Distal jejunal gallstone ileus-an unusual cause of bowel obstruction: a case report

Gallstone ileus is a rare entity that causes bowel obstruction by gaining access through a cysto-enteric fistula. This is a case report of a 70-year-old man presenting with small bowel obstruction secondary to distal jejunal gallstone ileus impaction. He is not known to have any predisposing factors. He was managed effectively with an enterolithotomy. Early diagnosis is key to a good prognosis. Although other management options are available, enterolithotomy with or without cholecystectomy remains the gold standard of management.

Small Bowel Obstruction by a Phytobezoar in a Patient With Previous Antrectomy and Billroth II Reconstruction

A phytobezoar is a conglomerate of improperly digested fruit and vegetable debris, and its development is associated, amongst other factors, with previous gastric surgery. Most phytobezoars remain asymptomatic and are incidentally found during imaging or interventional procedures. However, in some patients, they can cause small bowel obstruction, which can subsequently lead to severe complications. Although the clinical findings are similar to other causes of intestinal obstruction, there are some particular diagnostic and treatment features more specific to phytobezoars. We present a case of an 85-year-old man with a history of previous antrectomy and Billroth II reconstruction who came to the emergency department with bilateral aspiration pneumonia and intestinal obstruction due to a bezoar. The CT scan showed bilateral inferior lobe pulmonary consolidation, as well as a marked dilation of the small bowel with gas-fluid levels and a transition to normal caliber in the terminal ileum, where an oval mottled-appearing mass suggesting a bezoar was present. An urgent laparotomy confirmed the diagnosis, and an enterotomy with removal of the bezoar was performed. Phytobezoars must be considered as a cause of intestinal obstruction, particularly when patients have a history of previous gastric surgery. Its radiological findings, particularly in CT scans, are specific and should be appreciated to establish the diagnosis promptly. The treatment of small bowel obstruction due to a phytobezoar requires surgery most of the time, and the surgeon must bear in mind the need to look for the existence of other bezoars in the gastrointestinal tract to prevent reoccurrence.

Higher Fiber Intake is Associated with Reduced Risk of Related Surgery among Individuals with Inflammatory Bowel Disease in a Prospective Cohort Study

BACKGROUND

Evidence for the effects of dietary fiber on adverse outcomes in individuals with inflammatory bowel disease (IBD) is insufficient and controversial.

OBJECTIVES

We aimed to prospectively explore the association between dietary fiber intake and the risk of IBD-related surgery.

METHODS

We identified 5580 individuals with diagnosed IBD [Crohn disease (CD, n = 1908) and ulcerative colitis (UC, n = 3672)] at baseline in the UK Biobank via electronic medical records and self-reported information. Dietary fiber intake was estimated by a partial fiber score derived from a valid food frequency questionnaire. IBD-related surgery (enterotomy, perianal surgery, and others) was ascertained via inpatient data. Cox proportional model was applied to estimate hazard ratios with 95% confidence intervals (CIs) of dietary fiber in quartiles for the risk of IBD-related surgery.

RESULTS

During a mean follow-up period of 11.2 y, we documented 624 IBD-related surgery among 5580 individuals with IBD (mean age, 57.3; 52.8% females). Compared with individuals in the lowest quartiles, those with second to fourth quartiles of fiber intake were associated with 23% (95% CI: 5%, 38%, P = 0.015), 29% (95% CI: 11%, 43%, P = 0.003), and 28% (95% CI: 10%, 43%, P = 0.005) reduced risk (P-trend = 0.002) of IBD-related surgery. Similar associations were observed in CD (P-trend = 0.005) but not UC (P-trend = 0.131). We observed inverse associations of fiber in vegetables and fruits (P-trend = 0.017 and 0.007) but positive associations of fiber in bread (P-trend = 0.046) with the risk of IBD-related surgery.

CONCLUSIONS

Higher intake of fiber is associated with reduced IBD-related surgery risk in patients with IBD with CD but not UC.

A Phytobezoar Causing Terminal Ileal Obstruction Following Revision Bariatric Surgery: A Case Report

Bezoars are a rare complication causing small bowel obstruction. A phytobezoar causing terminal ileum obstruction following a Roux-en-Y gastric bypass (RYGB) is extremely rare. A middle-aged woman with post-sleeve gastrectomy weight regain, converted to RYGB, presented 17 months after surgery with obstructive symptoms due to an impacted phytobezoar in the terminal ileum. Diagnostic laparoscopy, enterotomy, and extraction of the large impacted phytobezoar from the terminal ileum relieved the obstruction. Swallowing improperly masticated food in altered gastrointestinal anatomy due to RYGB can cause a phytobezoar in any part of the gastrointestinal tract. These patients need proper nutritional counseling and psychological evaluation to prevent this rare complication.

Associations of abdominal discomfort and length of clinical signs with surgical procedure in 181 cases of canine small intestinal foreign body obstruction

BACKGROUND

Gastrointestinal foreign bodies are a common indication for abdominal exploratory surgery.

OBJECTIVES

The objective of this study was to evaluate the relationship of pre-operative abdominal discomfort and duration of clinical signs with surgical resolution of canine small intestinal foreign body obstructions (SIFBO).

METHODS

We performed a retrospective study of 181 canine abdominal exploratory surgeries for confirmed SIFBO at two referral hospitals. Animals were categorized into five surgical groups (gastrotomy after manipulation into the stomach, enterotomy, resection-and-anastomosis [R&A], manipulated into colon, already in colon) and further grouped by whether entry into the gastrointestinal tract (GIT) was required.

RESULTS

Abdominal discomfort was noted in 107/181 cases (59.1%), but no significant differences in abdominal discomfort rates were present among the surgical groups or between GIT entry and no entry groups. Clinical sign duration was associated with surgical procedure; median durations were R&A = 3 days (range, 1-9), enterotomy = 2 days (range, 1-14), gastrotomy = 2 days (range, 1-6), already in colon = 1.5 days (range, 1-2), and manipulated into colon = 1 day (range, 1-7). In a pairwise comparison, differences in the duration of clinical signs were found for obstructions manipulated into the colon versus R&A, gastrotomy versus R&A, and in colon versus R&A. When patients were grouped according to GIT entry, cases with entry had a longer duration of clinical signs (median = 2 days [range, 1-14] versus 1 day [range, 1-7], respectively).

CONCLUSIONS

Abdominal discomfort was not associated with surgical complexity; however, the duration of clinical signs was associated with surgical complexity, with longer duration being associated with entry into the GIT and R&A. Despite statistical significance, the maximum difference of 2 days between surgical groups is unlikely to be clinically relevant.

Retrospective analysis of postoperative complications following surgical treatment of ileal impaction in horses managed with manual decompression compared to jejunal enterotomy

Objective

The objective of this study was to compare the occurrence of post-operative complications and survival to discharge in horses with ileal impactions resolved by manual decompression compared with jejunal enterotomy.

Animals

A total of 121 client-owned horses undergoing surgical correction of an ileal impaction at three teaching hospitals.

Materials and methods

Data from the medical records of horses undergoing surgical correction of an ileal impaction was retrospectively collected. Post-operative complications, survival to discharge, or post-operative reflux present were evaluated as dependent variables and pre-operative PCV, surgery duration, pre-operative reflux, and type of surgery were evaluated as independent variables. Type of surgery was divided into manual decompression (n = 88) and jejunal enterotomy (n = 33).

Results

There were no significant differences in development of minor complications, development of major complications, presence of post-operative reflux, amount of post-operative reflux, and survival to discharge between horses that were treated with manual decompression and those treated with distal jejunal enterotomy. Pre-operative PCV and surgery duration were significant predictors of survival to discharge.

Conclusions and clinical relevance

This study showed that there are no significant differences in post-operative complications and survival to discharge in horses undergoing distal jejunal enterotomy versus manual decompression for correction of ileal impaction. Pre-operative PCV and duration of surgery were found to be the only predictive factors of survival to discharge. Based on these findings, distal jejunal enterotomy should be considered earlier in horses with moderate to severe ileal impactions identified at surgery.

Small Bowel Obstruction Caused by an Aggressive Weight Loss Diet in a Patient With No Predisposing Factors

Phytobezoars are a well-documented cause of small bowel obstruction. Previous reports include patients who have predisposing factors such as gastric surgery, diabetes mellitus, or poor dentition. Consequences of extreme dieting have also been reported, but a resultant phytobezoar and life-threatening bowel obstruction are rare. We present a case of phytobezoar solely due to a diet inordinately high in fiber.

Multidisciplinary Management for Intestinal Obstruction by Gel Ball Ingestion

Foreign body ingestion is common in young children. Very few cases require surgical exploration for removal. We report a case of superabsorbent gel ball ingestion causing intestinal obstruction, managed by a combination of endoscopic and open surgical removal under intraoperative ultrasound guidance.

A Review of Normal Intestinal Healing, Intestinal Anastomosis, and the Pathophysiology and Treatment of Intestinal Dehiscence in Foreign Body Obstructions in Dogs

Small intestinal anastomoses are commonly performed in veterinary medicine following resection of diseased or devitalized intestinal tissue. Traditionally, suture has been employed to anastomose intestinal ends. However, use of intestinal staplers has become increasingly popular due to the ability to produce a rapid anastomosis with purported superior healing properties. Under normal conditions, intestinal healing occurs in three phases: inflammatory, proliferative, and maturation. Dehiscence, a devastating consequence of intestinal anastomosis surgery, most often occurs during the inflammatory phase of healing where the biomechanical strength of the anastomosis is almost entirely dependent on the anastomotic technique (suture or staple line). The resulting septic peritonitis is associated with a staggering morbidity rate upwards of 85% secondary to the severe systemic aberrations and financial burden induced by septic peritonitis and requirement of a second surgery, respectively. Intraoperative and postoperative consideration of the multifactorial nature of dehiscence is required for successful patient management to mitigate recurrence. Moreover, intensive postoperative critical care management is necessitated and includes antibiotic and fluid therapy, vasopressor or colloidal support, and monitoring of the patient's fluid balance and cardiovascular status. An understanding of anastomotic techniques and their relation to intestinal healing will facilitate intraoperative decision-making and may minimize the occurrence of postoperative dehiscence.

Gallstone Ileus: An Unusual Cause of Intestinal Obstruction

Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction. Typically as a result of the formation of cholecystoduodenal fistula, surgical removal of the gallstone is the mainstay of treatment in order to relieve the intestinal obstruction. A 34-year-old male with no history of cholelithiasis presented with features of a small bowel obstruction. CT scan of the abdomen demonstrated pneumobilia, a cholecystoduodenal fistula and small bowel obstruction, features suspicious for a gallstone ileus. The patient underwent a laparotomy and removal of two gallstones via an enterotomy. He was discharged home after an uneventful post-operative period. Gallstone ileus is an uncommon cause of mechanical bowel obstruction with often delayed presentation and non-specific symptoms. A high level of suspicion is required in at-risk groups, and in patients presenting with a bowel obstruction and known gallstone disease.

Patient Reported Injuries After Ventral Hernia Repair

BACKGROUND AND AIMS:

The Swedish National Patient Insurance Company (LÖF) can compensate patients who believe they have been exposed to an avoidable injury or malpractice in healthcare. Its register covers 95% of Swedish healthcare providers.

MATERIAL AND METHODS:

Data on patients operated for primary or incisional ventral hernia in Sweden between 2010 and 2015 and who had filed a claim, were retrieved from LÖF. A total of 290 cases were identified and included. Files include a copy of records, relevant imaging, and an expert advisor's opinion.

RESULTS:

Inadvertent enterotomy occurred during 25 repairs and in these cases, laparoscopic repair was clearly overrepresented ( p  < 0.001). Complications related to the surgical site (infection and ugly scar) were predominantly related to open repairs ( p  < 0.001). Twenty percentage (57/290) of the claims were directly related to an anesthetic mishap. Univariate ordinal regression showed that the odds of receiving a high reimbursement was significantly increased if laparoscopic repair was performed p  < 0.001 (odds ratio: 0.37; 95% confidence interval: 0.21-0.65). Sixty-three percentage of claims were filed by women.

CONCLUSION:

Inadvertent enterotomy is overrepresented, and the probability that a claim filed for an avoidable injury leads to high reimbursement is greater if laparoscopic repair is performed rather than open ventral hernia repair. The high amount of injuries related to general anesthesia during umbilical hernia repair may be reduced with an increased proportion executed in local anesthesia.

An Unusual Cause of Small Bowel Obstruction: A Case Report

Small bowel obstruction is a common surgical emergency. The common causes are adhesions, malignancies, and hernias. We present a rare case of small intestinal obstruction caused by an enterolith in the distal ileum in a patient with an apparently normal gut. 

A 59-year-old male who underwent gastrojejunostomy 15 years back presented with features of intestinal obstruction of five days' duration. After initial conservative management, the patient was taken up for laparotomy. An enterolith causing obstruction was found in the distal ileum, and it was crushed and milked into the colon. The patient made an uneventful recovery. 

The chyme crossing the ileum is usually liquid or semi-solid and hence luminal obstruction by the faecal bolus in the ileum is very unusual. In patients with previous gastric surgeries where the pylorus is bypassed, the solid food particles enter the small intestine and can form a bezoar. This patient was managed with laparotomy and milking of the stool bolus into the colon. Other treatment options include enterotomy or resection of the diseased bowel and removal of the enterolith. 

Small bowel obstruction due to an enterolith is very rare and can pose a diagnostic challenge. 

Cloacal Prolapse in Raptors: Review of 16 Cases

Sixteen cases of cloacal prolapse in raptors were reviewed in this study. Colonic prolapse was the most common presentation (56% of cases). Red-tailed hawks ( Buteo jamaicensis ) were overrepresented, comprising 66% of colonic prolapse cases. In cases of colonic prolapse, postsurgical stricture formation was a commonly identified complication after resection and anastomosis of the colon. A novel technique was used in 2 cases of colonic prolapse, in which sterile, semirigid rubber tubing was placed in the distal colon and removed per-cloaca at the end of the procedure; this facilitated a secure, fluid-tight anastomosis while maintaining sufficient intestinal lumen. Oviductal prolapse (31% of cases) was associated with the most guarded prognosis (40% treatment success). Cloacoliths were treated successfully in 2 birds (13% of cases) by minimally invasive per-cloacal manual removal.

Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: a review of the literature

Laparoscopic incisional and ventral hernia (LVIH) repair is becoming more popular throughout the world. Although individual series have presented their own information, few data have been collected to identify the risk of the most serious complication, enterotomy. A literature review has identified this to occur in 1.78% of patients who undergo this procedure. Large bowel injury represents only 8.3% of these injuries. Eighty-two percent of the time, these injuries will be recognized and repaired. In the majority of published series in which this occurred, the hernia repair was completed with a laparoscopically placed prosthesis, as only 43% were converted to the open procedure. Complications related to this approach are infrequent. The mortality rate of this operation was noted to be 0.05%. However, if an enterotomy occurred, it increased to 2.8%. A recognized enterotomy was associated with a mortality rate of 1.7%, but an unrecognized enterotomy had a rate of 7.7%. Careful technique and close inspection of the intestine at the completion of the adhesiolysis and the herniorrhaphy is recommended. If the hernia repair proceeds as planned following repair of enterotomy, continuation of antibiotics and the placement of an antimicrobial impregnated prosthesis are recommended. More study is necessary before firm recommendations can be made, as the majority of these events are most likely unreported. Safety concerns may require postponement of the hernia repair if an enterotomy occurs.