Does intestinal obstruction influence hypo-albuminemia: assessment of the physio-pathogenesis of protein-losing enteropathy with literature review.

BACKGROUND: Non-steroidal anti-inflammatory drug (NSAID) use may cause diaphragm-like lesions in the bowel. Although NSAID-enteropathy is among the causes of protein-losing enteropathy (PLE), intractable hypoalbuminemia is rare. CASE REPORT: Here, we discuss a case of NSAID-enteropathy with a diaphragm-like disease that presented with Protein Losing Enteropathy (PLE) rather than obstruction. The hypoalbuminemia recovered immediately after resection of the obstructive segment, despite ongoing annular ulcerations in the early postoperative period. Thus, it was not clear whether obstructive mechanisms influenced resistant hypoalbuminemia besides the ulcers. We also reviewed the English-written literature for "diaphragm-type lesion, NSAID-enteropathy, obstruction, and protein-losing enteropathy". We noted that the role of obstruction in the pathophysiology of PLE was not clear. CONCLUSIONS: As our case and a couple of cases reported in literature, slow-onset obstructive pathology seems to contribute to well-known factors: inflammatory response, exudation, tight-junction dysfunction, and increase in permeability in the physiopathology of NSAID-induced PLE. Factors such as distention-induced low-flow ischemia and reperfusion, cholecystectomy-related continuous bile flow, bacterial overgrowth-related bile deconjugation and concomitant inflammation are among other potential influencers. The possible role of a slow-onset obstructive pathology in the physiopathology of NSAID-induced and other PLE needs to be further elucidated.

Socioeconomic disparities in the comorbidities and surgical management of pediatric Crohn's disease.

BACKGROUND: To examine differences in comorbidities and surgical management based on socioeconomics in hospitalized children with Crohn's disease (CD). METHODS: Using the Kids' Inpatient Database for 2006-2012, we identified patients (<21 years) with a CD diagnosis. Cases were analyzed and stratified by median parental income by zip code. Multivariable logistic regression was performed. RESULTS: Of the 28,337 pediatric CD hospitalizations identified, patients were more likely male (51.1%), non-Hispanic white (71.3%), and had a mean age of 15.9 years. The proportion of minority patients increased as income quartile declined. Higher income quartile patients were more likely to be coded with anxiety and less likely with anemia. The highest income quartile was more likely to have a bowel obstruction, and peritoneal/intestinal abscess and was also 28% more likely to undergo a major surgical procedure. CONCLUSIONS: Significant variability exists in the reported comorbidities and surgical interventions associated with CD by income quartile. Lower income quartile patients are more likely to be of minority ethnicity and anemic, but less likely to undergo a major surgical procedure. Further investigation is warranted to determine whether these differences represent disease variability, differences in healthcare resource allocation, or implicit bias in management. IMPACT: There is a disparity in the care of children and young adults with Crohn's disease based on parental income. Links between parental income and the treatment of Crohn's disease in children and young adults has not been assessed in national datasets in the United States. Children in the highest income quartile were more likely to undergo a major surgical procedure. The variations in healthcare for hospitalized children and young adults with CD found in this study may represent variability in patient disease, implicit bias, or a disparity in healthcare delivery across the United States.

Optimized protocol of multiple post-processing techniques improves diagnostic accuracy of multidetector computed tomography in assessment of small bowel obstruction compared with conventional axial and coronal reformations.

BACKGROUND: Axial and coronal reformations have been a widely used image post-processing protocol for the ordinary multidetector computed tomography (MDCT) examination of patients with small bowel obstruction (SBO) or other abdominal diseases. The diagnostic accuracy of MDCT for assessing SBO is expected to be further improved through the use of multiple post-processing techniques. AIM: To systemically evaluate the diagnostic accuracy and efficiency of an optimized protocol using multiple post-processing techniques for MDCT assessment of SBO and secondary bowel ischemia. METHODS: This retrospective cross-sectional study included 106 patients with clinically suspected SBO. Two readers applied three protocols to image post-processing and interpretation of patients' MDCT volume data. We compared the three protocols based on time spent, number of images, diagnostic self-confidence, agreement, detection rate, and accuracy of detection of SBO and secondary bowel ischemia. RESULTS: Protocol 2 resulted in more time spent and number of images than protocols 1 and 3 (P < 0.01), but the results of the two readers using the same protocol were not different (P > 0.05). Using protocol 3, both readers added multiple post-processing techniques at frequencies of 29.2% and 34.9%, respectively, for obstruction cause, and 32.1% and 30.2%, respectively, for secondary bowel ischemia. Protocols 2 and 3 had higher total detection rates of obstruction cause and secondary bowel ischemia than protocol 1 (P < 0.01), but no difference was detected between protocols 2 and 3 (P > 0.05). The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of protocols 2 and 3 were superior to those of protocol 1 for evaluating obstruction cause and secondary bowel ischemia. CONCLUSION: Our optimized protocol of multiple post-processing techniques can both guarantee efficiency and improve diagnostic accuracy of MDCT for assessing SBO and secondary bowel ischemia.

Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction.

BACKGROUND: Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups. RESULTS: Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization. CONCLUSIONS: Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

[Effect of a clinical pathway in patients with Crohn's disease complicated with intestinal obstruction].

OBJECTIVE: To evaluate the effect of a clinical pathway for Crohn disease (CD) complicated with intestinal obstruction. METHODS: CD patients complicated with intestinal obstruction in Inflammatory Bowel Disease(IBD) Center of Jinling Hospital were enrolled. One hundred and nineteen CD patients from March 2014 to September 2015 received treatment with the clinical pathway (CP), which was developed based on medical evidence and experience of the IBD center in February 2014, as CP group. The other 108 CD patients from September 2012 to February 2014 received treatment according to the management strategy made by individual attending physician as non-CP group. Rate of operation, rate of stoma, morbidity of surgical complications, hospital stay, hospital cost, and 6-month unplanned re-admission were compared between two groups. RESULTS: The baseline data were similar between the two group (all P > 0.05). No significant differences were noted between these the two groups in terms of rate of operation (73.9% vs. 77.8%, P = 0.605), rate of stoma (15.9% vs. 25.0%, P = 0.197), and morbidity of surgical complications (23.9% vs. 27.4%, P = 0.724). However, the mean postoperative hospital stay was shorter (10.9 d vs. 13.2 d, P = 0.000), the mean hospital cost was less (78 325 Yuan vs. 85 310 Yuan, P = 0.031) and the rate of 6-month unplanned re-admission was lower(3.4% vs. 11.1%, P = 0.035) in CP group. CONCLUSION: Treatment based on this CP for CD patients complicated with intestinal obstruction can reduce the rate of 6-month unplanned re-admission, shorten the postoperative hospital stay and decrease the hospital cost in patients requiring surgery.

Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT.

Purpose To determine whether adding unenhanced computed tomography (CT) to contrast material-enhanced CT improves the diagnostic performance of decreased bowel wall enhancement as a sign of ischemia complicating mechanical small bowel obstruction (SBO). Materials and Methods This retrospective study was approved by the institutional review board, which waived the requirement for informed consent. Two gastrointestinal radiologists independently performed retrospective assessments of 164 unenhanced and contrast-enhanced CT studies from 158 consecutive patients (mean age, 71.2 years) with mechanical SBO. The reference standard was the intraoperative and/or histologic diagnosis (in 80 cases) or results from clinical follow-up in patients who did not undergo surgery (84 cases). Decreased bowel wall enhancement was evaluated with contrast-enhanced images then and both unenhanced and contrast-enhanced images 1 month later. Diagnostic performance of decreased bowel wall enhancement and confidence in the diagnosis were compared between the two readings by using McNemar and Wilcoxon signed rank tests. Interobserver agreement was assessed by using κ statistics and compared with bootstrapping. Results Ischemia was diagnosed in 41 of 164 (25%) episodes of SBO. For both observers, adding unenhanced images improved decreased bowel wall enhancement sensitivity (observer 1: 46.3% [19 of 41] vs 65.8% [27 of 41], P = .02; observer 2: 56.1% [23 of 41] vs 63.4% [26 of 41], P = .45), Youden index (from 0.41 to 0.58 for observer 1 and from 0.42 to 0.61 for observer 2), and confidence score (P < .001 for both). Specificity significantly increased for observer 2 (84.5% [104 of 123] vs 94.3% [116 of 123], P = .002), and interobserver agreement significantly increased, from moderate (κ = 0.48) to excellent (κ = 0.89; P < .0001). Conclusion Adding unenhanced CT to contrast-enhanced CT improved the sensitivity, diagnostic confidence, and interobserver agreement of the diagnosis of ischemia, a complication of mechanical SBO, on the basis of decreased bowel wall enhancement. (©) RSNA, 2016.

[Analysis of experience in the use of dynamic pelvic magnetic resonance imaging in the assessment of obstructive defaecation syndrome]. / Análisis de nuestra experiencia mediante el uso de resonancia magnética dinámica pelviana en la evaluación del síndrome de defecación obstructiva.

INTRODUCTION: The aetiological diagnosis of obstructive defaecation syndrome (ODS) requires, among others, imaging tests. The purpose of this study is to descriptively analyse and compare the findings of dynamic pelvic magnetic resonance imaging (DPMRI) with the clinical examinations in patients with ODS. MATERIAL AND METHODS: A prospective comparative study was made between the physical examination and the DPMRI, with a descriptive analysis of the results. A total of 30 patients were included (2 males and 28 females), with a median age of 60 (range 23-76) years, with symptoms of ODS. An anamnesis and detailed physical examination and a DPMRI were performed on all of them. Functional (anismus) and morphological changes (rectocele, enterocele, intussusception, etc.), were analysed. RESULTS: The physical examination did not detect anomalies in 6 (20%) patients. A rectocele was diagnosed in 21 (70%) of the cases, and 2 (6.7%) a rectal mucosal prolapse. The DPMRI showed evidence of pelvic floor laxity in 22 (73.3%) cases, an enterocele in 4 (13.3%), a sigmoidocele in 2 (6.7%), intussusception in 8 (26.7%), rectal mucosal prolapse in 4 (13.3%), anismus in 3 (10%), and a cystocele in 4 (13.3%). The rectocele was the most frequent diagnosis, being given in 26 (86.6%) patients. CONCLUSIONS: Magnetic resonance imaging provides an overall pelvic assessment with good definition of the tissues, and does not use ionising radiation, is well tolerated, and provides us with complementary information to arrive at the diagnosis, and establish the best treatment for ODS. Larger studies comparing videodefaecography (VD), currently considered the Gold Standard technique, are needed to be able to demonstrate whether it is superior or not to DPMRI.

Risk assessment for adverse outcome in term and late preterm neonates with bilirubin values of 20 mg/dL or more.

The aim of this study is to identify clinical, etiologic, and laboratory factors that potentiate adverse outcome of hyperbilirubinemia among term and late preterm neonates in logistic regression analysis. A retrospective cohort of infants with total serum bilirubin (TSB) ≥ 20 mg/dL from 1995 to 2007 was surveyed. Eighteen infants had adverse outcome. Controls were 270 infants without sequelae. Risks were significantly higher in infants with six etiologies causing hyperbilirubinemia: sepsis (odds ratio [OR] = 161.7, 95% confidence interval [CI] = 11.7 to 2242.8), gastrointestinal obstruction (OR = 39.2, 95% CI = 2.7 to 567.3), Rh incompatibility (OR = 31.0, 95% CI = 5.1 to 188.9), hereditary spherocytosis (OR = 19.6, 95% CI = 1.6 to 235.5), ABO incompatibility (OR = 5.1, 95% CI = 1.3 to 19.7), and glucose-6-phosphate dehydrogenase deficiency (OR = 4.7, 95% CI = 1.3 to 16.7). Infants with acute bilirubin encephalopathy were more likely to have adverse outcome than subjects without acute bilirubin encephalopathy (OR = 281.7, 95% CI = 25.8 to 3076.7). Adverse outcome was more common in infants with a positive direct Coombs test (OR = 4.5, 95% CI = 1.3 to 15.4). Infants with hemoglobin < 10 g/dL tended to have adverse outcome more often than those with hemoglobin ≥ 13 g/dL (OR = 11.8, 95% CI = 3.3 to 42.9). Infants with TSB of 35 mg/dL or more (OR = 472.5, 95% CI = 47.8 to 4668.8) and of 30 to 34.9 mg/dL (OR = 9.5, 95% CI = 1.6 to 57.9) carry greater risks as compared with those with TSB of 20 to 24.9 mg/dL. In conclusion, this study quantitatively verified the potential risks for adverse outcome of neonatal hyperbilirubinemia.

Room for improvement? A quality-of-life assessment in patients with malignant bowel obstruction.

This prospective study followed 35 patients admitted to hospital with malignant bowel obstruction (MBO) to evaluate quality of life (QOL). Subjects completed the Edmonton Symptom Assessment Scale (ESAS) and Rotterdam Symptom Checklist (RSCL) at recruitment, and at one week, one month and three months.The highest ranked ESAS scores at recruitment (which was generally 18-36 hours post admission to hospital) included loss of appetite (median=7.5), fatigue (6.5) and overall well-being (6.0). The total ESAS score improved by 7.5, 11.5 and 11.0 points respectively at one week, one month and three months (p<0.05, p<0.01, NS).RSCL median scores for physical and psychological subscales were high at baseline (36.2, 42.9) and improved significantly at one week and one month (p<0.05). Psychological functioning appeared to be worsening by three months and at no time did activity level improve significantly. The overall QOL score was extremely poor at baseline (6.0 median) improving to 3.3 at one month (median fall=1.0, p<0.05) and 3.4 at three months.Further work should address the lack of improvement in activity and apparent deterioration in psychological functioning after one month.

Assessment of the patient with acute abdominal pain.

Abdominal pain has many causes, from simple to complex presentations. Patients with abdominal pain may have a number of physiological and psychological needs. Nurses have a key role to play in patient assessment, history talking and management.

The impact of blood loss, obstruction and perforation on survival in patients undergoing curative resection for colon cancer.

BACKGROUND: Previous studies have drawn attention to the high postoperative mortality and poor survival of patients who present as an emergency with colon cancer. However, these patients are a heterogeneous group. The aim of the present study was to establish, having adjusted for case mix, the size of the differences in postoperative mortality and 5-year survival between patients presenting as an emergency with evidence of blood loss, obstruction and perforation. METHODS: The study included 2068 patients who presented with colon cancer between 1991 and 1994 in Scotland. Five-year survival rates and the adjusted hazard ratios were calculated. RESULTS: Thirty-day postoperative mortality following potentially curative resection was consistently higher in patients who presented with evidence of blood loss, obstruction or perforation (all P < 0.005) than in elective patients. Following potentially curative surgery, cancer-specific survival at 5 years was 74.6 per cent compared with 60.9, 51.6 and 46.5 per cent in those who presented with blood loss, obstruction and perforation respectively (all P < 0.001). The corresponding adjusted hazard ratios (95 per cent confidence interval) for cancer-specific survival, relative to elective patients, were 1.62 (1.22 to 2.15), 2.22 (1.78 to 2.75) and 2.93 (1.82 to 4.70) for patients presenting with evidence of blood loss, obstruction or perforation (all P < 0.001). CONCLUSION: Compared with patients who undergo elective surgery for colon cancer, those who present as an emergency with evidence of blood loss, obstruction or perforation have higher postoperative mortality rates and poorer cancer-specific survival.

The diagnostic evaluation of children with cyclic vomiting: a cost-effectiveness assessment.

Because patients with cyclic vomiting often (82%) have a family history of migraines and often (60%) respond to antimigraine therapy, we investigated whether an initial therapeutic trial could precede diagnostic testing. We used a decision analysis program to compare the cost and benefit of three initial treatment strategies. The costs of the three strategies were extensive diagnostic evaluation, $3020; empiric treatment alone, $1830, and upper GI series with small-bowel follow-through (UGI-SBFT) plus empiric treatment, $1600, respectively. When compared with the extensive evaluation strategy, initial antimigraine treatment avoided 65% of the esophagogastroduodenoscopys. On the basis of this decision analysis, a UGI-SBFT plus empiric migraine therapy was the most cost-effective initial strategy to treat cyclic vomiting syndrome. The cost of complications of a missed malrotation with volvulus was higher than that of adding a UGI-SBFT to each evaluation.

Hospital costs and risk factors associated with complications of the ileal pouch anal anastomosis.

BACKGROUND: The purpose of this study was to estimate the costs associated with the most common complications of the ileal pouch anal anastomosis (IPAA) and identify factors that predispose to them. METHODS: Hospital costs of 135 patients undergoing the IPAA were combined with information abstracted from charts. Logistic and linear regression modeling were used to estimate the marginal costs for the most common IPAA complications and determine factors predisposing to their occurrence. RESULTS: The average overall cost for the IPAA was $20,865. Just more than half (53%) of patients experienced complications, the 3 most common being small-bowel obstruction (24.4%), pelvic/abdominal sepsis (6.7%), and dehydration (5.9%). The average cost to treat an episode of small-bowel obstruction was $6709. Treatment of pelvic/abdominal sepsis averaged $9268 per occurrence, whereas dehydration averaged $4860. Steroid use > 3 months before colectomy significantly increased the risk for any complication (P =.02). No factors were found to be good predictors of bowel obstruction. However, age > 42 years and low patient hematocrit were significant predictors of dehydration as a complication (P <.05). Trending toward significance were urgent operation and weight loss greater than 5%. CONCLUSIONS: The most common complications of the IPAA are small-bowel obstruction, pelvic/abdominal sepsis, and dehydration. Complications were responsible for approximately 44% of the overall cost of an IPAA. Factors that increase risk of IPAA complications are steroid use, low hematocrit, age > 42 years, nonelective procedures, and preoperative weight loss.

[Effects of over feeding on the energy expenditure and substrates oxidative rate in surgical patients].

In this study, computerized indirect calorimetric measurements were made using a medical graphics critical care monitor (CCM) desktop analysis system in the observation of metabolic state of 20 patients complicated with external gastrointestinal fistula. While these malnourished patients were provided with 1.5 x REE in total energy intake, the malnutrition state could be reversed. But with 1.75 or 2.0 x REE or up total energy intake, the general nutritional state could not be improved faster, the O2 consumption and CO2 production and energy expenditure increased, while the net glucose oxidation increased and net lipid oxidation decreased or net lipogenesis occurred simultaneously. We believed that superfluous energy intake is harmful to critically ill patients and may lead to cell injury and dysfunction.

Perforation and obstruction of the gastrointestinal tract. Assessment by conventional radiology.

Proliferation of new imaging modalities has changed the way abdominal emergencies are evaluated in medical centers where ready access to equipment and personnel make emergency CT, ultrasonography, interventional radiology, and endoscopy available at all hours of the day or night. In many cases, plain abdominal radiography is being relegated to an ancillary diagnostic role. Conversely, in medical centers with fewer resources, plain radiography remains a primary screening modality for most acute abdominal conditions. Even in centers with unlimited resources, plain films supplemented by gastrointestinal contrast studies as needed remain the modern standard for evaluation of patients who have suspected gastrointestinal perforation and mechanical obstruction. These widely available, easy to perform, and relatively inexpensive procedures are relatively sensitive and specific for evaluation of these problems. It is, therefore, crucial for radiologists to be familiar with the often subtle signs of gastrointestinal perforation and obstruction on plain films. Skills of plain film interpretation should not be permitted to erode in the environment of newer technologies.

Intraoperative assessment of blood flow and tissue viability in small-bowel ischemia by laser Doppler flowmetry.

Laser Doppler flowmetry (LDF) was used for intraoperative assessment of blood flow and tissue viability in 23 patients with small-bowel ischemia, and the signal levels in ischemic bowel were compared with previously obtained reference values from normal ileum and jejunum. The average LD signal was 6.8 +/- 2.9 V in nonischemic bowel, 0.3 +/- 0.2 V in segments with macroscopically irreversible ischaemia and 2.1 +/- 1.2 V in segments with clinically uncertain viability. In 12 cases with strangulated bowel it was possible, following LDF, to avoid resecting nine of ten bowel segments with clinically uncertain viability. In four of the six patients with mesenteric vascular occlusion, LDF indicated that clinical judgement had underestimated the extent of severe ischemia. Among the five cases of iatrogenic ischemia there was one failure, with postoperative irreversible ischemia and anastomotic leakage. LDF is concluded to be a useful method for intraoperative assessment of intestinal blood flow in patients with small-bowel ischemia and it provides substantial information on tissue viability affecting surgical strategy.