Diagnostic Performance of Ultrasonography for Identification of Small Bowel Obstruction; a Systematic Review and Meta-analysis.

Introduction: Small bowel obstruction (SBO) is known as a common cause of acute abdominal complaints in the emergency department (ED). The modality of choice for the diagnosis of SBO has not yet been established. This systematic review and meta-analysis aimed to investigate the accuracy of ultrasonography for the diagnosis of SBO. Methods: Systematic search was performed on five electronic databases including Medline, Scopus, Web of Sciences, Embase, and Cochrane Library, and the retrieval period was from the inception of each database to November 2023. The quality of the included studies were investigated using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). The pooled values of diagnostic characteristics for ultrasonography were estimated using meta-Disc and Stata statistical software. Results: Twenty-one studies with a total of 1977 patients were included in the meta-analysis. The pooled estimate for sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary ROC curve of ultrasonography for diagnosing SBO were 0.93 (95% CI: 0.91-0.95), 0.8 (95% CI: 0.77-0.83), 5.69 (95% CI: 3.64-8.89), 0.1 (95% CI: 0.07-0.16), 83.51 (95% CI: 18.12-182.91) and 0.96, respectively. Conclusion: The findings of this meta-analysis showed that the utilization of ultrasonography holds promise as a diagnostic imaging for SBO with high accuracy. However, additional worldwide studies are essential to get more evidence on the value of ultrasonography for the diagnosis of SBO.

Chronic Encapsulated Sclerosing Peritonitis: A Case Report.

Chronic encapsulated sclerosing peritonitis (CESP) is a very rare cause of intestinal obstruction that has been associated with certain chronic conditions. It is characterized by the thickening of the peritoneum, generating a membrane that covers the intestinal loops and prevents their adequate mobilization. Most cases present as a surgical emergency, leading to a diagnosis during surgery; however, imaging studies can support the pre-surgical diagnosis. Treatment is based on the clinical context of the patient, based on medical management with corticosteroids in a stable patient, or surgical management when it presents as an acute complication. The morbidity and mortality associated with this condition are high and epidemiological data are scarce. There is still a lack of studies to describe the associated demographic data, diagnosis, and treatment.

Jejunal Atresia With a Rare Association: A Case Report and Literature Review.

Jejunoileal atresia, a common cause of neonatal intestinal obstruction, typically manifests shortly after birth. This case report highlights a rare instance of a late preterm female neonate presenting with type 4 jejunoileal atresia along with proximal rectal atresia, an exceedingly uncommon combination. Initial symptoms included bilious emesis and failure to pass meconium, leading to surgical correction of jejunoileal atresia. However, postoperative complications, including vomiting and jaundice, prompted further investigation, revealing rectal atresia during a fluoroscopic study on day 29. Subsequent surgery was required to address the rectal atresia, resulting in additional challenges such as short bowel syndrome and infection. The complexity of diagnosis and management underscores the importance of thorough evaluation of the lower gastrointestinal tract in neonates with jejunoileal atresia to prevent misdiagnosis and reduce the need for multiple surgeries. Rectal atresia, which is a very rare anorectal abnormality, in combination with jejunoileal atresia is considered an incredibly unusual, exceptionally unique case; as to our knowledge, no similar presentation had previously occurred. Prompt identification and simultaneous treatment of both conditions can help mitigate complications, minimize the risk of necrosis and perforation, and improve overall outcomes. Comprehensive management strategies that encompass thorough diagnostic evaluation and coordinated surgical interventions are crucial for optimizing the care of neonates with complex intestinal malformations, ensuring timely resolution of symptoms, and reducing long-term morbidity.

Right paraduodenal hernia presenting with strangulated obstruction with intestinal malrotation: a case report.

A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of malrotation, strangulation may occur both inside and outside the hernial sac. Strangulation outside the hernial sac makes the preoperative diagnosis more difficult. Herein, we report a patient with a right paraduodenal hernia, intestinal malrotation, and strangulation outside the hernia. An 86-year-old woman was admitted to our hospital with abdominal pain. Enhanced computed tomography showed a closed-loop obstruction of the hypo-enhancing small bowel and absence of a horizontal duodenal leg. The patient underwent an emergency laparotomy and was diagnosed with strangulated bowel obstruction due to a right paraduodenal hernia and malrotation. The patient underwent resection of the ischemic ileum, closure of the hernial orifice, and repositioning of the intestine. The postoperative course was uneventful. The patient reported no abdominal discomfort after 7 months of follow-up.

Gallstone Ileus as an Infrequent Cause of Bowel Obstruction: A Review of Small Cohort.

Introduction Gallstone ileus is an uncommon cause of small bowel obstruction; it is a rare complication of calculus chronic cholecystitis which leads to cholecystoenteric fistula and impaction of gallstone in the gastrointestinal tract leading to mechanical bowel obstruction. Our aim is to report the natural history and management of this rare condition in a teaching hospital. Materials and methods It is a retrospective study, where 10 years of data related to the management of intestinal obstruction secondary to gallstone ileus was collected. The cohort included 10 patients, whose demographic data, clinical findings, and management outcomes were evaluated. Results Majority of patients were female (90%, n=9) with a median of 83 years (range 61-96) although 90% of the population were above 70 years. Presenting complaints were mostly pain and vomiting. The onset of symptoms was between two and seven days. The site of obstruction was mostly the ileum (n=9) with the exception of one case in the sigmoid proximal to a benign stricture, and the size of the stone ranged from 2.5 to 4 cm. Moreover, most of the patients had a previous history of gallstone (n=7) with one post-cholecystectomy status. The laboratory investigations in 50% of patients had deranged liver function test (LFT) and acute kidney injury (AKI), and 60% had raised inflammatory markers, namely, white blood cells (WBC) and C-reactive protein (CRP). Intervention as enterolithotomy was the preferred approach (n=8 (two laparoscopic, six open surgery)), and two patients were managed conservatively. The mean postoperative length of stay was 10 days in the open approach and five days in the laparoscopic approach, respectively. Conclusions Elderly female patients are more prone to have gallstone ileus particularly with a past medical history of gallstones, and the preferred management option is enterolithotomy which could be open or laparoscopic depending on the expertise of the surgeon.

Unveiling a Silent Obstructor: Phytobezoar in the Third Duodenal Segment.

We present a case of obstruction in the third portion of the duodenum secondary to a phytobezoar in an adult patient with no surgical history and without a vegan diet. High intestinal obstruction due to a phytobezoar is rarely described in the literature, posing a diagnostic challenge when evaluating potential differentials in the emergency setting. Subsequently, we conduct a review focusing on tomographic findings and the surgical specimen, highlighting key points to consider when addressing such pathologies.

Mesocolic hernia, a case series.

INTRODUCTION AND IMPORTANCE: Paraduodenal hernias are difficult to diagnose due to their unusual presentation. Herein, five new cases are added to the literature. CASE PRESENTATION: Four male and one female child complained of paraduodenal hernias, two on the right side and three on the left side. The intestinal part that herniated inside the hernia sac was also malrotated in four patients. One patient had Meckel's diverticulum with a herniated intestine. One infant had extrahepatic biliary disease, a single atrium, polysplenia, intestinal malrotation, and a left paraduodenal hernia. Exploratory labarotomy was done for reduction of the intestine, reorientation, and repair of hernia orifices. CLINICAL DISCUSSION: Paraduodenal hernia is a component of malrotation. Cautious dissection of the hernia orifice is required to keep away from injuries to the inferior mesenteric vein or left colic artery in the course of the restoration of the left paraduodenal hernia. Also, the superior mesenteric vessels may be injured in the course of the restoration of the right paraduodenal hernia. CONCLUSION: There is a correlation between the occurrence of PDH with malrotation. The diagnosis of malrotation can be made with an ultrasound abdomen; however, it is true that ultrasound cannot make a confirmed diagnosis in all patients. Once the diagnosis of a mesocolic hernia has occurred, surgical repair is mandatory by closure of the defect.

Intestinal perforation due to colorectal cancer during pregnancy: case report and literature review.

Colorectal cancer (CRC) in pregnancy is sporadic. We reported a case of a woman at 23 + 4 weeks of gestation who presented with abdominal pain. The patient underwent an ultrasound and MRI, during which a colonic mass was noted. Considering a probable incomplete intestinal obstruction, a colonoscopy, biopsy, and colonic stenting were performed by a multidisciplinary team. However, sudden hyperthermia and CT demonstrated intestinal perforation, and an emergency caesarean section and colostomy were conducted. The histological analysis confirmed moderately high-grade adenocarcinoma.

Intestinal obstruction induced by portal vein thrombosis in a female undergoing oral contraceptive therapy: a case report with comprehensive review.

Introduction: Portal vein thrombosis (PVT) is a rare medical condition that obstructs blood flow in the portal vein, with cirrhosis as a common predisposing factor. However, its association with oral contraceptive pills (OCPs), particularly with progestins, remains inadequately explored. This case report aims to contribute to this understanding, focusing on the rare presentation of PVT-induced intestinal obstruction in a female on prolonged OCP therapy. Case presentation: A 45-year-old female presented with severe abdominal pain, vomiting, and constipation. Diagnosis revealed PVT-induced intestinal obstruction, an exceptionally rare occurrence in the context of prolonged OCP therapy. The patient's symptoms improved with conservative management, including rivaroxaban, highlighting the crucial role of early intervention. Discussion: This case brings attention to the limited literature exploring the link between OCPs and PVT. Despite the generally safe reputation of OCPs, they can induce pro-thrombotic conditions, emphasizing the need for heightened clinical awareness. In this case, the rarity of intestinal obstruction in PVT, compounded by the absence of common risk factors, underscores the diagnostic challenges associated with such presentations. Conclusion: PVT-induced intestinal obstruction in a patient on prolonged OCP therapy is exceptionally rare, emphasizing the necessity for multidisciplinary management. It provides crucial insights into suspecting, identifying, and treating this uncommon complication in non-cirrhotic individuals, contributing to the limited existing literature on the subject.

Inoperable malignant bowel obstruction: palliative interventions outcomes - mixed-methods systematic review.

BACKGROUND: Parenteral nutrition (PN) and palliative venting gastrostomies (PVG) are two interventions used clinically to manage inoperable malignant bowel obstruction (MBO); however, little is known about their role in clinical and quality-of-life outcomes to inform clinical decision making. AIM: To examine the impact of PN and PVG on clinical and quality-of-life outcomes in inoperable MBO. DESIGN: A mixed-methods systematic review and narrative synthesis. DATA SOURCES: The following databases were searched (from inception to 29 April 2021): MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Bielefeld Academic Search Engine, Health Technology Assessment and CareSearch for qualitative or quantitative studies of MBO, and PN or PVG. Titles, abstracts and papers were independently screened and quality appraised. RESULTS: A total of 47 studies representing 3538 participants were included. Current evidence cannot tell us whether these interventions improve MBO survival, but this was a firm belief by patients and clinicians informing their decision. Both interventions appear to allow patients valuable time at home. PVG provides relief from nausea and vomiting. Both interventions improve quality of life but not without significant burdens. Nutritional and performance status may be maintained or improved with PN. CONCLUSION: PN and PVG seem to allow valuable time at home. We found no conclusive evidence to show either intervention prolonged survival, due to the lack of randomised controlled trials that have to date not been performed due to concerns about equipoise. Well-designed studies regarding survival for both interventions are needed. PROSPERO REGISTRATION NUMBER: CRD42020164170.

Abdominal cocoon syndrome-a rare culprit behind small bowel ischemia and obstruction: Three case reports.

BACKGROUND: Abdominal cocoon syndrome (ACS) represents a category within sclerosing encapsulating peritonitis, characterized by the encapsulation of internal organs with a fibrous, cocoon-like membrane of unknown origin, resulting in bowel obstruction and ischemia. Diagnosing this condition before surgery poses a challenge, often requiring confirmation during laparotomy. In this context, we depict three instances of ACS: One linked to intestinal obstruction, the second exclusively manifesting as intestinal ischemia without any obstruction, and the final case involving a discrepancy between the radiologist and the surgeon. CASE SUMMARY: Three male patients, aged 53, 58, and 61 originating from Northern Thailand, arrived at our medical facility complaining of abdominal pain without any prior surgeries. Their vital signs remained stable during the assessment. The diagnosis of abdominal cocoon was confirmed through abdominal computed tomography (CT) before surgery. In the first case, the CT scan revealed capsules around the small bowel loops, showing no enhancement, along with mesenteric congestion affecting both small and large bowel loops, without a clear obstruction. The second case showed intestinal obstruction due to an encapsulated capsule on the CT scan. In the final case, a patient presented with recurring abdominal pain. Initially, the radiologist suspected enteritis as the cause after the CT scan. However, a detailed review led the surgeon to suspect encapsulating peritoneal sclerosis (ACS) and subsequently perform surgery. The surgical procedure involved complete removal of the encapsulating structure, resection of a portion of the small bowel, and end-to-end anastomosis. No complications occurred during surgery, and the patients had a smooth recovery after surgery, eventually discharged in good health. The histopathological examination of the fibrous membrane (cocoon) across all cases consistently revealed the presence of fibro-collagenous tissue, without any indications of malignancy. CONCLUSION: Individuals diagnosed with abdominal cocoons commonly manifest vague symptoms of abdominal discomfort. An elevated degree of clinical suspicion, combined with the application of appropriate radiological evaluations, markedly improves the probability of identifying the abdominal cocoon before surgical intervention. In cases of complete bowel obstruction or ischemia, the established norm is the comprehensive removal of the peritoneal sac as part of standard care. Resection with intestinal anastomosis is advised solely when ischemia and gangrene have been confirmed.

Mesenteric Cystic Lymphangioma, an acute presentation in a 9-year-old child.

Mesenteric lymphangioma is a rare malformation of the lymphatic system. Misdiagnosis of mesenteric cystic lymphangioma can occur due to its rarity and resemblance to other cystic lesions and ascites. The authors report an acute presentation of a mesenteric lymphangioma in a 9-year-old child. Clinical, radiological, and surgical findings are illustrated accordingly. As authors, we aim to add to the limited data of acute presentations of mesenteric lymphangiomas.

Pharmacological intestinal obstruction because of calcium polystyrene sulfonate administration.

Cation exchange resins are commonly used as treatment for hyperkalaemia in patients with chronic renal disease. There is a relation between cation exchange resins and the development of gastrointestinal adverse effects. A case of an intestinal obstruction at the terminal ileum is presented that underwent an ileocolic resection because of a critical stenosis of the intestine. The pathologist revealed abundant inflammatory cells together with deposits of calcium polystyrene crystals responsible of the intestinal obstruction. A rare cause of intestinal obstruction to bear in mind in chronically medicated patients with cation exchange resins.

Exploring the Landscape of General Surgery in the Adolescent Age Group: Challenges and Considerations.

INTRODUCTION: The adolescent age group typically ranges from 10 to 19 years. This age group differs from the paediatric and adult populations based on their physiological, psychological, and social behaviour. Patients of this age group usually present with trauma, swellings, burns, hernias, hydroceles, haemorrhoids, fibroadenomas, abscesses, pilonidal diseases, etc. The objective of this study was to identify various causes requiring surgical intervention in adolescent patients and to determine the demography of these patients, reasons for surgery, and surgical outcomes in the patients of the adolescent age group. MATERIALS AND METHODS: This single-centre, hospital record-based, retrospective, cross-sectional study was conducted on 445 adolescent patients who underwent various general surgical interventions from August 2022 to July 2023 in the Department of General Surgery, Rajendra Institute of Medical Sciences (RIMS), Ranchi. RESULTS: A total of 445 patients were included in this study; among them, 277 underwent elective surgeries and 168 emergency surgeries. Major surgeries included 315 patients, while 130 were daycare procedures. Males were 294, and 151 were females. Cyst excision was the most performed, followed by fibroadenoma excision. Burn (10.78%) was the most common cause requiring major intervention, followed by intestinal obstruction (6.96%) and perforation (6.51%). Mortality was observed in 6.51% of patients. CONCLUSION: In this study, the adolescent age group required more elective surgical care as compared to emergency care. Among major surgeries, abdominal laparotomy was most common, and in daycare procedures as well as overall, cyst excision was most performed.

Cytomegalovirus colitis as intestinal obstruction in an immunocompetent adolescent: a case report and literature review.

BACKGROUND: Cytomegalovirus infection manifests varying clinical characteristics and severity in diverse populations with different immune statuses. The signs and symptoms of gastrointestinal involvement are nonspecific. Here, we present a case of cytomegalovirus colitis in an immunocompetent adolescent, which manifested as intestinal pseud-obstruction. CASE PRESENTATION: A 15-year-old man who had contracted novel coronavirus infection one month earlier was admitted to our hospital with fever, abdominal pain, and hematochezia. His abdomen was distended, and laboratory evaluation revealed a decrease in the blood count, an increase in inflammatory indicators and hepatic impairment. Imaging shows bowel wall thickening and dilatation of the colon. A diagnosis of intestinal infection combined with acute intestinal pseud-obstruction was made. Diarrhea persisted despite conservative treatment with empirical antibiotics. A colonoscopy was performed. Pathology confirmed cytomegalovirus infection. Ganciclovir therapy was initiated, and subsequent review showed a good recovery. CONCLUSIONS: The case was diagnosed as cytomegalovirus colitis. We reviewed the reports of 9 cases of bowel obstruction, including our own, and found that the majority of the adult patients were elderly with underlying disease. Clinical and endoscopic manifestations are typically nonspecific, and imaging shows typical signs of intestinal obstruction. The final diagnosis was confirmed by pathology. Most of them have a good prognosis. We suggest that cytomegalovirus colitis can also lead to intestinal obstruction and that viral reactivation in immunocompetent individuals may be associated with inflammatory conditions and viral coinfection, particularly with the novel coronavirus.

Perforated Meckel's Diverticulum and Adhesive Intestinal Obstruction in a Preterm Neonate: A Case Report.

Perforated bowel and adhesive intestinal obstruction are common indications for emergency surgical intervention in a preterm neonate. The initial approach to managing perforation involves either peritoneal drain insertion or formal laparotomy. Once a neonate presents with complete bowel obstruction, prompt abdominal exploration becomes crucial. One prevalent cause of bowel obstruction in this population is adhesions resulting from previous surgeries. This report details the case of a preterm, extremely low birth weight neonate experiencing pneumoperitoneum, initially managed with an intraperitoneal drain. Despite temporary improvement, the infant developed recurrent pneumoperitoneum, necessitating formal exploratory laparotomy. Approximately one month post-surgery, the baby encountered complete bowel obstruction due to adhesive intestinal obstruction, requiring a second exploratory laparotomy. The child survived both surgical interventions and is thriving at follow-up. Our findings suggest that in select cases, intraperitoneal drain placement may suffice. However, there is a need for further research to improve the suspicion and diagnosis of Meckel's diverticulum perforations in neonates. Additionally, vigilant assessment and timely intervention for adhesive intestinal obstruction can enhance bowel salvage outcomes.

Surgical Management of Pericaecal Hernia in a Virgin Abdomen.

Internal hernia is an uncommon cause of mechanical small bowel obstruction. This case report details a 66-year-old Chinese male with no prior abdominal surgeries who presented with colicky abdominal pain, abdominal distension, and vomiting. Initial investigations were unyielding, but escalating symptoms prompted a diagnostic laparoscopy. Laparotomy then revealed a closed-loop obstruction through a lateral type pericecal hernia, with a segment of ischemic jejunum. Adhesion bands in the right iliac fossa and a congenital hernia orifice in the mesentery were identified and addressed. The patient recovered well postoperatively. This discussion explores the Meyer's classification of pericecal hernias, potential etiologies, clinical manifestations, diagnostic considerations, and the choice between laparoscopic and open surgeries. This case underscores the importance of a high index of suspicion, prompt surgical intervention, and the diagnostic utility of laparoscopy in managing pericecal hernias.

Preventing an 8-mm Port Site Hernia in Robot-Assisted Laparoscopic Surgery: Insights From Two Rare Cases and Future Preventive Measures.

Port-site incisional hernia (PIH) is an uncommon complication that can arise subsequent to a laparoscopic procedure, potentially leading to severe adverse effects such as intestinal obstruction. We currently present two cases of incarcerated hernia that occurred at an 8-mm trocar site after robot-assisted laparoscopic surgery (RALS). While occurrences of an 8-mm port-site incisional hernia are infrequent, it is imperative to note that most PIH cases are due to inadequate fascial closure of the port site. Therefore, surgeons must pay attention to closing the fascia of an 8-mm trocar site following RALS.