Capsule endoscopy for small bowel bleed: Current update.

Small intestine, hitherto an obscure area for endoscopists before 2000, is now easily evaluated non-invasively using capsule endoscopy and invasively by device-assisted enteroscopies. Major advances in understanding the causes and management of small bowel diseases have been in obscure gastrointestinal (GI) bleed, currently re-named as small bowel bleed, after the discovery of capsule endoscopy. The current article is a narrative review of the technology of capsule endoscopy, its advantages and limitations, future perspective and Indian studies on its utility in patients with small bowel bleed. Till date, eight large series reporting 2319 patients with obscure GI bleed (1554 overt and 765 occult) undergoing capsule endoscopy have been reported from India. Overall yield of capsule endoscopy to detect lesions in these studies varied from 43.5% to 90%. The major causes detected in various studies for small bowel bleed include vascular malformation, portal hypertensive enteropathy, ulcer, stricture, tumor, polyps, etc. Hookworm can cause both occult as well as overt small bowel bleed as shown mainly from India. Capsule endoscopy has also been quite safe in patients with small bowel bleed as despite 0.6% to 15% retention of imaging capsule in Indian studies, development of clinically evident small bowel obstruction has rarely been reported. The major limitations of capsule endoscopy include lack of maneuvrability and therapeutic capability. Research is in progress to overcome some of the limitations of the current capsule endoscopy system. It is concluded that discovery of capsule endoscopy has brought a new paradigm in GI endoscopy and explored a hitherto unexplored area of GI tract, i.e. small bowel that continued to be a black box for the endoscopists.

Management of a small bowel hemangioma causing intussusception in an infant: A rare case report and literature review.

INTRODUCTION: Hemangiomas of the small intestine are rare and usually present in young people. They are very difficult to diagnose preoperatively. We report a rare case of mixed intestinal hemangioma (IH) causing intussusception in a pediatric patient. CASE PRESENTATION: A 3-month-old girl, with no prior medical or surgical history, was admitted with rectal bleeding and paroxysmal crying due to intermittent abdominal pain. An urgent abdominal ultrasound revealed ileo-ileal intussusception. Operative findings confirmed the intussusception, and a segmental resection of the intussuscepted jejunum was performed. Histopathological examination found a mixed hemangioma. The postoperative course was uneventful. DISCUSSION: Clinical presentation may include intestinal bleeding leading to anemia, obstruction, intussusception and perforation. Intussusception caused by small bowel hemangioma is extremely rare. Notably, we didn't find any cases of small bowel hemangioma revealed by intussusception in children. The main treatment for hemangiomas is surgical resection of the affected segment. No evidence in the literature on postoperative recurrence of hemangiomas. CONCLUSION: Intussusception secondary to intestinal hemangiomas is extremely rare. Preoperative diagnosis is challenging as they are often undetectable with traditional techniques. Enhanced awareness and understanding of this condition can facilitate earlier diagnosis and improve management outcomes.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass.

BACKGROUND: Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE: This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS: PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS: Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS: This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Localization and etiological stratification of non-neoplastic small bowel bleeding via CT imaging: a 10-year study.

OBJECTIVES: The purpose of this study is to assess the diagnostic efficacy of contrast-enhanced CT scans for small bowel bleeding. METHODS: This retrospective study evaluated patients diagnosed with non-neoplastic small intestinal bleeding (including duodenum) who underwent abdominal CT at our institution from December 2013 to March 2023. Patients were categorized into diverticulum and non-diverticulum groups based on the cause of bleeding. Active bleeding was defined on the CT images as extravasation of contrast material in the intestinal lumen during the arterial phase and/or progressive accumulation of contrast material during the venous phase. We have documented the original report (extracted from the medical record system and additional consultation opinions from senior radiologists), including the presence of active bleeding and its potential bleeding location. Furthermore, two radiologists reassessed the CT images, seeking consensus on the diagnosis between them. RESULTS: The study included 165 patients, predominantly male, with a median age of 30 years. Active bleeding was identified in 48.3% of patients. Notably, all identified bleeding diverticula in the diverticulum group exhibited cul-de-sac termination. Among the identified causes of bleeding, Crohn's disease was most prevalent (46.7%, N of causes = 64). Significant differences were observed in the diagnostic methods between the diverticulum and non-diverticulum groups, with surgery predominantly applied in the diverticulum group, and endoscopy in the non-diverticulum group (n = 49 vs n = 15, p = 0.001). Contrast agent extravasation was significantly higher in the diverticulum group (n = 54 vs n = 16, p = 0.001), and Meckel's diverticulum cases appearing tubular were significantly higher than in other diverticulum cases (n = 25 vs n = 3, p < 0.001). CONCLUSION: CT allows for a higher detection rate of diverticular bleeding, even if asymptomatic, guiding classification into multiple potentially clinically relevant categories. CRITICAL RELEVANCE STATEMENT: Contrast-enhanced CT imaging is effective in determining the location and cause of non-neoplastic small bowel bleeding, especially diverticular bleeding. Therefore, the use of enhanced CT should be prioritized in the diagnosis and management of small bowel bleeding. KEY POINTS: CT has potential value in the diagnosis of small bowel bleeding. CT imaging suggests possible surgical intervention for active bleeding detection. CT diagnoses and localizes small bowel bleeding, aiding in treatment and prioritizing in guidelines.

The Utility of Magnetic Resonance Enterography and Double Balloon Enteroscopy-Assisted Endoscopic Balloon Dilatation for Small Bowel Strictures in Crohn's Disease: A Retrospective Observational Study.

Introduction: Crohn's disease (CD) of the small bowel is associated with a severe course and increased risk of complications. Strictures at this location are challenging to diagnose and out-of-reach of colonoscopy. We aimed to evaluate the detection rate of small bowel strictures with magnetic resonance enterography (MRE) and assess the efficacy of double balloon enteroscopy-assisted endoscopic balloon dilatation (DBE-assisted EBD) in managing these strictures. Methods: A retrospective study included all patients with DBE-assisted EBD of small bowel strictures in CD in our facility. All patients had MRE to detect strictures prior to the dilatation. Sequential dilatation protocol was performed using through-the-scope (TTS) working channel balloons. The outcomes included technical success defined by the passage of the enteroscope post-dilatation, resolution of symptoms, and the requirement of repeated procedures or surgery during 12 months of follow-up. Results: Twenty DBE-assisted EBDs of small bowel strictures were attempted during 13 DBE procedures in 10 patients (6 males, median age 42). MRE identified 75% of the strictures with 100% accuracy in localisation. Retrograde DBE was the approach in 16/20 (80%) strictures. Anaesthetic intubation was used in 8/20 (40%). DBE reached 19/20 strictures. All the reached strictures were dilated successfully; the technical success following dilatation was 72.2%. The median DBE insertion time with TTS balloon dilatation was 66 min. Three patients required follow-up dilatations within 2-3 months. Surgery was not needed during the follow-up period. Conclusions: MRE is essential in diagnosing and localising small bowel strictures in CD. DBE reached 95% of strictures with successful dilatation. Immediate technical success was high, and safety was demonstrated. Planned repeat procedures for sequential dilatation were performed in a few patients. Surgical resection was avoided in all patients.

Biopsy samples from patients with irritable bowel syndrome, but not from those with mastocytosis or unspecific gastrointestinal complaints reveal unique nerve activation in all gut regions independent of mast cell density, histamine content or specific gastrointestinal symptoms.

Introduction: We previously showed enteric nerve activation after application of colonic mucosal biopsy supernatants from patients with irritable bowel syndrome (IBS). The question remains whether this is a region-specific or a generalized sensitization. We tested the nerve-activating properties of supernatants from large and small intestinal regions of IBS patients with diarrhea (IBS-D) in comparison to those from mastocytosis patients with diarrhea (MC-D) or non-IBS/non-MC patients with GI-complaints. MC-D patients were included to test samples from patients with an established, severe mast cell disorder, because mast cells are suggested to play a role in IBS. Methods: Voltage-sensitive dye imaging was used to record the effects of mucosal biopsy supernatants from IBS-D, MC-D, and non-IBS/non-MC on guinea pig submucous neurons. Mast cell density and histamine concentrations were measured in all samples. Results: The median neuroindex (spike frequency × % responding neurons in Hz × %) was significantly (all p < 0.001) increased for IBS-D (duodenum and colon, proximal and distal each, 49.3; 50.5; 63.7; 71.9, respectively) compared to non-IBS/non-MC (duodenum and colon, proximal and distal each, 8.7; 4.9; 6.9; 5.4, respectively) or MC-D supernatants (duodenum and colon, proximal and distal each, 9.4; 11.9; 0.0; 7.9, respectively). Nerve activation by MC-D and non-IBS/non-MC supernatants was comparable (p>0.05). Mast cell density or histamine concentrations were not different between IBS-D, MC-D, and non-IBS/non-MC samples. Discussion: Nerve activation by biopsy supernatants is an IBS hallmark that occurs throughout the gut, unrelated to mast cell density or histamine concentration. At least as important is our finding that GI complaints per se were not associated with biopsy supernatant-induced nerve activation, which further stresses the relevance of altered nerve behavior in IBS.

Successful Multidisciplinary Treatment of Small Bowel Obstruction With an Ileal Stricture Resulting in Bowel Perforation in the Setting of Multidrug-Resistant Gastrointestinal Tuberculosis: A Case Report.

We present the case of a male in his 40s who recently emigrated from Russia and was actively undergoing treatment for multidrug-resistant (MDR) pulmonary tuberculosis (TB) with the BPaL-M (bedaquiline, pretomanid, linezolid, moxifloxacin, and pyridoxine) regimen who presented to the emergency department (ED) with abdominal pain, vomiting, and no bowel movements. A computed tomography (CT) scan of the abdomen and pelvis revealed a small bowel obstruction (SBO) from ileal stricture consistent with gastrointestinal (GI) TB. He did not require an emergent surgical intervention and was managed conservatively via bowel rest and initiation of total parenteral nutrition (TPN). An oral BPaL-M regimen was held and an intravenous (IV) regimen consisting of linezolid, moxifloxacin, meropenem, and ampicillin/sulbactam was started per infectious disease (ID) recommendations. He improved clinically over the next several days and was started on a diet that was initially well tolerated. Shortly after transitioning to a regular diet, he developed severe abdominal pain. A CT scan of the abdomen and pelvis revealed pneumoperitoneum and he was taken emergently to the operating room (OR) for exploratory laparotomy (ex-lap). A perforation was found in the terminal ileum and he underwent a right hemicolectomy. He returned to the OR two days later for ileocolic anastomosis and fascial closure. A diet was initiated once again which was tolerated well. He was then transitioned back to his oral BPaL-M regimen which was also tolerated well. He was discharged home on an oral diet after a 23-day hospital course with follow-up appointments with acute care surgery (ACS) and ID.

[Comparison of early operative treatment and 48-hour conservative treatment in small bowel obstruction (COTACSO): intermediate results]. / Promezhutochnye rezul'taty otkrytogo prospektivnogo randomizirovannogo mnogotsentrovogo sravnitel'nogo issledovaniya rannei operatsii i 48-chasovogo neoperativnogo lecheniya spaechnoi kishechnoi neprokhodimosti.

Optimal treatment for adhesive small bowel obstruction (SBO) is not defined. Surgery is the only method of treatment for obvious strangulating SBO. Non-operative management (NOM) is widely used among patients with low risk of strangulation, i.e. no clinical, laboratory and CT signs. Randomized controlled trials (RCTs) are recommended to determine the optimal method (early intervention or NOM), but their safety is unclear due to possible delay in surgery for patients needing early intervention. MATERIAL AND METHODS: A RCT is devoted to outcomes of early operative treatment and NOM for adhesive SBO. The estimated trial capacity is 200 patients. Thirty-two patients were included in interim analysis. In 12 hours after admission, patients without apparent signs of strangulation were randomized into two clinical groups after conservative treatment. Group I included 12 patients who underwent immediate surgery, group II - 20 patients after 48-hour NOM. The primary endpoint was success of non-surgical regression of SBO and reduction in mortality. To evaluate patient safety, we analyzed mortality, complication rates and bowel resection in this RCT with previously published studies. RESULTS: In group I, all 12 (100%) patients underwent surgery. Only 4 (20%) patients required surgery in group II. Mortality, complication rates and bowel resection rates were similar in both groups. Strangulating SBO was found in 8 (25%) patients. Overall mortality was 6.3%, bowel resection rate - 6.3%, iatrogenic perforation occurred in 3 (18.8%) patients. These values did not exceed previous findings. CONCLUSION: Non-operative management within 48 hours prevented surgery in 80% of patients with SBO. Interim analysis found no significant between-group differences in mortality, complication rates and bowel resection rate. Patients had not been exposed to greater danger than other patients with adhesive SBO. The study is ongoing.

[Influence of diagnostic period on the outcomes in patients with Crohn's disease]. / Vliyanie dlitel'nosti diagnosticheskogo poiska na iskhod zabolevaniya pri bolezni Krona.

OBJECTIVE: To analyze archival data on emergency hospitalization of patients with Crohn's disease, indications for surgical treatment, structure of surgeries, localization of gastrointestinal lesions and relationship between diagnostic period and surgical treatment. MATERIAL AND METHODS: A retrospective analysis of medical records of patients with Crohn's disease in 3 large hospitals was performed over the past 6 years. We estimated cases of surgical treatment, localization of gastrointestinal lesions, clinical and laboratory parameters of patients, period between clinical manifestation and diagnosis, as well as outcomes of disease depending on duration of diagnostic searching. CONCLUSION: Duration of diagnostic searching in patients with Crohn's disease is a significant predictor of complications and surgical treatment.

Submucosal Lipoma-Induced Small Bowel Intussusception: A Case Study of Surgical Intervention and Management in an Adult Female.

We present an adult patient, a 39-year-old female, with chief complaints of pain in the umbilical region. The patient was further evaluated by radiological investigations and was diagnosed with small bowel intussusception caused by submucosal lipoma as the lead point. She had undergone ileal resection and anastomosis of the affected segment. The postoperative period was uncomplicated, and the patient continued with regular oral intake. The histopathological analysis revealed it to be adipose tissue with no features of atypia. This case shows the rare presentation of small bowel intussusception due to a submucosal lipoma. It emphasizes the significance of diagnostic imaging tools for diagnosis and the need for surgery for proper administration.

Poorly Cohesive Carcinoma of the Nonampullary Small Bowel: A Rare Cause of Recurrent Small Bowel Obstruction.

Poorly cohesive carcinoma (PCC) is an uncommon neoplasm characterized by tumorous cells exhibiting a lack of adhesion. PCC has been reported rarely in the small intestine other than at the ampulla of Vater. We present a 40-year-old man with recurrent abdominal pain and small bowel obstruction. Imaging revealed an abnormal appearing distal small bowel, with only nonspecific mucosal changes discovered on antegrade and retrograde enteroscopy. On subsequent diagnostic laparoscopy, an ileal mass was found and resected with histopathology showing PCC with signet ring formation. This is an aggressive cancer with a worse prognosis than other small bowel adenocarcinomas.

Early Postoperative Small Bowel Obstruction after Colorectal Surgery: Incidence and Exploratory Analysis of Potential Risk Factors.

Background: Early postoperative small bowel obstruction (EPSBO) is a common complication following colorectal surgery, which can significantly impact patient outcomes. This study aimed to investigate the incidence of EPSBO and identify potential risk factors among patients who underwent colorectal surgery. Methods: A descriptive study was conducted on a cohort of 100 patients who underwent colorectal surgery at a tertiary center at SKIMS, Srinagar, Jammu & Kashmir, India. Descriptive, bivariate, and predictive screening analyses were performed to examine patient characteristics, assess association between different relevant variables and EPSBO, and identify significant predictors, respectively. Results: Our study included a total of 100 patients, with a mean age of 50.39 years. Postsurgery, 11% of the individuals in the cohort developed EPSBO. Early postoperative small bowel obstruction developed around 4.30 days after surgery, and radiographic data revealed dilated gut loops in 72.70% of EPSBO cases. Bivariate analysis revealed significant association between EPSBO and variables such as previously operated, medical comorbidities, smoking status, anemia, neoadjuvant chemoradiotherapy (NACRT), bowel preparation, operative procedure, surgery duration, and type of anastomosis (p < 0.05). History of previous bowel habits, previously operated, perioperative bowel preparation, and blood transfusion were identified as the most influential predictors of EPSBO in the predictive screening study. Conclusion: This study provides insights into the incidence of EPSBO and its potential risk factors for postcolorectal surgery among patients. The findings emphasize the need to take the patient's history of past bowel habits and other factors into account when determining the risk of EPSBO. Future studies should go deeper into these correlations and consider treatments to reduce the occurrence of EPSBO in this patient population. How to cite this article: Ahmad B, Ul Hag MF, Shah MA, et al. Early Postoperative Small Bowel Obstruction after Colorectal Surgery: Incidence and Exploratory Analysis of Potential Risk Factors. Euroasian J Hepato-Gastroenterol 2024;14(1):70-74.

Small bowel adenocarcinoma of the jejunum detected by double contrast enhanced ultrasound: a case report of a novel ultrasound modality.

Background: Small Bowel Adenocarcinoma (SBA) is rare, occult and life-threatening malignancy in digestive system. Given low incidence and nonspecific symptoms, SBA is frequently detected in later stages. Double contrast enhanced ultrasound (DCEUS) is an innovative imaging technique applied to visualize the gastrointestinal tract, merging intravenous contrast-enhanced ultrasound with oral contrast-enhanced ultrasound. In this case, DCEUS was utilized and successfully detected an SBA of the jejunum. Case presentation: A Chinese woman, aged 64, sought consultation in the gastroenterology department at our hospital, reporting symptoms of abdominal pain. Three months before entering the hospital, she underwent gastroscopy and colonoscopy which suggested chronic gastritis, and she was treated with oral drugs. However, her symptoms were not relieved, and even worsened. To further investigate, DCEUS was performed. The oral contrast agent dilated the luminal space of the upper gastrointestinal tract, resolving the hindrance caused by gas in the gastrointestinal tract and creating an acoustic window for scanning. Through this acoustic window, oral agent contrast-enhanced ultrasound (OA-CEUS) revealed a localized thickening of jejunal intestinal wall measuring 4x3 cm. Following intravenous injection of ultrasound contrast agent, the jejunal lesion exhibited faster enhancement and heterogeneous hyper-enhancement. Finally, the patient underwent jejunal tumor resection. Pathological examination revealed a jejunal adenocarcinoma. Conclusion: The timely diagnosis of SBA can be challenging. DCEUS may have the potential to contribute to diagnosis and detailed evaluation of SBA, particularly in cases involving jejunum. Further researches are needed to fully explore the benefits of DCEUS in the standard diagnostic approach for small bowel diseases.

As the Worm Turns-A Rare Cause of Intestinal Obstruction.

BACKGROUND: Anisakiasis, a zoonotic disease caused by the nematode Anisakis, poses a significant concern for public health, particularly in regions with high consumption of raw or undercooked fish. CASE PRESENTATION: We present a case report of a 41-year-old woman who developed severe abdominal symptoms, ultimately diagnosed with intestinal obstruction due to Anisakis infestation, requiring surgery. Despite the absence of prominent eosinophilia or specific radiological findings, the diagnosis was confirmed through histological examination, highlighting the importance of considering anisakiasis in patients with a history of raw seafood consumption. CONCLUSION: The case underscores the diagnostic challenges associated with anisakiasis, emphasizing the need for increased awareness among healthcare professionals and the public regarding the risks of consuming raw or undercooked seafood. Effective management requires a multidisciplinary approach, including clinical assessment, imaging studies, and histological evaluation, to ensure timely diagnosis and appropriate treatment.

A Fork in the Road: An Unusual Case of Duodenal-Cecal Fistula Due to a Chronic Foreign Body.

A duodenal-cecal fistula is characterized as an unnatural connection between the duodenum and cecum. Here, we present the case of a 40-year-old male with unintentional weight loss and a history of foreign body ingestion a few years prior. Computerized tomography (CT) small bowel enterography showed a linear soft tissue tract extending from the inferior aspect of the distal duodenum to the cecum. Ultimately, a diagnosis of duodenal-cecal fistula was made following esophagogastroduodenoscopy (EGD) revealing a fistula in the third part of the duodenum. A duodenal-cecal fistula secondary to foreign body ingestion is rare, with surgical intervention or endoscopic fibrin glue closure being potential treatment modalities if the fistula fails to close spontaneously. Duodenal-cecal fistulas are generally seen secondary to malignancies of the duodenum or colon, peptic ulcers, or inflammatory bowel disease. However, a duodenal-cecal fistula due to a foreign body is rare, thus highlighting the importance of keeping a broad differential, as appropriate in the clinical context.

Does Microbiome Matter in Chronic Intestinal Failure Due to Type 1 Short Bowel Syndrome in Adults?

The exact microbiome composition and function of patients with Short Bowel Syndrome (SBS) and Chronic Intestinal Failure (CIF) are still unknown. Patients with type I SBS-CIF (end-jejunostomy/ileostomy) are little represented in available studies. The aim of this study is to evaluate the microbiome characteristics of adult type 1 SBS-CIF patients according to their clinical features. Fecal microbiota was studied by amplicon-based sequencing and volatile organic compounds (VOCs) were assessed by solid-phase microextraction and gas chromatography-mass spectrometry. A total of 44 adult type 1 SBS-CIF patients were enrolled. At the family level, Lactobacillaceae (38% of the relative frequency) and Streptococcaceae (24%) were predominant; at the genus level, Streptococcus (38% of the relative frequency) and Lactobacillus (24%) were the dominant amplicon sequence variants (ASVs). Patients with increased stomal output showed higher ASVs for Lactobacillus (Rho = +0.38; p = 0.010), which was confirmed after adjusting for small bowel length (OR = 1.04; 95% CI 1.01-1.07, p = 0.023). Hyperphagia was associated with higher concentrations of short-chain fatty acid (SCFA) esters, such as butanoic acid ethyl ester (p = 0.005) and hexanoic acid ethyl ester (p = 0.004). Dietary fiber intake was directly correlated with most VOCs. Hyperphagia was associated with dietary fiber, after adjusting for small bowel length (OR = 1.35; 95% CI 1.01-1.81; p = 0.040). In type 1 SBS-CIF patients, a greater frequency of Lactobacilli was associated with increased stomal outputs, while increased fiber intake and concentrations of SCFA esters were associated with hyperphagia. These results might have implications for clinical practice.

Spontaneous Sigmoid Colon Perforation and Ruptured Subserosal ("Zebra" Pattern) Small-Bowel Hematomas in Type IV Ehlers-Danlos Syndrome: A Case Report and a Short Review.

Background and Objectives: Spontaneous colonic perforations (SCPs) in teenagers and young adults are extremely rare. Common underlying conditions, such as colonic tumors and diverticulitis, are absent at that age. The vascular type of Ehlers-Danlos Syndrome (vEDS) is one cause of SCP. Methods: A 23-year-old male presented with an acute abdomen. The abdominal CT showed pneumoperitoneum with a large amount of fluid in the pelvis and abdomen, indicating hollow viscus rupture. At the level of the sigmoid colon, a defect in the intestinal wall and gas bubbles were seen. Results: Exploratory laparotomy confirmed sigmoid colon perforation without underlying pathology. Loop sigmoid colostomy was performed. Revisional surgery was undertaken due to clinical deterioration and intra-abdominal free fluid with small-bowel distension and air-liquid levels on abdominal CT 6 days later. Ileal subserosal hematomas were found, and many had ruptured, leaving a "zebra" pattern with lines of residual hematomas on the borders of subserosal hematomas. Genetic analysis confirmed vEDS. Conclusions: SCP in young adults or teenagers, in the absence of colonic disease, with clinical manifestations of connective tissue disorders should trigger genetic investigations for vEDS. SCP with a known vEDS could be treated with total colectomy to prevent further SCPs in the remaining colon. If segmental resections are performed, further SCP should be immediately excluded with any significant abdominal pain.

An Unexpected Challenge: Marked Small Bowel Obstruction Arising From a Poorly Differentiated Metastatic Mucinous Adenocarcinoma of the Distal Ileum in a Risk-Free Healthy Patient.

Adenocarcinoma, while constituting the predominant variant among small bowel cancers, is a component of the broader category of primary small bowel malignancies, which are notably infrequent in occurrence. The diagnosis of such malignancies is often markedly delayed, a consequence of their insidious onset and the nonspecific nature of the abdominal symptoms presented. A 69-year-old Caucasian male presented to the emergency department manifesting acute, sharp, and colicky abdominal pain accompanied by a single episode of vomiting, all developing over one day. His medical history was notable for gastroesophageal reflux disease (GERD) and regionally confined prostate adenocarcinoma, which was under meticulous surveillance by the urological team. The patient's lifestyle was characterized by abstention from alcohol and tobacco, adherence to a nutritious diet, and a commitment to regular physical activity. Subsequent examination and surgical excision of an abnormal mass, as delineated on computed tomography (CT), culminated in the diagnosis of a stage IV, poorly differentiated adenocarcinoma. We have reported this case to spark research regarding early diagnostic techniques for small bowel adenocarcinoma (SBA). In this case, a healthy individual presented with vague abdominal pain and a single episode of vomiting. Diagnosis required the surgical resection of the tumor, where metastasis was also visualized. Due to the rare nature of SBA, we believe different diagnostic measures and adjuvant therapy should be researched for earlier diagnosis and subsequently better patient outcomes.

Small Bowel Obstruction Associated With Ureterocutaneous Fistula After a Radical Cystectomy: A Case Report.

This is a case report of a man in his 60s who was diagnosed with a small bowel obstruction due to an internal hernia caused by a ureterocutaneous fistula. Internal hernia caused by the ureter following urinary diversion is rare, posing challenges in preoperative diagnosis and carrying the risk of intraoperative injury due to the resemblance of a ureterocutaneous fistula to an adhesive band. The presentation and surgical management are discussed in this case report.

Managing abdominal cocoon syndrome complicated by intestinal necrosis and unexpected amelioration of depression after surgery: a case report.

BACKGROUND: Abdominal cocoon is a very uncommon yet dangerous cause of intestinal obstruction. CASE PRESENTATION: We present a case of a 62-year-old Asian male patient with a history of depression who exhibited an idiopathic abdominal cocoon complicated by necrosis. Upon laparotomy investigation, nearly the entire small intestine was enveloped in a thick membrane resembling a cocoon, and it was discovered that he lacked a greater omentum. The patient recovered well and was discharged on an oral diet on the 20th day following surgery. During the 3-month follow-up, the patient was asymptomatic, even gaining 10 kg in weight, and noted that his depression had improved. CONCLUSIONS: Small bowel obstruction presents with nonspecific symptoms, posing challenges in differential diagnosis. Contrast-enhanced computed tomography is recommended since it facilitates precise preoperative assessment, optimizing surgical planning and reducing postoperative complications. Remarkably, cessation of antidepressant medication post-surgery hints at a potential correlation between omental deficit, gut microbiota alterations, and depressive symptoms.