Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries.

INTRODUCTION: Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia. METHODS: We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa. RESULTS: Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%). CONCLUSIONS: The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

Factors associated with D-lactic acidosis in pediatric intestinal failure: A case-control study.

BACKGROUND: D-lactic acidosis (DLA) is a serious complication of short bowel syndrome (SBS) in children with intestinal failure (IF). Malabsorbed carbohydrates are metabolized by bacteria in the intestine to D-lactate which can lead to metabolic acidosis and neurologic symptoms. METHODS: A retrospective chart review was performed in children ≤18 years old with SBS who had one of the following criteria: unexplained metabolic acidosis, neurologic signs or symptoms, history of antibiotic therapy for small bowel bacterial overgrowth, or high clinical suspicion of DLA. Cases had serum D-lactate concentration >0.25 mmol/L; controls with concentrations ≤0.25 mmol/L. RESULTS: Of forty-six children, median age was 3.16 (interquartile range (IQR): 1.98, 5.82) years, and median residual bowel length was 40 (IQR: 25, 59) cm. There were 23 cases and 23 controls. Univariate analysis showed that cases had significantly lower median bicarbonate (19 vs. 24 mEq/L, p = 0.001), higher anion gap (17 vs. 14 mEq/L, p < 0.001) and were less likely to be receiving parenteral nutrition, compared with children without DLA. Multivariable analysis identified midgut volvulus, history of intestinal lengthening procedure, and anion gap as significant independent risk factors. Midgut volvulus was the strongest independent factor associated with DLA (adjusted odds ratio = 17.1, 95% CI: 2.21, 133, p = 0.007). CONCLUSION: DLA is an important complication of pediatric IF due to SBS. Patients with IF, particularly those with history of midgut volvulus, having undergone intestinal lengthening, or with anion gap acidosis, should be closely monitored for DLA.

High risk and low incidence diseases: Pediatric digestive volvulus.

INTRODUCTION: Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION: An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Spleno-Sigmoid Knotting - An Unfamiliar Cause of Intestinal Obstruction.

INTRODUCTION: Spleno-sigmoid knotting is the twisting of the spleen around the sigmoid colon, causing obstruction of the sigmoid colon. It is an uncommon cause of intestinal obstruction. To our knowledge, there has been no previous case report of spleno-sigmoid knotting before our case. CASE REPORT: Here, we present the case of an 18-year-old female patient who visited the surgical emergency outpatient department with diffuse and progressive abdominal pain lasting for one and a half days. She also experienced obstipation and frequent episodes of vomiting of ingested matter. Upon initial evaluation, she exhibited tachycardia and tachypnea, and her abdomen was grossly distended with diffuse direct and rebound tenderness. Further investigation revealed significant leukocytosis with neutrophil predominance. Emergency laparotomy was performed with a possible diagnosis of generalized peritonitis secondary to gangrenous sigmoid volvulus, which revealed gangrenous spleno-sigmoid knotting. DISCUSSION: Various types of intestinal knots have been reported, with ileo-sigmoid knots being the most common and ileo-ileal knots being the rarest. Wandering spleen is a rare congenital anomaly with a variable clinical presentation ranging from asymptomatic to mild abdominal pain or acute abdomen due to torsion or acute pancreatitis. It can also cause intestinal obstruction, which may be the initial presentation. CONCLUSION: In patients presenting with acute abdominal pain and features of bowel obstruction, the possibility of spleno-sigmoid knotting should be considered, and early intervention should be instituted to prevent gangrenous progression and sepsis.

Cecal volvulus - a rare cause of acute abdomen with ileus.

In this article, we present case reports of two patients admitted to the University Hospital in Pilsen for acute abdomen due to a disorder of the passage through the gastrointestinal tract (GIT). Both were indicated for surgery. The patients were diagnosed intraoperatively with rarely occurring cecal volvulus (CV). The findings required an ileocecal resection; nevertheless, both patients fully recovered despite the need the resection.

Analysis of clinical diagnosis and treatment of intestinal volvulus.

BACKGROUND: The aim of this study is to investigate the clinical characteristics and treatment experience of intestinal volvulus, and to analyze the incidence of adverse events and related risk factors of intestinal volvulus. METHODS: Thirty patients with intestinal volvulus admitted to the Digestive Emergency Department of Xijing Hospital from January 2015 to December 2020 were selected. The clinical manifestations, laboratory tests, treatment and prognosis were retrospectively analyzed. RESULTS: A total of 30 patients with volvulus were enrolled in this study, including 23 males (76.7%), with a median age of 52 years (33-66 years). The main clinical manifestations were abdominal pain in 30 cases (100%), nausea and vomiting in 20 cases (67.7%), cessation of exhaust and defecation in 24 cases (80%), and fever in 11 cases (36.7%). The positions of intestinal volvulus were jejunum in 11 cases (36.7%), ileum and ileocecal in 10 cases (33.3%), sigmoid colon in 9 cases (30%). All 30 patients received surgical treatment. Among the 30 patients underwent surgery, 11 patients developed intestinal necrosis. We found that the longer the disease duration (> 24 h), the higher the incidence of intestinal necrosis, and the higher the incidence of ascites, white blood cell count and neutrophil ratio in the intestinal necrosis group were significantly higher than those in the non-intestinal necrosis group (p < 0.05). After treatment, 1 patient died of septic shock after operation, and 2 patients with recurrent volvulus were followed up within 1 year. The overall cure rate was 90%, the mortality rate was 3.3%, and the recurrence rate was 6.6%. CONCLUSION: Laboratory examination, abdominal CT and dual-source CT are very important for the diagnosis of volvulus in patients with abdominal pain as the main symptom. Increased white blood cell count, neutrophil ratio, ascites and long course of disease are important for predicting intestinal volvulus accompanied by intestinal necrosis. Early diagnosis and timely intervention can save lives and prevent serious complications.

Laparoscopic Ladd's procedure for intestinal malrotation in small infants with midterm follow-up.

BACKGROUND: The objective of this study was to evaluate the safety and efficacy of laparoscopic Ladd's procedure (LL) for intestinal malrotation (IM) in small infants. METHODS: All patients aged < 6 months with IM who underwent Ladd's procedures between January 2012 and December 2019 were enrolled. The perioperative demographics and midterm follow-up results were retrospectively reviewed and compared between patients who underwent LL and open Ladd's operation (OL). RESULTS: Fifty-five patients were enrolled for analysis. The baseline characteristics were well matched in the two groups. The rate of volvulus was similar in the two groups (76.2% vs. 73.5%, P = 0.81). Two cases in the LL group were converted to OL due to intraoperative bleeding and intestinal swelling. The operative time (ORT) was not significantly different between the two groups (73.8 ± 18.7 vs. 66.8 ± 11.6 min, P = 0.76). Compared to the OL group, the LL group had a shorter time full feed (TFF) (3.1 ± 1.2 vs. 7.3 ± 1.9 days, P = 0.03) and a shorter postoperative hospital stay (PHS) than the OL group (5.5 ± 1.6 vs. 11.3 ± 2.7 days, P = 0.02). The rate of postoperative complications was similar in the two groups (9.5% vs. 11.8%, P = 0.47). The LL group had a lower rate of adhesive obstruction than the OL group, but the difference was not significant (0.0% vs. 11.8%, P = 0.09). One patient suffered recurrence in the LL group, while 0 patients suffered recurrence in the OL group (4.8% vs. 0.0%, P = 0.07). The rate of reoperation in the two groups was similar (4.8% vs. 8.8%). CONCLUSIONS: The LL procedure for IM in small infants was a safe and reliable method that had a satisfactory cosmetic appearance and shorter TFF and PHS than OL.

Intestinal obstruction due to bariolith impaction.

"Bariolith" is defined as the concretion of barium sulfate in the intestine after performing a radiological study with said contrast. Complications derived from the use of barium are exceptional, but appendicitis, intussusception, volvulus, ulceration, ischemia and perforation have been described. We present the case of a 62 years old woman, who underwent a EGD exploration on the 15th of January 2021 as a part of her study for suspected GERD.

A rare case of intestinal malrotation in pregnancy resulting in hemicolectomy postnatally.

INTRODUCTION: Small and large bowel obstruction secondary to volvulus on the background of intestinal malrotation is a very rare occurrence, especially in pregnancy. This can be associated with significant feto-maternal morbidity and mortality. CASE REPORT: We report a case of a pregnant lady who developed symptoms of subacute intestinal obstruction during the 2nd trimester of pregnancy and was subsequently dia-gnosed with intestinal malrotation on imaging. Though she had symptoms of abdominal pain and constipation persisting for 9 long weeks during pregnancy, there was no evidence of definite intestinal obstruction or volvulus on her abdominal magnetic resonance imaging. She underwent a caesarean section at 34 weeks of pregnancy due to worsening abdominal pain. Postnatally, she was dia-gnosed with midgut volvulus on a computer tomography scan, leading to obstruction of both small and large bowels and needed an emergency laparotomy and right hemicolectomy. CONCLUSION: The case highlights the importance of timely dia-gnosis and prompt management of intestinal obstruction in pregnancy with a multidisciplinary team approach.

[Small bowel volvulus due to a giant mesenteric lipoma]. / Zavorot tonkoi kishki, obuslovlennyi gigantskoi lipomoi bryzheiki.

Mesenteric lipomas are very rare. They are asymptomatic in most cases, but some patients can develop certain complications such as small bowel volvulus and acute small bowel obstruction. We report a 78-year-old patient with giant mesenteric lipoma complicated by jejunum volvulus and acute small bowel obstruction. The patient underwent laparotomy, en-bloc resection of small bowel, mesentery and lipoma followed by side-to-side anastomosis.

Epileptogenesis in Common Parasitic Infections.

PURPOSE OF THE REVIEW: Neurocysticercosis (NCC) has been well recognized as a leading cause of epilepsy. More recently, studies of other parasitic diseases such as cerebral malaria (CM) and onchocerciasis are yielding novel insights into the pathogenesis of parasite-associated epilepsy. We compare the clinical and electrophysiological findings in epilepsy associated with these highly prevalent parasites and discuss the mechanisms involved in epileptogenesis. RECENT FINDINGS: Electrophysiological and imaging biomarkers continue to emerge, and individuals who are at-risk of developing parasite-associated epilepsies are being identified with greater reliability. While both Taenia solium and Plasmodium falciparum directly affect the brain parenchyma, Onchocerca volvulus is not known to invade the central nervous system. Thus, the causal association between O. volvulus and epilepsy remains controversial. Both NCC and CM have a well-defined acute phase when the parasites directly or indirectly invade the brain parenchyma and lead to local inflammatory changes. This is followed by a chronic phase marked by recurrent seizures. However, these stages of epileptogenic process have not been identified in the case of O. volvulus.

Increased expression of OLFM4 and lysozyme during necrotizing enterocolitis in neonates: an observational research study.

BACKGROUND: In neonatal patients with necrotizing enterocolitis (NEC) the inflammatory response is mediated by a plurality of different proteins. The proteins olfactomedin 4 (OLFM4) and lysozyme (LYZ) are part of the intestinal mucosal defense and especially OLFM4 has rarely been evaluated in neonatal gastrointestinal diseases. The aim of this study was to analyze whether expression levels of both proteins of innate immunity, OLFM4 and lysozyme, were increased during NEC in neonates. METHODS: Intestinal tissues of patients with NEC were examined with immunohistochemical staining of formalin-fixed and paraffin-embedded sections of resected tissue using antibodies against OLFM4 and lysozyme. Staining-positive tissues were semi-quantitatively scored from 0 (no staining), 1 (weak staining), 2 (moderate staining) to 3 (highly intense staining) by two individual investigators. Intestinal tissue of infants with volvulus was used as a control as other intestinal tissue without major inflammation was not available. RESULTS: Both applied antibodies against OLFM4 showed different staining patterns with higher staining intensity of the antibody OLFM4 (D1E4M). OLFM4 (median score of the antibody OLFM4 (D1E4M): 3.0) and lysozyme (median score: 3.0) are highly expressed in intestinal and immune cells during NEC. Expression of OLFM4 and lysozyme in the control samples with volvulus was observable but significantly lower (median score of the antibody OLFM4 (D1E4M): 1.25; median score of the antibody against LYZ: 2.0; p = 0.033 and p = 0.037, respectively). CONCLUSIONS: Both proteins, OLFM4 and lysozyme, may play a role in the pathogenesis of NEC in neonatal patients, but the exact mechanisms of OLFM4 and lysozyme function and their role in immunological responses have not yet been resolved in detail. These observations add new insights as basis for further large-scale population research.

Cecal volvulus associated with carfilzomib use for al amyloidosis.

INTRODUCTION: Proteasome inhibitors have emerged as quintessential therapies for light-chain (AL) amyloidosis and multiple myeloma in the last decade. While these agents are highly effective, reports have also documented toxicities affecting various organ systems. Whereas gastrointestinal (GI) toxicities are a relatively common occurrence with proteasome inhibitors, severe GI complications are exceedingly rare. CASE REPORT: We describe a unique case of a patient with AL amyloidosis who developed cecal volvulus after four weeks of treatment with carfilzomib. This severe GI manifestation has not been previously described in the literature. MANAGEMENT AND OUTCOME: The patient required right hemicolectomy. After clinical recovery, she restarted reduced-dose carfilzomib. She did not have any severe GI side effects following dose reduction, and continues with the current treatment regimen to the present day. DISCUSSION/CONCLUSION: The causality between volvulus and the treatment with carfilzomib was probable, with a documented score of 6 on the Naranjo probability nomogram. The exact mechanism behind this effect of carfilzomib has yet to be elucidated.

How should the neonatal retrieval team respond to the neonate referred with bilious vomiting?

AIM: Bilious vomiting (BV) in the neonatal period may herald malrotation with life-threatening volvulus. In New South Wales, contrast fluoroscopy is not available in non-tertiary paediatric centres; therefore, transfer is required. An infant with BV referred to Newborn and Paediatric Emergency Transport Service is prioritised for urgent retrieval to a surgical centre for contrast fluoroscopy and paediatric surgical review. This study analysed how many neonates with BV needed retrieval to prevent bowel loss or to save one life and to identify predictors of malrotation and/or volvulus. METHODS: All neonatal referrals (<29 days) to Newborn and Paediatric Emergency Transport Service between 31 July 2014 and 31 July 2020 with BV or aspirates were examined. Data on time of onset of BV, time of call for retrieval, vital signs, lactate level and blood glucose at referral, time of arrival at the surgical centre and outcome were analysed. RESULTS: Of 391 neonates referred with BV, 113 (28.9%) had a surgical cause and 31 (7.9%) had a time-critical malrotation and/or volvulus. All 31 neonates were well at referral with normal vital signs including three neonates who subsequently died. Lactate levels at referral (1-7.5 mmol/L) were not predictive of outcome. The odds of a time-critical diagnosis increased with every day of age (odds ratio = 1.097), heart rate >140 (P = 0.04) and decreased for each kilogram of birthweight (odds ratio 0.475; confidence interval 0.294-0.768). CONCLUSIONS: Neonates with BV require urgent referral to paediatric surgery and contrast fluoroscopy. Thirteen urgent transfers are required to preserve the bowel integrity and life in one baby.

Time limit to rescue intestine with viability at risk caused by blood flow disruption in patients presenting with acute abdomen.

PURPOSE: Early management is crucial for acute intestinal blood flow disorders; however, no published study has identified criteria for the time limit for blood flow resumption. This study specifically examines the time factors for avoiding intestinal resection. METHODS: The subjects of this retrospective cohort study were 125 consecutive patients who underwent emergency surgery for a confirmed diagnosis of intestinal strangulation (n = 86), incarceration (n = 27), or volvulus (n = 12), between January 2015 and March 2021. Intestinal resection was performed when intestinal irreversible changes had occurred even after ischemia was relieved surgically. We analyzed the relationship between the time from computed tomography (CT) imaging to the start of surgery (C-S time) and intestinal resection using the Kaplan-Meier method and calculated the estimated intestinal rescue rate. Patient background factors affecting intestinal resection were also examined. RESULTS: The time limit for achieving 80% intestinal rescue rate was 200 min in C-S time, and when this exceeded 300 min, the intestinal rescue rate dropped to less than 50%. Multivariate analysis identified the APACHE II score as a significant influencing factor. CONCLUSION: A rapid transition from early diagnosis to early surgery is critical for patients with acute abdomen originating from intestinal blood flow disorders. The times from presentation at the hospital to surgery should be reduced further, especially for severe cases.

Rare Pediatric Cecal Anomalies: A Lesson in Pediatric Surgery.

BACKGROUND: Rare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases. Objectives: To describe the presentation, workup, management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment. METHODS: A retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected. RESULTS: Five cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17-24 months was unremarkable in all cases. CONCLUSIONS: A wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.

Atypical image of pneumoperitoneum secondary to colon perforation.

The case was a 66-year-old female with a diagnosis of bilateral ovarian carcinoma with peritoneal carcinomatosis and liver metastases. She had only undergone one cycle of chemotherapy and could not be given other cycles because of her poor general condition. She was admitted due to intermittent vomiting for a week and severe heartburn, with the last stool passed two days before, presenting abdominal distension and lower abdominal pain, without signs of peritonism and no peristaltic sounds. After performing several complementary tests a computed tomography scan showed a large amount of intra-abdominal air, which was thought to be a possible transverse colon volvulus, that caused extrinsic compression on the stomach. A colonoscopy was performed in an attempt to devolvulate, which was unsuccessful.

Counterclockwise gastric dilatation and volvulus in a dog.

A 6-year-old neutered male golden retriever mix dog was presented for investigation of acute restlessness, increased respiratory effort, non-productive retching, and anorexia. Initial abdominal radiography revealed marked gastric dilation with a normal gastric shape and position, along with mineralized granular material in the pyloric region, consistent with a pyloric outflow obstruction secondary to suspected sand impaction. The dog was stabilized with gastric trocharization and medical management with intravenous fluids, antiemetics, polyethylene glycol via a nasogastric tube, and analgesia was initiated. The dog developed aspiration pneumonia during hospitalization and became oxygen-dependent. There was no significant improvement of clinical status despite 72 h of medical management, and surgical intervention was subsequently recommended. Exploratory laparotomy revealed a counterclockwise gastric dilatation and volvulus. The stomach was repositioned into normal anatomic position and an incisional gastropexy was performed. The dog was maintained in the intensive care unit for 4 d postoperatively. Currently, 3 mo postoperatively, the dog is healthy without recurrence of clinical signs. Key clinical message: Counterclockwise gastric dilatation and volvulus is a rare condition in veterinary medicine; however, it should be considered in a patient with acute gastric distension and signs of pyloric outflow obstruction when characteristic radiological signs of clockwise gastric dilatation and volvulus are absent, and there is radiological evidence of persistent gastric foreign material despite medical management. Misdiagnosis of counterclockwise gastric dilatation and volvulus can delay definitive surgical intervention and lead to higher morbidity and mortality.

Dilatation gastrique dans le sens inverse des aiguilles d'une montre et volvulus chez un chien. Un chien golden retriever mâle castré âgé de 6 ans a été présenté pour évaluation à la suite d'agitation aiguë, d'un effort respiratoire accru, des haut-le-coeur non productifs et d'anorexie. La radiographie abdominale initiale a révélé une dilatation gastrique marquée avec une forme et une position gastrique normales, ainsi qu'un matériau granulaire minéralisé dans la région pylorique, compatible avec une suspicion d'obstruction de l'écoulement pylorique secondaire à une impaction par du sable. Le chien a été stabilisé avec une trocarisation gastrique et une prise en charge médicale avec des fluides intraveineux, des antiémétiques, du polyéthylène glycol via une sonde nasogastrique, et une analgésie a été initiée. Le chien a développé une pneumonie par aspiration pendant l'hospitalisation et est devenu dépendant de l'oxygène. Il n'y a pas eu d'amélioration significative de l'état clinique malgré 72 h de prise en charge médicale et une intervention chirurgicale a été recommandée. La laparotomie exploratrice a révélé une dilatation gastrique dans le sens inverse des aiguilles d'une montre et un volvulus. L'estomac a été repositionné en position anatomique normale et une gastropexie incisionnelle a été réalisée. Le chien a été maintenu en unité de soins intensifs pendant 4 jours après l'opération. Actuellement, 3 mois après l'opération, le chien est en bonne santé sans récidive des signes cliniques.Message clinique clé :La dilatation dans le sens inverse des aiguilles d'une montre et le volvulus gastriques sont une affection rare en médecine vétérinaire; cependant, cela doit être envisagé chez un patient présentant une distension gastrique aiguë et des signes d'obstruction de l'écoulement pylorique en l'absence de signes radiologiques caractéristiques de dilatation gastrique dans le sens des aiguilles d'une montre et de volvulus, et en cas de preuve radiologique de corps étranger gastrique persistant malgré la prise en charge médicale. Un diagnostic erroné de dilatation gastrique dans le sens inverse des aiguilles d'une montre et de volvulus peut retarder l'intervention chirurgicale définitive et entraîner une morbidité et une mortalité plus élevées.(Traduit par Dr Serge Messier).

Pediatric volvulus induced thyroid storm.

Thyroid storm is an unusually rare but life-threatening pediatric occurrence, carrying significant mortality. Skewed towards the adolescent population, thyroid decompensation occurs due to inciting factors ranging from infection, trauma, surgery, burns, medications, direct thyroid trauma, and rarely volvulus. Emergent care focuses on both reversing the inciting event as well as quelling the metabolic hyperactivity associated with thyroid storm. In review of the available literature, this case is the first to date of thyroid storm secondary to malrotation with midgut volvulus in a previously euthyroid adolescent patient.

Long-term outcomes of various pediatric short bowel syndrome in China.

PURPOSE: The goal of this study was to analyze long-term outcome of various pediatric short bowel syndrome (SBS) at an intestinal rehabilitation center in China. METHODS: One hundred and fifty-seven children with SBS were enrolled in this study from October 1988 to July 2019. Their long-term follow-up outcome was analyzed according to the age of disease onset, parenteral nutrition (PN) duration, and anatomic types of short bowel, respectively. The clinical characteristics, which included demographics, the length of residual small bowel, PN duration, PN dependence, SBS-related complications such as IF-related liver disease (IFALD), catheter-related bloodstream infection (CRBI), and mortality were compared among the groups. RESULTS: The main etiology for SBS were intestinal atresia, NEC, and volvulus. Five of 157 patients did not wean off PN. The incidence of IFALD and CRBI was 24.2 and 22.3%, respectively. Sixteen cases died because of infection and liver failure and eight patients lost to follow-up. The survival rate of the 157 patients was 84.7%. PN duration was longer in the infants and children group (284 ± 457 d vs. 110 ± 64 d, P = 0.021; R = 0.264, P = 0.001) and more patients did not wean off PN than in the neonates group (11.6% vs. 0, P = 0.001; R = 0.295, P < 0.001). Patients with PN with a duration of longer than 90 days had more CRBIs (30.6%, P = 0.025; R = 0.236, P = 0.003). Additionally, the rate of CRBI was higher in patients with stoma (30.0%, P = 0.032). There was no difference in mortality among the groups. In five PN dependence patients, none was SBS onset in neonates. CONCLUSION: Pediatric patients with SBS could achieve favorable long-term survival and enteral autonomy. Different standards of SBS classification such as the age of disease onset, PN duration, and anatomic types of short bowel did not impact the overall mortality of pediatric SBS. Prolonged PN duration positively correlated with the age of disease onset and the incidence of CRBI. Patients with the complete continuity of intestinal tract suffered less from CRBI.