ventriculoperitoneal shunt for progressive obstructive hydrocephalus, confirmed by a normal postoperative abdominal radiograph. One week later, he returned with worsening lethargy and a computed tomography consistent with pneumomediastinum and pneumoperitoneum. Due to concern for bowel perforation, the patient underwent diagnostic laparoscopy and removal of ventriculoperitoneal shunt. Focal sigmoid pneumatosis was identified without any signs of bowel perforation or ischemia. Bevacizumab was discontinued, and the patient's radiologic and clinical findings improved.

CONCLUSIONS

With increasing utilization of MTTs in brain tumor management, we raise MTT as a potential cause for pneumoperitoneum in neurosurgical patients. Pneumoperitoneum after extracranial procedures still requires workup and management for potential bowel perforation, but alternative causes such as bevacizumab should also be considered. Pneumatosis intestinalis patients on MTT can have benign physical examinations and will resolve, in the majority of cases, on discontinuation of the drug.

Novel device to detect enterotomies in real time during laparoscopy: first in human trial during Roux-en-y gastric bypass

BACKGROUND

Undetected bowel perforations occur in 0.3-1% of laparoscopic surgical procedures with an associated mortality rate of 5.3%.

OBJECTIVE

The purpose of the study was to evaluate the clinical feasibility of a novel medical device to accurately detect bowel gas, specifically hydrogen (H₂) and methane (CH₄), from a sample of gas from the abdominal cavity during laparoscopic surgery when a known bowel wall perforation has occurred.

SETTING

University (Academic) Hospital.

METHODS

A prospective single arm study was composed of 8 patients undergoing a standard laparoscopic roux-en-y gastric bypass. At seven time points during the operation intra-abdominal gas was pulled from the abdominal cavity and analyzed using the novel device for H₂ and CH₄. The time points included after insufflation (T1), after first jejunotomy (T2), after closure of jejunotomy (T3), after recycle of carbon dioxide gas (T4), after gastrostomy (T5), after jejunotomy (T6), at procedure end (T7).

RESULTS

Eight patients were enrolled in the study; in 7 (87.5%) patients data from all 7 time points were obtained. After the first opening of the small bowel (T2) mean hydrogen levels were significantly increased compared to baseline hydrogen levels (T1, T4, T7) (p < 0.001). At all time points, there was no significant detection of methane. There were no intra-operative or post-operative complications during the study.

CONCLUSION

Hydrogen gas is released into the intra-abdominal cavity when bowel is opened and can be detected in real time using a novel device during laparoscopic surgery. The presence or absence of hydrogen directly correlates to whether the bowel is open (perforated) or intact. This device could be used in the future to detect unintended bowel perforations during laparoscopic surgery, prior to the conclusion of the operation. This technology could also potentially lead to novel mechanism for detecting postoperative leaks using gas detection technology.