Maternal Preeclampsia and a Preterm Neonate With Small Bowel Stenosis, Volvulus, and Severe Intrauterine Growth Restriction.

Preeclampsia is a human-specific hypertensive disorder of gestation. It is associated with short-term adverse effects in the fetus and long-term complications in the neonate, mainly due to disrupted blood flow during critical periods of intrauterine development. An ischemic event in the uterus can affect many systems of the fetus, including a small bowel involvement. We present a case of a preterm, small for gestational age neonate with severe intrauterine growth restriction, small bowel stenosis, and volvulus without malrotation, born to a mother with severe preeclampsia.

Delayed bowel stenosis following subtotal resection of the small intestine for non-occlusive mesenteric ischemia.

We report herein a case of delayed bowel stenosis after surgery for non-occlusive mesenteric ischemia (NOMI), which was successfully treated with endoscopic stenting. The patient was a 78-year-old woman who underwent an emergency laparotomy for NOMI and duodeno-ileal anastomosis. Necrosis was observed in almost all areas of the small intestine except for the beginning of the jejunum and the end of the ileum. Postoperatively, the patient was discharged with central venous nutrition, but was readmitted on postoperative day 54 with a diagnosis of postoperative ileus. The patient failed to respond to conservative treatment. Fluoroscopic endoscopy revealed wall stiffness and circumferential stenosis in the ascending colon at a different site from that of the anastomosis. Based on this finding, delayed stenosis of the ascending colon after NOMI treatment was diagnosed. Bougie dilatation was performed for the stenosis, leading to temporary improvement. However, stenosis along with ileus soon recurred. To prevent restenosis, a metallic stent was endoscopically implanted at the stenotic site. Thereafter, the patient was discharged without any further episodes of restenosis. Delayed bowel stenosis may occur after a subtotal resection of the small intestine for NOMI. Endoscopic stenting is an effective treatment option if resection is difficult.

Leaving behind a diseased small bowel during surgery for Crohn's disease: Long-term outcomes.

PURPOSES: Stricture is a common complication of Crohn's disease (CD) and may be treated with bowel-sparing procedures. Our study analyzed what happens in terms of intestinal and systemic inflammation when the diseased bowel is left behind following surgery. METHODS: In this retrospective study, we enrolled 42 consecutive patients who underwent strictureplasty (alone or with resection) for stricturing CD. Control patients who underwent complete diseased bowel resection were identified and propensity score-matched for the sex, age, and history of abdominal surgery. Biohumoral values were collected at follow-up examinations at 1, 6, and 12 months after surgery. Magnetic resonance imaging (MRI) was performed before and after strictureplasty in 19 patients. RESULTS: In the strictureplasty group, fecal calprotectin levels were decreased at 12 months (p = 0.03), whereas in the resectiongroup, they were decreased at 6 months (p = 0.02). On MRI, the ADC [apparent diffusion coefficient] (p < 0.001), wall thickness (p = 0.046) and Magnetic Resonance Index of Activity (MaRIA) (p < 0.001) and Clermont (p < 0.001) scores were improved after strictureplasty. Surgical recurrence was more frequent in the strictureplasty group than in the resection group (p = 0.003). CONCLUSIONS: Our retrospective study showed that even if the diseased bowel was left behind after surgery, the intestinal inflammatory activity still decreased. However, the permanence of the diseased bowel still increased the risk of reoperation, probably because of the fibrotic nature of the stenosis and the multifocality of CD.

Small bowel cancer in a patient with Crohn's disease diagnosed preoperatively by double-balloon enteroscopy.

A 53-year-old female patient, who had been treated for Crohn's disease for approximately 20 years, was admitted to our hospital with a chief complaint of persistent bloody stools. Colonoscopy, computed tomography, and magnetic resonance enterography revealed two stenoses of the ileum and multiple enlarged lymph nodes around the oral-side ileal stenosis. We accordingly performed transoral double-balloon enteroscopy and found ileal stenosis with an irregular mucosal surface. Based on pathological examination of the stenosis, adenocarcinoma of the small bowel was diagnosed for the oral-side stenosis. The stenosis on the anal side was benign. The two stenoses were resected simultaneously, and lymph node dissection was performed on the cancerous lesion. The diagnosis of the cancerous lesion was pStage IIIB, and immunohistochemical staining was positive for tumor protein 53. Patients with Crohn's disease are at a high risk of small bowel cancer, but no surveillance protocol has been established to date. We encountered a case of Crohn's disease in which radical surgery was possible, owing to preoperative pathological diagnosis, by using balloon-assisted enteroscopy. In this paper, we report a case that suggests the importance of performing balloon-assisted enteroscopy when small bowel stenosis is detected in patients with Crohn's disease.

Colon capsule retention in a patient with large bowel stenosis due to diverticulosis - a case report.

Capsule retention is a rare complication to capsule endoscopy. It is often asymptomatic and resolves itself spontaneously. In some cases, endoscopy or surgery is necessary to remove the capsule. Cases of capsule retention in the colon are not reported very often and precautions in subsequent investigations must be considered. We present a case of a 74-year-old woman who underwent colon capsule endoscopy (CCE) due to a positive fecal immunochemical test. The CCE was incomplete, and the patient was referred to conventional colonoscopy, which was complicated by perforation of the large bowel during the procedure. This lead to a CT scan showing the capsule proximal to a stenotic colon segment which was subsequently surgically removed. In patients who report lack of capsule excretion and stenosis is not verified, colonoscopy can be carried out, but with caution.

A pilot study investigating the safety and feasibility of endoscopic dilation using a radial incision and cutting technique for benign strictures of the small intestine: a study protocol.

BACKGROUND: Small benign intestinal stenosis is usually treated by endoscopic balloon dilation (EBD) or surgery. Although EBD and surgery are able to resolve the stenosis in most cases, they are associated with several problems such as insufficient dilation and surgical stress, respectively. On the contrary, a novel approach called radial incision and cutting (RIC) is reported to have several benefits when compared to EBD and surgery. We can currently adopt RIC only for the strictures in the colon or terminal ileum and not for those stenotic lesions present further in the small intestine where balloon-assisted endoscopy is utilized, because the long-type electric knife is currently not approved for use in Japan. We will herein conduct a pilot study to investigate the safety and feasibility of RIC for treating the benign stenoses of the small intestine using the long-type electric knife. METHODS: This will be a single-center, single-arm, interventional trial. The major criteria for inclusion will be age ranging from 20 to 80 years and the presence of benign stenosis in the small intestine. We will perform RIC on 10 participants. The primary outcome is the safety of this procedure, which will be assessed by measuring the frequency of adverse events of special interest. The secondary outcomes will be technical success rate, improvement in subjective symptoms, procedure time, and duration of hospitalization. DISCUSSION: This pilot study will provide useful information that will aid in adopting RIC for treating the benign strictures present in the small intestine. TRIAL REGISTRATION: jRCT Identifier, jRCTs022200040 . Registered on 1 March 2021.

Predictors of necessity for endoscopic balloon dilatation in patients with Crohn's disease-related small bowel stenosis.

BACKGROUND AND AIM: In patients with Crohn's disease (CD) and small bowel stenosis, endoscopic balloon dilation (EBD) is considered to be useful in improving stenotic symptoms and avoiding surgery. However, it carries risks such as bleeding and perforation. The aim of this study was to identify the indications for endoscopic intervention in patients with CD and small bowel stenosis. METHODS: From November 2007 to March 2020, 143 CD patients with small bowel stenosis were enrolled in this study. We identified the factors associated with not requiring endoscopic intervention during long-term follow-up of these patients. RESULTS: Forty of the 143 patients had abdominal symptoms of stenosis and had undergone EBD, whereas the remaining 103 were asymptomatic and had not undergone endoscopic intervention. During long-term follow-up, 95 of those 103 patients never required endoscopic or surgical intervention. Multivariate logistic regression analysis revealed that not consuming an elemental diet (OR 3.18, 95% CI 1.48-6.82; p < .01) and ileocecal valve (ICV) stenosis (OR 0.30, 95% CI 0.11-0.83; p = .02) were independently associated with not requiring EBD. The cumulative emergency hospitalisation-free rate also tended to be higher in patients not consuming an elemental diet or with ICV stenosis. CONCLUSIONS: Two factors, namely not consuming an elemental diet and ICV stenosis, predict a long-term intervention-free prognosis in CD patients with small bowel stenosis.Key messagesWhen an endoscopically impassable small bowel stenosis is found in a CD patient, long-term follow-up without endoscopic intervention may be possible if the patient is asymptomatic, is not using an elemental diet, and the stenosis is ICV.

Risk of Postoperative Stenosis after Segmental Resection versus Disk Excision for Deep Endometriosis Infiltrating the Rectosigmoid: A Retrospective Study.

STUDY OBJECTIVE: To assess the prevalence, risk factors, and management of bowel stenosis after surgery for deep infiltrating endometriosis of the rectosigmoid using either disk excision (DE) or segmental resection (SR). DESIGN: Retrospective study using data from consecutive cases recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database. SETTING: University tertiary referral center. PATIENTS: Four hundred thirty-one consecutive patients managed for rectosigmoid endometriosis were enrolled in our study. INTERVENTIONS: Laparoscopic SR or DE. MEASUREMENTS AND MAIN RESULTS: One hundred sixty-five patients underwent DE, and 266 patients underwent SR. Large nodules ≥3 cm in diameter were more frequent in the SR group (73.3% vs 66.1%), whereas nodules infiltrating the low rectum were 3 times more frequent in the DE group (35.9% vs 11.3%). The frequency of vaginal excision (67.9% vs 62%) and stoma (46.7% vs 44.4%) were comparable between the DE and SR groups. Twenty-three patients presented with postoperative colorectal stenosis after SR (8.6%) versus none after DE (p <.001). Treatment of colorectal stenosis involved dilatation in 20 (87%) cases and SR in 4 (17.4%) cases. For 1 patient, dilatation resulted in rectosigmoid injury requiring SR, followed by rectovaginal fistula. The logistic regression model identified a diverting stoma as the sole risk factor independently related to the risk of postoperative stenosis after SR. CONCLUSION: Bowel stenosis after surgery for deep infiltrating endometriosis occurred in patients who underwent SR, most of them with a diverting stoma, whereas no cases of stenosis were reported in patients who underwent DE, with or without stoma.

Tag-less patency capsule for suspected small bowel stenosis: Nationwide multicenter prospective study in Japan.

STUDY AIMS: The PillCam patency capsule (PPC) is an Agile tag-less patency capsule used to evaluate gastrointestinal (GI) patency. We determined the appropriate use of PPC to preclude subsequent small bowel capsule endoscopy (SBCE) retention. METHODS: This prospective multicenter study consecutively enrolled patients indicated for SBCE with suspected or established small bowel stenosis. Excretion of an intact PPC or its radiologic visualization in the large bowel was considered GI patency. Primary and secondary study endpoints were SBCE retention rates in patients with confirmed patency and identification of factors associated with patency and SBCE retention, respectively. RESULTS: Of 1096 patients enrolled in the study, patency was confirmed in 976 (89.1%). PPC excretion occurred in 579 patients. Of the remaining 517 patients, patency was confirmed using imaging modalities in 401 (77.5%). SBCE retention occurred in five (0.51%) of 963 patients who underwent SBCE: 1.0% in established Crohn's disease (CD) patients, 0% in suspected CD, 0% in tumors, and 1.6% in patients with obscure GI bleeding, for which PPC localization had been radiographically misinterpreted. The non-confirmation of patency was associated with established CD, stenosis identified using imaging modalities, abdominal fullness, serum albumin levels <4.0 g/dL, and previous small bowel obstruction (adjusted odds ratios: 4.21, 2.60, 2.47, 2.12, and 2.00; 95% confidence intervals: 2.62-6.78, 1.62-4.17, 1.43-4.27, 1.32-3.40, and 1.15-3.47, respectively). CONCLUSIONS: The PillCam™ patency capsule helped preclude SBCE retention in most patients, but its accurate localization was essential for cases without excretion (Study registered the University Hospital Medical Information Network, #UMIN000010513).

Small bowel stenosis after blunt abdominal trauma: a case report.

BACKGROUND: Small bowel stenosis after blunt abdominal trauma is relatively rare, and progression from trauma to bowel stenosis might sometimes be delayed. Herein, we report the case of a patient who was diagnosed with small bowel stenosis relatively early and received laparoscopic surgery. CASE PRESENTATION: An 18-year-old Japanese male was in a traffic accident and was urgently transported to our hospital. On arrival, he was admitted with right kidney and right adrenal injury and abdominal aortic aneurysm. On hospital day 13, he vomited during conservative treatment without surgery, and computed tomography revealed small bowel stenosis and dilatation of the oral-side small bowel. No improvement with the ileus tube occurred, and he received laparoscopic surgery on hospital day 21. Briefly, the abdominal cavity was observed with a laparoscope. The mesentery was congested, scarring around the stenotic small bowel regions was present, and three stenotic regions were observed 40-50 cm from the Treitz ligament. The patient received partial resection and anastomosis of the small bowel. The postoperative course was stable, and he was discharged on postoperative day eight. CONCLUSIONS: Most cases of bowel stenosis after abdominal trauma are irreversible and usually require surgical treatment. Therefore, small bowel stenosis should be considered in patients with abdominal symptoms after blunt abdominal trauma.

A Prospective Study Comparing Three-Dimensional Rectal Water Contrast Transvaginal Ultrasonography and Computed Tomographic Colonography in the Diagnosis of Rectosigmoid Endometriosis.

(1) Objectives: In patients with symptoms suggestive of rectosigmoid endometriosis, imaging techniques are required to confirm the presence and establish the extent of the disease. The objective of the current study was to compare the performance of three-dimensional rectal water contrast transvaginal ultrasonography (3D-RWC-TVS) and computed tomographic colonography (CTC) in predicting the presence and characteristics of rectosigmoid endometriosis. (2) Methods: This prospective study included patients with suspicion of rectosigmoid endometriosis who underwent both 3D-RWC-TVS and CTC and subsequently were surgically treated. The findings of imaging techniques were compared with surgical and histological results. (3) Results: Out of 68 women included in the study, 37 (48.9; 95% C.I. 38.2-59.7%) had rectosigmoid nodules and underwent bowel surgery. There was no significant difference in the accuracy of 3D-RWC-TVS and CTC in diagnosing the presence of rectosigmoid endometriotic nodules (p = 0.118), although CTC was more precise in diagnosing endometriosis located in the sigmoid (p = 0.016). 3D-RWC-TVS and CTC had similar precision in estimating the largest diameter of the main endometriotic nodule (p = 0.099) and, in patients undergoing segmental resection, the degree of the stenosis of the bowel lumen (p = 0.293). CTC was more accurate in estimating the distance between the lower margin of the intestinal nodule and the anal verge (p = 0.030) but was less tolerated than 3D-RWC-TVS (p < 0.001). (4) Conclusion: This was the first study comparing the performance of 3D-RWC-TVS and CTC in the diagnosis of rectosigmoid endometriosis. Both techniques allowed for the evaluation of the profile of the bowel lumen in a pseudoendoscopic fashion and had a similar performance for the diagnosis of rectosigmoid endometriosis, although CTC was more accurate in diagnosing and characterizing sigmoid nodules.

Predictors for Small Bowel Stenosis in Balloon-Assisted Enteroscopy.

BACKGROUND: Predictors besides symptoms of obstruction indicating small bowel stenosis are little known. AIMS: To detect predictors of small bowel stenosis in balloon-assisted enteroscopy. METHODS: Over a 6-year period, 461 patients had enteroscopy for suspected small intestinal disease. Details of clinical manifestations, medical history, demographic characteristics, findings of examinations, information on enteroscopy, and treatment were retrospectively collected based on medical records. Small bowel stenosis was defined as stricture that over-tube cannot go through in enteroscopy. Univariate and multivariate analyses were performed to identify predictors for small bowel stenosis. RESULTS: A total of 314 patients had definite diagnosis after enteroscopy, imaging modalities, and/or even surgical exploration. They were included in this study for analyses. Mean age for them was 48.2 years old (range 15-81 years). Small bowel stenosis was present in 59 patients (18.8%). Analyses showed that CT/MRI indicating stenosis was significantly associated with severe stenosis (p = 0.014) but insignificant related to general stenosis (p = 0.097). Predictive factors that accompanied stenosis were age ≥ 60 years (OR = 2.1, 95% CI 1.1-4.0), underweight (BMI ≤ 18.5) (OR = 3.4, 95% CI 1.4-8.4), symptoms of obstruction (OR = 3.6, 95% CI 1.8-7.4), and overt small bowel bleeding (OR = 0.5, 95% CI 0.2-0.9). CONCLUSIONS: Small bowel stenosis more tended to occur to patients with symptoms of obstruction, no overt small bowel bleeding, age ≥ 60 years, or underweight.

Familial Mediterranean Fever with Small Bowel Stenosis.

A 37-year-old man developed abdominal pain and the frequency of severe abdominal pain steadily increased to once a month. He was therefore admitted to our hospital. Abdominal CT showed bowel obstruction. It revealed transient stenosis in the small intestine. There were no symptoms such as fever or weight loss, it seemed unlikely that the patient had inflammatory bowel disease. Considering the history of recurrent abdominal pain, Familial Mediterranean Fever (FMF) was considered. As a result, a genetic analysis revealed mutations in exons 3 and 8 of the MEFV gene. We herein report the first known case of FMF with transient small bowel stenosis in Japan.

Fetal intra-abdominal bowel dilation in prediction of complex gastroschisis.

OBJECTIVE: To investigate intra-abdominal bowel dilation (IABD) in the prediction of complex gastroschisis. METHODS: This was a retrospective study of 174 singleton pregnancies with isolated fetal gastroschisis, resulting in live birth and with available ultrasound images from visits at both 20-22 and 30-32 weeks' gestation. IABD was measured as the greatest transverse diameter of the most dilated intra-abdominal bowel segment, by an operator blinded to postnatal outcome. The distribution of IABD measurements in those with complex and those with simple gastroschisis was determined and the best cut-off value to predict complex gastroschisis was selected using receiver-operating characteristics (ROC) curves. The area under the ROC curve (AUC), detection rate (DR), false-positive rate (FPR), positive predictive value (PPV) and negative predictive value (NPV) were determined. RESULTS: The study population included 39 (22.4%) cases of complex and 135 (77.6%) cases of simple gastroschisis. In the prediction of complex gastroschisis, the AUC at 20-22 weeks' gestation was 0.742 (95% CI, 0.628-0.856) and the respective value for 30-32 weeks was 0.820 (95% CI, 0.729-0.910). At the IABD cut-off of 7 mm at 20-22 weeks, DR, FPR, PPV and NPV for complex gastroschisis were 61.5%, 6.7%, 72.7% and 89.4%, respectively, and at IABD cut-off of 14 mm at 30-32 weeks, the respective values were 64.9%, 5.9%, 75.0% and 90.7%. CONCLUSION: Measurement of IABD at 20-22 or at 30-32 weeks' gestation is useful in the prediction of complex gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Sonographic Markers in the Prediction of Fetal Complex Gastroschisis.

OBJECTIVE: To investigate the ultrasound (US) markers predictive of complex gastroschisis (CG), mortality, and morbidity in fetuses with gastroschisis. MATERIALS AND METHODS: This was a retrospective cohort study of 186 pregnancies with isolated fetal gastroschisis. Eight US markers were analyzed. The predictions and associations of US markers with CG, mortality, and morbidity were assessed. Combinations of US markers predictive of CG were investigated. RESULTS: Extra-abdominal bowel dilatation (EABD), intra-abdominal bowel dilatation (IABD), and polyhydramnios were predictive of CG. EABD between 25 and 28 weeks had a sensitivity of 64%, a specificity of 89%, a positive predictive value (PPV) of 56.2%, and negative predictive value (NPV) of 91.8%. The predictions of IABD were sensitivity = 26.7%, specificity = 96.7%, PPV = 61.5%, and NPV = 86.8%. The odds ratios for CG in the presence of 1 and 2 US markers, compared with the absence of a US marker, were 18.3 (95% CI, 3.83-87.64) and 73.3 (95% CI, 6.14-876), respectively. CONCLUSION: US markers predictive of CG were established. The combination of these markers increases the probability of CG.

Small bowel stenosis: a manifestation of chronic graft-versus-host disease in children?

Digestive graft-versus-host disease (GVHD) is a frequent complication after bone marrow transplantation, but small bowel obstruction is an extremely rare event. We present herein the first pediatric series of 4 cases of small bowel obstruction after bone marrow transplantation with detailed gross, histological data and their genetic status of the NOD2 gene. All patients had a history of severe acute GVHD treated by immunosuppressive agents and/or infliximab (in 3 cases). Acute or progressively worsening abdominal pain accompanied by small bowel occlusion occurred 5-16 months after graft, and computed tomographic scan revealed multiple small intestinal stenoses. Failure of intensive medical treatment led to surgical resection of affected loops. Stigmata of acute (apoptosis of crypts and satellitosis) and chronic GVHD features (submucosal fibrosis and serosae sclerolipomatosis), as well as extensive ulcerations, were observed in all ileal specimens. NOD2 mutation was found in only 1 patient. The follow-up showed successful outcome after surgery.

Small bowel stenosis following blunt abdominal trauma: a case report.

Blunt abdominal trauma is a rare case of intestinal obstruction, and only few cases have been reported in the world literature. Stenotic intestinal obstruction following blunt abdominal trauma is a very rare complication. This case highlights the need for clinical suspicion serial clinical assessment and radiological evaluation and the need for early surgery in patients presenting with abdominal symptoms following blunt abdominal trauma.

Videocapsule retention: role of surgical treatment (a case report).

Video capsule endoscopy (VCE) is a safe innovative tool for investigating obscure gastrointestinal diseases. The capsule is usually excreted with faeces within 24-48 h. Retention of capsule rarely occurs, and it usually depends on the indication of VCE. Retention may long remain asymptomatic or manifest as subocclusif syndrome. Acute complications of retention are very rare but can be life-threatening illness. Surgical approach is considered effective to retrieve the retained capsule, treat the pathology responsible and prevent acute complications. We report the case of a 30 years old patient, followed for Crohn's disease. She received during the assessment reviewed by VCE that has been held for three months. The retention caused subocclusif symptoms of which had needed surgically procedure. Treatment consisted of remove the VCE and repair of stenosis of small bowel by stricturoplasty.