Long-term gastrointestinal morbidity in patients born with gastroschisis: A national register-based cohort study.

OBJECTIVES: In gastroschisis, the intestines are exposed to amniotic fluid during pregnancy. The defect in the abdominal wall may also compress the mesentery and impair the intestinal blood supply. There is a varying degree of intestinal damage at birth. Complex gastroschisis is defined as gastroschisis with severe complications such as intestinal atresia, volvulus, necrosis and perforation. The aim of this study was to investigate long-term gastrointestinal morbidity and compare simple and complex cases. METHODS: A nation-wide retrospective cohort study with data from national registers was conducted. All children born with gastroschisis in Sweden from 1 January 1997 to 31 December 2016 were included in the study. Exposure was complex gastroschisis and the primary outcomes were intestinal failure and bowel obstruction. RESULTS: The study included 315 cases with gastroschisis, 260 classifieds as simple gastroschisis and 55 as complex. The median time to follow was 8 years. A significantly higher risk of developing intestinal failure (hazard ratio: 11.7) was found in complex cases. Nine percent of the complex cases underwent autologous gastrointestinal reconstructive surgery for intestinal failure, none of the simple cases did. The complex cases had a higher risk for bowel obstruction (hazard ratio: 4.3) with a higher proportion requiring surgery (18.2% vs. 6.9%) compared to simple cases. CONCLUSIONS: This nationwide study showed that the risk for intestinal failure and bowel obstruction is significantly higher for children with complex gastroschisis compared to simple gastroschisis. Most of the events occurred during the first 2 years of life.

A Case Report of a Young Adult With Peutz-Jeghers Syndrome Presenting With Acute Small Bowel Obstruction: A Common Complication of an Uncommon Disease.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by hamartomatous polyposis of the gastrointestinal tract, melanin pigmentation of the skin and mucous membranes, and an increased risk for cancer. Radiological imaging, contrast studies, and scopy-directed biopsies confirm the diagnosis and help in surveillance. Hamartomatous mucosal polyps, which are characterized by a central core of branching smooth muscle connected to a mucosa unique to the site of origin, are pathognomonic for PJS. We present the case of a young male with a history of pain in the abdomen and vomiting. The patient had mucocutaneous pigmentations on the buccal mucosa. CT scan revealed jejuno-jejunal intussusception with multiple small and large bowel polyps causing acute intestinal obstruction. Intraoperatively, jejunal polyps were found to be the cause of jejuno-jejunal intussusception. Histopathology revealed hamartomatous polyps of PJS. Our interest in this case is due to the uncommon case of intussusception in an adult where radiological imaging played an important role in diagnosis.

Evaluation of Multidetector Computed Tomography in the Diagnosis of Intestinal Obstruction.

Background Acute intestinal obstruction is a commonly encountered surgical emergency that is prevalent worldwide and has substantial morbidity and fatality rates. Therefore, swift and precise diagnosis is essential. While mortality rates in urban areas have declined due to timely medical intervention following early detection, the situation contrasts starkly in rural areas. Delays in presentations often lead to complications because of hesitancy toward surgery, economic challenges, and limited access to healthcare information. Therefore, this study aimed to evaluate how well multidetector computed tomography (MDCT) can help determine the site, cause, and level of intestinal obstruction compared to what the surgeons confirmed intraoperatively. Methodology A prospective study involving 101 patients was conducted at a tertiary care center in western Maharashtra from July 2022 to July 2024. The emergency department referred patients with clinical symptoms such as nausea and vomiting, abdominal distension, abdominal pain, inability to pass flatus, constipation, or diarrhea, which are commonly seen with intestinal obstruction. The study involved all patients who underwent a contrast-enhanced MDCT scan using both intravenous and oral contrast agents. We selected patients from both genders, regardless of their age; however, considerations were taken to include characteristics convenient and relevant to the study. Patients with abnormal serum creatinine levels or allergies to contrast were excluded from the study. We conducted CT examinations, noting findings such as the transition point between the dilated and collapsed loops, mesenteric fat stranding, and intestinal dilatation. An experienced radiologist made the final report, and the operating surgeons' notes on laparoscopy or open surgery for the same patient were reviewed to understand the operative findings. Results MDCT scans had high diagnostic accuracy for small and large bowel obstruction. Of the 101 patients, the mean age was 43.7 years. There were 70 (69.30%) males and 31 (30.69%) females. Sensitivity was 100%, specificity was 98.1%, positive predictive value was 83.7%, and negative predictive value was 100%. Conclusions MDCT demonstrated high sensitivity and specificity for diagnosing and determining the underlying cause of intestinal obstruction. It identified the location of the obstruction and discerned whether it originated from intrinsic, extrinsic, or intraluminal factors.

Incidental Carcinoid Tumor Arising in a Meckel's Diverticulum.

This case report describes a patient who presented with concern for a closed-loop small bowel obstruction (SBO). During exploratory laparotomy, an area of ischemic bowel due to closed loop obstruction was resected, along with an incidentally discovered inflamed-appearing Meckel's diverticulum (MD). The resected specimen contained a well-differentiated carcinoid tumor of benign behavior with a maximum diameter of 0.6 cm, which invaded the submucosal layer (pT1b and pN0). Over the last several years, there has been a debate with little consensus regarding the proper surgical management in the case of an asymptomatic MD that is discovered incidentally during abdominal exploration. The intention of sharing this case is to underline the importance of the decision-making process in treating patients with this intraabdominal pathologic condition found incidentally at the time of surgery.

Malrotation with mid-gut volvulus and partial small bowel peritoneal membrane encapsulation.

Urgent investigation is crucial for infants with bilious vomiting, potentially indicating bowel obstruction. Upper gastrointestinal fluoroscopy aids diagnosis, but is not without its challenges. This case report describes a rare case of neonatal intestinal malrotation and mid-gut volvulus with an additional complication of congenital peritoneal encapsulation. Contribution: This case study offers insights into associated diagnostic challenges and underscores the value of utilising fluoroscopy in diagnosing complex gastrointestinal conditions.

Small Bowel Obstruction Caused by a Rare Foreign Body: A Case Report and Literature Review.

BACKGROUND: Ingestion of gastrointestinal foreign bodies (FB) is a common clinical problem worldwide. Approximately 10-20% of FBs require an endoscopic procedure for removal, and < 1% require surgery. CASE DESCRIPTION: An 89-year-old male with Alzheimer's disease was hospitalized because of abdominal pain, abdominal distention, vomiting for three days, and cessation of bowel movements for six days. Abdominal computed tomography (CT) scan showed a small intestinal obstruction and an atypical FB in the small intestine. A pill and remaining plastic casing were removed from the small intestine during surgery. FB is a square with four sharp acute angles at its edge. The patient was discharged after two weeks of treatment, and no recurrence or complications were observed during the 6- month follow-up. CONCLUSION: Atypical intestinal FBs may cause misdiagnosis and easily lead to serious complications. Therefore, an appropriate radiological examination, such as CT, is necessary for unexplained intestinal obstruction. Symptomatic intestinal FBs should be actively removed to avoid serious complications.

Adult ileo-ileal intussusception caused by inflammatory fibroid polyp leading to small bowel obstruction: a case report with comprehensive literature review.

Ileo-ileal intussusception, an infrequent cause of small bowel obstruction in adults, can be initiated by inflammatory fibroid polyps. These are uncommon, benign submucosal lesions of the gastrointestinal tract. This case report explores an adult patient with inflammatory fibroid polyps-induced ileo-ileal intussusception.

Bowel Obstruction as the Initial Presentation of Urothelial Carcinoma.

Bowel obstructions are one of the main causes of hospital admissions for acute abdominal pain. In addition, bladder cancer is one of the most common cancers in the world. This said, bowel obstruction and bladder cancer are very frequent diseases but the same cannot be said about the association between these two pathologies. We report a unique case of an 80-year-old patient admitted to the emergency room with a bowel obstruction caused by a urothelial carcinoma with adrenal metastasis. The patient underwent an urgent laparotomy, and intraoperative inspection of the peritoneal cavity confirmed a large tumorous mass suspected of gastrointestinal etiology. The mass infiltrated the ileum and sigmoid colon and was apparently in contact with the bladder wall. An en-bloc resection of the lesion was performed. An R0 excison was not possible and fragments of the lesion were excised from the bladder wall for separate analysis. Histopathological examination of the resected specimen described a high-grade, undifferentiated urothelial carcinoma that originated in the bladder and invaded the ileum and sigmoid colon. The presence of an invasive urothelial carcinoma presenting with bowel obstruction represents an unexpected diagnosis and, although rare, the surgeon must be aware of this possibility. This case should serve as a reminder that a broad differential diagnosis should be considered when investigating an abdominal tumor.

Outcomes of patients admitted with malignant small bowel obstruction: a subgroup multicentre observational cohort analysis.

INTRODUCTION AND PURPOSE OF THE STUDY: Small bowel obstruction (SBO) accounts for a substantial proportion of emergency surgical admissions. Malignancy is a common cause of obstruction, either due to a primary tumour or intra-abdominal metastases. However, little is known regarding the current treatment or outcomes of patients with malignant SBO. This study aimed to characterise the treatment of malignant SBO and identify areas for potential improvement and compare overall survival of patients with malignant SBO to patients with non-malignant SBO. MATERIALS AND METHODS: This was a subgroup analysis of a multicentre observational study of patients admitted with SBO. Details regarding these patients' diagnoses, treatments, and outcomes up to 1-year after admission were recorded. The primary outcome was overall survival in patients with malignant SBO. RESULTS: A total of 316 patients with small bowel obstruction were included, of whom 33 (10.4%) had malignant SBO. Out of the 33 patients with malignant SBO, 20 patients (60.6%) were treated with palliative intent although only 7 patients were seen by a palliative team during admission. Nutritional assessments were performed on 12 patients, and 11 of these patients received parenteral nutrition. 23 patients underwent surgery, with the most common surgical interventions being loop ileostomies (9 patients) and gastrointestinal bypasses (9 patients). 4 patients underwent right hemicolectomies, with a primary anastomosis formed and 1 patient had a right hemicolectomy with a terminal ileostomy. Median survival was 114 days, and no difference was seen in survival between patients treated with or without palliative intent. CONCLUSION: Malignant SBO is associated with significant risks of short-term complications and a poor prognosis. Consideration should be given to the early involvement of senior decision-makers upon patient admission is essential for optimal management and setting expectation for a realistic outcome.

Appendico-ileal knot: A rare form of small bowel obstruction: A case report.

INTRODUCTION AND IMPORTANCE: Small bowel obstruction (SBO) is a common surgical emergency with various causes. However, SBO resulting from appendicitis is uncommon and often overlooked. Appendico-ileal knotting, a rare and dangerous form of SBO, occurs when the appendix becomes twisted around the small intestine, leading to strangulation. Despite being reported since 1901, there have been very few documented cases of this condition. Diagnosing appendico-ileal knotting preoperatively is challenging, and even imaging techniques like computed tomography scans may not provide definitive diagnostic findings. Our current case report is a valuable addition to the limited literature and enhances understanding of this infrequent cause of SBO from a resource limited setting. CASE PRESENTATION: We present the case of a 28-year-old female who presented with symptoms of dynamic SBO, including abdominal pain, vomiting, and constipation. Preoperative evaluation couldn't determine the exact cause. CLINICAL DISCUSSION: Diagnosis of a strangulated ileum was discovered, with the appendix identified as the source intraoperatively, leading to an open retrograde appendectomy. Postoperatively, the patient received IV ceftriaxone (1 g daily), metronidazole (500 mg tds), paracetamol (1 g tds), and IV crystalloids. Oral intake resumed gradually, and discharge occurred on day 4. Follow-up on 10th day was uneventful. CONCLUSION: Appendico ileal knotting is a rare cause of mechanical SBO. Knowledge of its pathophysiology, diagnosis, and management is very crucial to reduce its associated morbidity and mortality.

Keys to successful laparoscopic adhesiolysis for adhesive small bowel obstruction: A scoping review.

Background: Adhesive small bowel obstruction (ASBO) is a common acute abdominal complication. Although non-surgical treatment is the primary treatment approach, more and more studies show that surgical treatment can reduce the incidence rate. Laparoscopic adhesiolysis (LA) has many advantages of minimally invasive surgery.But not all patients with ASBO are suitable for LA. Objective: The aim of this scoping review was to summarize the keys to successful LA by analyzing the extensive literature. Methods: A literature search was conducted in PubMed for articles on laparoscopic treatment of ASBO published between January 2000 and February 2024. This scoping review followed the framework suggested by Arksey and O'Malley for a scoping review. Results: By analyzing the included studies we found that LA does have many advantages and can be performed safely. However, the prerequisite is to select patients with simple adhesions whenever possible and to focus on reasonable intraoperative measures. To improve the success rate of LA, we summarized the following characteristics of patients: no contraindications related to pneumoperitoneum, few previous abdominal operations (≤2), no pregnancy, bowel dilatation < 4 cm in diameter, simple adhesions, no diffuse peritonitis, no history of abdominal radiotherapy, <24 h of ASBO, limited previous abdominal surgery (appendix, cholecystectomy), no bowel strangulation ischemia, and bowel necrosis or bowel resection required for other reasons. In addition, we also summarized reasonable intraoperative measures. Conclusions: Laparoscopic adhesiolysis has many advantages.Specific patients can benefit from LA. This scoping review Summarized the conditions for patient screening and reasonable intraoperative measures with the aim of providing a reference for surgeons, thereby ensuring that more patients benefit from LA.

Small cell lung cancer associated small bowel obstruction, a diagnostic conundrum: A case report.

Small cell lung cancer (SCLC), a neuroendocrine aggressive subtype of lung cancer, is associated with paraneoplastic disorders in about 9% of patients. In this report, we describe a middle-aged man who presented with chronic bowel obstruction caused by chronic intestinal pseudo-obstruction (CIPO) due to SCLC.

Pediatric colonic adenocarcinoma: A deceptive case of gastroenteritis and constipation.

Adenocarcinoma of the colon is a rare diagnosis in pediatric patients. We present a previously healthy 15-year-old female who began experiencing escalating colicky abdominal pain and associated vomiting over 2 weeks in the setting of presumed acute gastroenteritis. A computed tomography scan revealed an obstruction in her descending colon. A multidisciplinary decision was made to perform a colonoscopy upon which a large, circumferential, friable lesion was discovered 40 cm from the anus. A colon decompression catheter was successfully inserted following controlled radial expansion (CRE) Balloon dilation to 13.5 mm beyond the mass, resulting in a significant discharge of fluid and gas. The patient underwent hemicolectomy with mass resection and colostomy. Biopsies confirmed poorly differentiated adenocarcinoma with "napkin-ring" morphology and positive lymph node metastasis with extranodal extension.

Intraoperative Diagnosis and Surgical Management of Encapsulating Peritoneal Sclerosis: A Case Report.

Encapsulating peritoneal sclerosis (EPS) is a serious complication of chronic peritoneal dialysis (PD) that results in encapsulation of the bowel in a thick, fibrocollagenous membrane. Given its rare and complex nature, diagnosis of EPS often arises late in the disease process or intraoperatively. We report the case of an 86-year-old male with a history of renal failure managed with PD who presented with multiple hospital admissions for recurrent abdominal pain and symptoms of small bowel obstruction. Open laparotomy revealed encasement of the entire abdominal cavity in a cocoon-like membrane, consistent with EPS, which was successfully managed with extensive excision and adhesiolysis. This discussion, enriched by unique radiographic insights and delineation of a surgical strategy, seeks to enhance the understanding of this underreported disease characterized by a lack of definitive treatment and an enigmatic pathophysiology.

Can we improve the management of inoperable malignant bowel obstruction? Results of a feasibility study of elemental diet as an alternative to parenteral nutrition in patients with advanced gynaecological cancer.

PURPOSE: Nutrition support in inoperable bowel obstruction (IBO) remains challenging. Parenteral nutrition (PN) is recommended if the prognosis is > 2 months. An elemental diet (ED) is licensed for strictures in Crohn's disease but has not been used in malignant bowel obstruction. The aim of this study was to evaluate the use of ED in patients with IBO and provide a proof of concept of ED as an acceptable feeding option. METHODS: This was a mixed-methods single-arm feasibility study. The primary endpoint was to provide a 'proof of concept' of ED as an acceptable feeding option for patients with IBO. Secondary endpoints included taste acceptability, incidences of vomiting and pain, the proportion of women who tolerated ED, the number of cartons drunk, quality of life (QOL) and the number of women treated with chemotherapy. Patients (> 18 years) with CT-confirmed IBO who could tolerate 500 ml of liquid in 24 h remained on the trial for 2 weeks. RESULTS: A total of 29 patients were recruited; of those, 19 contributed to the analysis for the primary endpoint; 13 (68.4%) participants tolerated the ED; 26 patients contributed to MSAS and EORTC QLQ questionnaires at baseline to allow for the assessment of symptoms. At the start of the study, 18 (69%) of patients experienced vomiting, reducing to 4 (25%) by the end of day 15 of the study; 24 (92%) of patients reported pain at consent, reducing to 12 (75%) by the end of day 15. QOL scores improved from 36.2 (95% CI 27.7-44.7) at baseline to 53.1 (95% CI 40.3-66) at the end of day 15; 16 (84%) participants commenced chemotherapy within the first week of starting ED. The number of cartons across all participants showed a median of 1.3 cartons per day (range 0.8 to 2.5). CONCLUSION: ED is well tolerated by patients with IBO caused by gynaecological malignancies and may have a positive effect on symptom burden and QOL.

Unraveling Twisted Pouch Syndrome: A Narrative Review of Classification, Diagnosis, Treatment, and Prevention.

BACKGROUND: We recently described a cluster of symptoms known as twisted pouch syndrome that rarely affects patients with ileoanal pouches. Herein, we present a narrative review in which we describe the diagnosis, treatment, and prevention of twisted pouch syndrome, with a focus on a simple classification schema. METHODS: Diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies are presented. RESULTS: Patients with twisted pouch syndrome suffer from a triad of obstructive symptoms, erratic bowel habits, and pain which may be severe, debilitating visceral pain, all in the setting of a mechanical pouch abnormality. Diagnostic modalities include imaging, careful pouchoscopy, functional testing, diagnostic laparoscopy or laparotomy, and recently 3-dimensional pouchography. Classification of twisted pouch syndrome is based on the location and degree of rotation of the pouch and its mesentery. Outlet twists may result when the distal pouch rotates >90° to 360° clockwise inadvertently during anastomosis; when only the distal most pouch is twisted, it results in an iris-like deformity of the pouch outlet, or when the distal half of the pouch is twisted, a mid-pouch stenosis and an hourglass-shaped pouch may result. Inlet twists are either a full 360° (mesentery posterior), unintentional 180° (mesentery anterior), or 90° counterclockwise twists. Both inlet and outlet twists are fixed deformities and may only be reduced by disconnecting the entire pouch from the anus. If they result in twisted pouch syndrome, a redo pouch procedure or pouch excision is required to reduce the twist; 90° counterclockwise twists may undergo pouch inlet transposition. Adhesive twists result when the pouch becomes fixed in the pelvis in an abnormal configuration, such as when the efferent limb becomes twisted underneath the afferent limb secondary to an occult tip of the J leak, and may be reduced by pelvic adhesiolysis with or without pouch revision. CONCLUSIONS: Pouches may rarely be inadvertently twisted during construction or twisted owing to adhesive disease or leaks. A high index of suspicion is needed to establish the diagnosis. We present a simple classification of twisted pouch syndrome that may aid in the prevention and recognition of these often difficult to diagnose postoperative complications.

In this article, we report a simple classification system for the mechanical pouch complication known as twisted pouch syndrome, including diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies.

Pediatric water bead-related visits to United States emergency departments.

OBJECTIVE: To evaluate the characteristics and trends of pediatric water bead-related visits to US emergency departments (EDs) using a large national database. METHODS: Data from the National Electronic Injury Surveillance System regarding ED visits by individuals <20 years old associated with water beads from January 1, 2007, through December 31, 2022, were retrospectively analyzed. RESULTS: Based on 307 reported cases, there were an estimated 8159 visits (95% CI: 4447-11,870) to US EDs from 2007 through 2022 involving water beads among <20-year-olds, and more than half (55.0%) of the 307 ED cases involved <5-year-olds. Most cases were treated and released (92.2%), which was consistent across all age groups. The proportion of cases admitted was highest among children <5 years old (10.1%), and this age group accounted for 17 of the 19 admissions (89.5%) in this study. All admissions among children <5 years old involved ingestions. Ingestion was the most common mechanism of injury (45.9%), followed by ear canal insertion (32.6%), nasal insertion (11.7%), and eye injury (8.8%). Although ingestions occurred most frequently among children one (28.4%) and two (23.4%) years of age, children 3 and 4 years old accounted for one-fifth of ingestions. The number of ED cases increased rapidly by 130.9% from 55 cases in 2021 to 127 in 2022. CONCLUSIONS: The number of pediatric water bead-related ED visits is increasing rapidly. Children <5 years old are most commonly involved, usually via water bead ingestion. Increased prevention efforts are needed.

A rare case of chicken wishbone in Meckel's diverticulum causing partial perforation and diverticulitis.

Meckel's diverticulum (MD), a rare congenital abnormality, can lead to issues like diverticulitis and bleeding. Foreign bodies in MD are even rarer, causing vague symptoms and perforation, requiring urgent surgery. This case report highlights a patient with a foreign body in MD, focusing on clinical presentation and management. A 55-year-old male presented with abdominal pain, nausea, and vomiting. Computed tomography scan revealed a foreign body perforating the small bowel. Exploratory laparotomy found a partially perforated MD with a foreign body. Diverticulectomy was performed, and the patient recovered, discharged the next day. Foreign bodies in MD are exceedingly rare and can cause inflammation, infection, and perforation, mimicking appendicitis. Diagnosis is challenging due to nonspecific symptoms, with imaging and clinical evaluation crucial. Surgical intervention, like diverticulectomy, is primary. Early diagnosis and prompt surgery are critical in managing MD complicated by foreign bodies, ensuring favorable outcomes. This report underscores symptom recognition and effective management strategies.

From an incidental lipoma to ileo-ileal intussusception in an adult: A case report.

INTRODUCTION AND IMPORTANCE: Intussusception in adults is rare, constituting a miniscule number of bowel obstruction pathologies. Clinical practice often considers it a last-resort diagnosis, as other causes of mechanical small bowel obstruction are more common. The diagnosis is a challenging one to make, as the "telescoping" motion of the intestines fluctuates in a waxing-and-waning nature. In adults, the etiology is predominantly a pathological lead point being either benign or malignant. When encountering an obscure cause of abdominal pain, intussusception caused by a small bowel lipoma may be the culprit. CASE PRESENTATION: In this unique case, we present the journey of a 55-year-old Emirati male who presented with severe abdominal pain, nausea and vomiting. The patient underwent various imaging modalities, initially an "incidental" lipoma finding in the terminal ileum until a diagnosis of ileo-ileal intussusception emerged in later imaging, given its unusual and fluctuating nature. Ultimately, a resection of the bowel segment with side-to-side anastomosis was done. CLINICAL DISCUSSION: This case report aims to illuminate the diverse clues and incidental findings encountered during our patient's path to a diagnosis. By exploring the elements of this patient's journey to a diagnosis, we aspire to aid future clinicians in navigating the challenges of identifying obstructive pathologies and considering intussusception as a rare yet crucial differential diagnosis. CONCLUSION: This case highlights the importance of a comprehensive approach to diagnosis and management of patients presenting with obstructive symptoms, incorporating both clinical insight and imaging modalities such as CT to ensure optimal patient outcomes. When confronting such an obscure cause of abdominal pain, intussusception caused by a small bowel lipoma may be the culprit.