Can small bowel obstruction during pregnancy be treated with conservative management? A review.

BACKGROUND: Small bowel obstruction can occur during pregnancy, which, if missed, can lead to dire consequences for both the mother and foetus. Management of this condition usually requires surgical intervention. However, only a small number of patients are treated conservatively. OBJECTIVE: The objective was to review the literature to determine the feasibility of conservative management for small bowel obstruction. METHODS: A systematic search of the PubMed and Embase databases was performed using the keywords [small bowel obstruction AND pregnancy]. All original articles were then reviewed and included in this review if deemed suitable. CONCLUSION: Conservative management of small bowel obstruction in pregnant women is feasible if the patient is clinically stable and after ruling out bowel ischaemia and closed-loop obstruction.

Presentation, characteristics and management of obstructive intestinal conditions in cystic fibrosis.

Objective: Constipation and distal intestinal obstruction syndrome (DIOS) are common gastrointestinal manifestations of cystic fibrosis (CF). The primary aim was to describe the characteristics of constipation and DIOS hospitalisations in a paediatric and adult CF service over a 12-year period. The secondary aims were to determine the proportion of constipation and DIOS presentations which met the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) CF Working Group definitions and to describe management strategies of both conditions. Method: A retrospective study of children and adults with CF who were admitted with a primary diagnosis of constipation or DIOS between 1 January 2011 and 31 December 2022. ESPGHAN definitions for constipation and DIOS were retrospectively applied to all admissions to determine if the primary medical diagnosis met ESPGHAN criteria. Results: During the 12-year study period, 42 hospitalisations for constipation were recorded in 19 patients, and 33 hospitalisations for DIOS were recorded in 23 patients. 88.10% of constipation episodes met ESPGHAN definitions, compared with 3.0% of DIOS episodes. Constipation and DIOS were primarily treated with polyethylene glycol (PEG). The use of sodium amidotrizoate meglumine enemas was significantly higher in the DIOS group (p=0.045). Those admitted with DIOS were significantly less likely to be recommended a weaning dose of PEG (p=0.018). Conclusion: Children and adults with CF are more commonly admitted for the management of constipation than DIOS. There is considerable variation in diagnostic and therapeutic practice, and this study highlights the need to enhance the translation and adoption of existing best-practice guidelines.

Recurrent pembrolizumab-induced mechanical small bowel obstruction in a patient with metastatic cervical cancer.

•Adverse events of pembrolizumab have been documented, but more severe gastrointestinal effects are not as well described.•We report a case of a patient with cervical cancer treated with pembrolizumab who developed small bowel obstruction (SBO)•Histological analysis and gastrointestinal workup points to pembrolizumab as likely cause of SBO.

Perforated jejunal diverticulitis in the setting of biologic therapy presenting as transverse Colon diverticulitis: A case report.

INTRODUCTION: Small bowel diverticula are a rare entity and are mostly found in the duodenum on diagnosis. Some common complications of this pathology include bleeding, obstruction, diverticulitis, and perforation. Furthermore, there is growing evidence supporting an association between biologic therapies and spontaneous intestinal perforation. PRESENTATION OF CASE: We present a case of a 79-year-old female on prednisone, hydroxychloroquine, and tofacitinib for rheumatoid arthritis who was misdiagnosed with transverse colonic diverticulitis and eventually found to have perforated jejunal diverticulitis on laparotomy. DISCUSSION: While tofacitinib has been associated with spontaneous intestinal perforation, it has not been documented as an aggravating factor in small bowel diverticular disease. CONCLUSION: It is imperative to maintain a high index of suspicion for this pathology in immunosuppressed patients with an atypical presentation of diverticular disease.

Peritoneal encapsulation - An unusual cause of acute bowel obstruction: A case report.

INTRODUCTION/IMPORTANCE: Peritoneal encapsulation (PE) is a rare congenital anomaly characterised by the presence of an accessory peritoneal membrane which encases part of the small bowel. Typically, this remains asymptomatic, however; in rare cases, a person may present with symptoms suggestive of a small bowel obstruction. CASE PRESENTATION: Here we present a case of a 58 year old gentleman with congenital PE causing a bowel obstruction which was revealed on commuted tomography scan. He required a laparotomy and excision of the accessory sac. CLINICAL DISCUSSION: Pre-operative diagnosis of PE can be challenging. It can present as a bowel obstruction with unique features including asymmetric distension of the abdomen on clinical exam and cocoon-like cluster of small bowel on imaging. CONCLUSION: Congenital PE is a rare cause of bowel obstruction and should be considered early in patients presenting with symptoms of bowel obstruction without previous abdominal surgery.

Integrating Pre-test Probability and Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED) Diagnosis of Small Bowel Obstruction (SBO).

Introduction A computed tomography (CT) scan and point-of-care ultrasound (POCUS) are commonly employed for diagnosing small bowel obstructions (SBOs). Prior studies demonstrated that POCUS has 90-95% sensitivity and specificity compared with CT scanning, which is the gold standard. Unlike other imaging modalities (in which the ordering and performing clinician are not the same), POCUS-performing/interpreting sonologists must recognize the risk of confirmation bias in the POCUS application. Per Bayesian analysis, the likelihood of a diagnosis being true following a diagnostic test is based on the ordering clinician's pre-test probability and the test characteristics (sensitivity and specificity, from which positive and negative likelihood ratios can be calculated). Consequently, establishing pre-test probability is important in informing downstream diagnostic or therapeutic interventions, as pre-test probability influences post-test odds. Little research has been done on the role of POCUS sonologist's pre-test probability and actual POCUS results regarding SBO. This study assessed the role of POCUS, integrating pre-test probability and POCUS results to determine post-test odds. Methods One hundred six patients were recruited on a convenience basis and underwent POCUS and CT between April 2017 and December 2022. All sonographers were credentialed in POCUS. POCUS sonologists' pre-test probabilities and POCUS and CT results were captured, which were compared. Sensitivity, specificity, LR+, and LR- were calculated, and correlations were made between pre-test probability and POCUS and CT results.  Results POCUS exhibited a sensitivity of 92% and specificity of 90%, with a corresponding positive likelihood ratio (LR+) of 9.3 and a negative likelihood ratio (LR-) of 0.09 for diagnosing SBO. Among patients with a high pre-test probability of SBO, a negative ultrasound yielded post-test odds of 0.4%, whereas a positive POCUS yielded post-test odds of 39.6%. Among patients with a low pre-test probability, a negative POCUS resulted in post-test odds of 0%, while a positive POCUS led to post-test odds of 2.1%, yielding a number needed to scan (NNS) of ~50 to identify a patient with an SBO on CT. Conclusion This study confirmed POCUS's sensitivity and specificity of ~90-95% and a corresponding LR+ of 9.2 and LR- of 0.9. Pre-test probability substantially affected post-test odds. Patients with a high pre-test probability and a positive POCUS had post-test odds of 39.6 and should have a confirmatory CT, while those with a negative POCUS have very low post-test odds and very likely will not benefit from CT. Patients with low pre-test probability and a positive POCUS have post-test odds of 2.1%, similar to the Wells Score and HEART score; such patients may not benefit from a CT, though clinicians should use their judgment/discretion. Patients with a low pre-test probability and a negative POCUS have post-test odds of 0% and should not have a CT. Among low pre-test probability patients, the NNS was ~50 to identify patients with an SBO on CT.

A Pelvic Hernia Through Two Defects in the Pouch of Douglas in a Patient With Peritoneal Xanogranuloma: A Report of a Very Rare Case.

Pelvic internal hernias, including pouch of Douglas hernias, are a very rare cause of small bowel obstruction. They pose a challenge in diagnosis due to their rarity and lack of specific radiological features. The definitive diagnosis is usually reached intraoperatively. The treatment consists of reduction with or without resection of the herniated bowel and primary repair of the defect. Mesh placement has been reported but is still arguable, as no musculofacial defect is involved. Here, we present a case of a 28-year-old female patient, a nulliparous with multiple medical conditions including familial Mediterranean fever (FMF) and an extremely rare tumor, peritoneal xanthogranuloma. She had a history of laparoscopic left ovarian cystectomy, and complained of abdominal pain and distention for three days prior to admission. Her symptoms were associated with constipation and recurrent vomiting and she was admitted as a suspected case of small bowel obstruction. CT scan suggested the possible diagnosis of a pelvic hernia, yet the definitive diagnosis was reached intraoperatively after noticing the presence of two defects on the left side of the pouch of Douglas. A primary repair of the defects was performed after reduction of the viable herniated bowel. The patient was discharged on the third postoperative day with uneventful course of recovery.

Deep learning and capsule endoscopy: Automatic multi-brand and multi-device panendoscopic detection of vascular lesions.

Background and study aims Capsule endoscopy (CE) is commonly used as the initial exam for suspected mid-gastrointestinal bleeding after normal upper and lower endoscopy. Although the assessment of the small bowel is the primary focus of CE, detecting upstream or downstream vascular lesions may also be clinically significant. This study aimed to develop and test a convolutional neural network (CNN)-based model for panendoscopic automatic detection of vascular lesions during CE. Patients and methods A multicentric AI model development study was based on 1022 CE exams. Our group used 34655 frames from seven types of CE devices, of which 11091 were considered to have vascular lesions (angiectasia or varices) after triple validation. We divided data into a training and a validation set, and the latter was used to evaluate the model's performance. At the time of division, all frames from a given patient were assigned to the same dataset. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and an area under the precision-recall curve (AUC-PR). Results Sensitivity and specificity were 86.4% and 98.3%, respectively. PPV was 95.2%, while the NPV was 95.0%. Overall accuracy was 95.0%. The AUC-PR value was 0.96. The CNN processed 115 frames per second. Conclusions This is the first proof-of-concept artificial intelligence deep learning model developed for pan-endoscopic automatic detection of vascular lesions during CE. The diagnostic performance of this CNN in multi-brand devices addresses an essential issue of technological interoperability, allowing it to be replicated in multiple technological settings.

A Rare Case of Small Bowel Obstruction due to Migration of a Percutaneous Biliary Stent.

Biliary endoprostheses are widely used in the treatment of biliary lithiasis, malignant and benign strictures, and occasionally in long-lasting biliary fistulas. They can be placed endoscopically during endoscopic retrograde cholangiopancreatography and radiologically (percutaneous) when the endoscopic route is not feasible. Complications associated with the endoscopic placement of biliary endoprostheses are well described in the literature, with migration being the most common. Intestinal obstruction is a rare complication associated with the migration of these devices. There are no reports in the literature of this complication occurring after percutaneous placement. We present a case of a patient who arrived at the emergency department with ileal obstruction secondary to the migration and concurrent embedding of a covered stent placed radiologically to treat a biliary leak after surgery. The patient underwent diagnostic laparoscopic and ileal resection, revealing a lithiasic concretion at the tip of the stent, causing the small bowel obstruction.

Don't Let the Sun Rise on Small Bowel Obstruction Without Surgical Consultation-Redefining Nonoperative Management Pathways.

Introduction: Small bowel obstruction (SBO) is a common cause of hospital admission leading to resource utilization. The majority of these patients require non-operative management (NOM) which can lead to increased length of stay (LOS), readmissions, resource utilization, and throughput delays. Early surgical consultation (SC) for SBO may improve efficiency and outcomes. Methods: We implemented an institution-wide intervention (INT) to encourage early SC (<1 day of diagnosis) for SBO patients in July 2022. A retrospective analysis was performed on all patients with SBO requiring NOM from January 2021 to June 2023, categorized into pre- and post-INT groups. The primary outcome was the number of SC's and secondary outcomes were early SC (<1 day of diagnosis), utilization of SBFT, LOS, 30-day readmission, and costs of admission. Results: A total of 670 patients were included, 438 in the pre-INT and 232 in the post-INT group. Overall, SBFT utilization was significantly higher in cases with SC (17.2% vs 41.4%, P < .001). Post-INT patients were more likely to receive SC (94.0% vs 83.3%, P < .001) and increased SBFT utilization (47.0% vs 33.6%, P = .001). Additionally, early SC improved significantly in the post-INT group (74.3% vs 65.7%, P = .03). There was no difference in LOS between groups (4.0 vs 3.8 days, P = .48). There was a trend toward decreased readmission rates in the INT group at 30 days (7.3% vs 11.0%, P = .13) and reduced direct costs in the INT group (US$/admission = 8467 vs 8708, P = .1). Conclusion: Hospital-wide interventions to increase early surgical involvement proved effective by improving early SC, increased SBFT utilization, and showed a trend towards decreased readmission rates and direct costs.

Measuring Small Bowel Length in Bariatric Surgery: An Ex Vivo Laparoscopic Training Experiment.

INTRODUCTION: Determining limb length in gastric bypass procedures is a crucial step to ensure significant weight loss without risking malnutrition. This study investigated the effect of ex vivo training on the skills needed to determine limb lengths. MATERIALS AND METHODS: This was a single-center ex vivo training experiment in a teaching hospital in the Netherlands. We designed a training exercise with marked ropes in a laparoscopic trainer box. All ten surgical residents participated and practiced the skill of estimating limb length. Before and after the two-week period their results on a 150-centimeter limb length task were evaluated. RESULTS: Before training, 10 surgical residents estimated 150 centimeters of small bowel with an absolute deviation of 21% [range 9-30]. After the training experiment, the residents measured with 8% [2-20] deviation (P = .17). The 8 residents who trained sufficiently improved statistically significantly to an absolute deviation of 5% [2-17] (P = .012). Over 70% of the participants felt their skills had improved. CONCLUSIONS: With sufficient training, surgical residents' skills in measuring small bowel length improved when tested in an ex vivo model. Residents became more confident in their laparoscopic measurement skills. This ex vivo training model is a alternative and addition to on-site training.

Adult Mesenteric Lymphangioma Resulting in Small Bowel Obstruction.

A mesenteric cystic lymphangioma (MCL) is a rare condition that primarily manifests in children. This case report illustrates an unusual presentation of an MCL causing a small bowel obstruction with volvulus in an adult. We present a 31-year-old male who presented to our hospital with a small bowel obstruction. He underwent laparotomy, and a lymphatic mass acting as a lead point and causing small bowel volvulus was discovered intra-operatively. The patient underwent a small bowel with associated mass resection and primary anastomosis; he recovered well. The final pathology demonstrated an MCL. Despite the MCL being a rare entity in adults, it must be considered as the differential for various abdominal pathologies. Although the majority of these masses lack malignant potential, they should be resected, as they pose a risk of mechanical obstruction, torsion, and perforation. Prior descriptions include individual case reports of symptomatic lesions, proposed non-operative management, and follow-up imaging.

Acute Gastric Ischemia in a Case of Small Bowel Obstruction.

Gastric ischemia is a relatively rare condition that can lead to severe or life-threatening outcomes. It can be caused by various etiological factors, including vascular occlusion, atherosclerosis, vasculitis, hypovolemic shock, cardiac failure, mesenteric ischemia, splanchnic vasoconstriction, and abdominal compartment syndrome. Furthermore, gastric dilation can be caused by volvulus and acute necrotizing gastritis. This condition may go unnoticed in the setting of intestinal obstruction. In this case report, we describe a 43-year-old female who presented with signs, symptoms, and radiological findings indicative of small bowel obstruction accompanied by a severely dilated stomach. Our aim is to highlight the importance of considering gastric ischemia in patients with small bowel obstruction and to demonstrate the outcomes of a surgical approach in such presentations.

Clinical features of intussusception in children secondary to small bowel tumours: a retrospective study of 31 cases.

BACKGROUND: Summarizing the clinical features of children with intussusception secondary to small bowel tumours and enhancing awareness of the disease. METHODS: Retrospective summary of children with intussusception admitted to our emergency department from January 2016 to January 2022, who underwent surgery and were diagnosed with small bowel tumours. Summarize the types of tumours, clinical presentation, treatment, and prognosis. RESULTS: Thirty-one patients were included in our study, 24 males and 7 females, with an age of onset ranging from 1 m to 11y 5 m. Post-operative pathology revealed 4 types of small intestinal tumour, 17 lymphomas, 10 adenomas, 4 inflammatory myofibroblastomas and 1 lipoma. The majority of tumours in the small bowel occur in the ileum (83.9%, 26/31). Abdominal pain, vomiting and bloody stools were the most common clinical signs. Operative findings indicated that the small bowel (54.8%, 17/31) and ileocolic gut were the main sites of intussusception. Two types of procedure were applied: segmental bowel resection (28 cases) and wedge resection of mass in bowel wall (3 cases). All patients recovered well postoperatively, with no surgical complications observed. However, the primary diseases leading to intussusception showed slight differences in long-term prognosis due to variations in tumor types. CONCLUSIONS: Lymphoma is the most common cause of intussusception in pediatric patients with small bowel tumours, followed by adenoma. Small bowel tumours in children tend to occur in the ileum. Therefore, the treatment of SBT patients not only requires surgeons to address symptoms through surgery and obtain tissue samples but also relies heavily on the expertise of pathologists for accurate diagnosis. This has a significant impact on the overall prognosis of these patients.

A Case Report on Internal Hernia as an Unusual Cause of Small Bowel Obstruction: A Diagnostic Triumph Unveiled by Computed Tomography Scan.

Paraduodenal hernia is a type of internal hernia caused by defects in the peritoneum during fetal development. It is one of the uncommon causes of intestinal obstruction; diagnosing it and intervening promptly are required. In this case report, we describe our experience treating an adult male patient who presented with symptoms of acute small bowel obstruction and was later diagnosed with internal hernia on further evaluation. The purpose of this case report is to demonstrate the importance of imaging modalities, particularly computed tomography (CT) scan, in diagnosing these cases. Because of their mysterious symptoms, paraduodenal hernias are usually diagnosed late or incidentally. Although they are uncommon, they are far more likely to cause bowel obstruction and strangulation. Immediate surgical intervention is required following the diagnosis.

A systematic review of participant descriptors reported in studies of adhesive small bowel obstruction.

AIM: Reporting of participant descriptors in studies of adhesive small bowel obstruction (ASBO) can help identify characteristics associated with favourable outcomes and allow comparison with other studies and real-world clinical populations. The aim was to identify the pattern of participant descriptors reported in studies assessing interventions for ASBO. METHOD: This systematic review was registered with PROSPERO (CRD42021281031) and reported in line with the PRISMA checklist. Systematic searches of Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were undertaken to identify studies assessing operative and non-operative interventions for adults with ASBO. Studies were dual screened for inclusion. Descriptors were categorised into conceptual domains by the research team. RESULTS: Searches identified 2648 studies, of which 73 were included. A total of 156 unique descriptors were identified. On average, studies reported 12 descriptors. The most frequently reported descriptors were sex, age, SBO aetiology, history of abdominal surgery, BMI and ASA classification. The highest number of descriptors in a single study was 34, compared to the lowest number of descriptors which was one. Pathway factors were the least frequently described domain. Overall, 37 descriptors were reported in just one study. CONCLUSION: There is a lack of consistency in participant descriptors reported in studies of SBO. Furthermore, a significant proportion of the descriptors were used infrequently. This makes it challenging to assess whether study participants are representative of the wider population. Further work is required to develop a Core Descriptor Set to standardise the reporting of patient characteristics and reduce heterogeneity between studies.

Jejunal Diverticulosis Presenting With Small Bowel Obstruction: A Diagnostic Challenge.

We report the case of a woman presenting with small bowel obstruction secondary to an enterolith that formed within a jejunal diverticulum. Prior to this acute presentation, the patient had experienced regular abdominal pain albeit not as severe as the current episode. The CT scan on admission required review by two consultant radiologists before the cause of the small bowel obstruction was diagnosed. Successful surgical management was performed involving a laparotomy, small bowel enterotomy, and removal of the enterolith. Although complications secondary to jejunal diverticula are documented, there is minimal literature on the complexities of making the diagnosis and the best management approach that should be adopted.

Jejunal Diverticulosis: An Atypical Lead Point for Small Bowel Volvulus.

The occurrence of small intestinal diverticula is relatively infrequent compared to its counterpart in the large bowel. Duodenal diverticula exhibit a significantly higher prevalence within the small intestine compared to jejunoileal diverticula, with a ratio of five to one. The occurrence of jejunoileal diverticula exhibits considerable variability and has been documented to range from 0.5% to 2.3% in radiographic series, while autopsy studies have reported rates as high as 7%. We present the clinical details of a 65-year-old male patient who sought medical attention due to a constellation of symptoms, including abdominal pain, vomiting, and obstipation. After adequate resuscitation with IV fluids and preoperative preparation, the patient was transported to the operating room for an emergency exploratory laparotomy. Multiple jejunal diverticuli were identified in the proximal jejunum at the antimesenteric border, less than three feet from the duodenojejunal (DJ) junction. The terminal ileum was found to be 360° rotated counterclockwise around the small bowel mesentery, causing the small intestine to appear congested; however, after clockwise de-rotation, the small bowel regained its normal color. Adhesiolysis and small bowel decompression were performed, and the patient had an uneventful recovery.

The Rapid Growth of Burkitt Lymphoma Causing Partial Small Bowel Obstruction.

Burkitt lymphoma (BL) is a neoplasm of the lymphoid tissue and one of the most prevalent malignancies worldwide. Classically, these patients present with unregulated B-cell differentiation causing fever, chills, night sweats, and weight loss. Although more common in children, in sporadic Burkitt lymphoma, symptoms often can be present in the abdomen. These patients also additionally report nausea, vomiting, and abdominal distention, which in rare instances can cause small bowel obstruction (SBO). Early detection and the initiation of chemotherapy remain highly effective in providing adequate care. This provides better outcomes and prevents surgical management.

Pneumatosis Cystoides Intestinalis Discovered During Exploratory Laparotomy.

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts that develop in the mucosal and submucosal layers of the digestive tract. PCI is typically a benign disease but complications can occur that require surgical intervention. This patient presented to the emergency department with a two-day history of abdominal and back pain. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis led to suspicion of free intraperitoneal air potentially due to bowel perforation, and exploratory laparotomy was indicated. Bowel perforation was ruled out during the procedure, but outpouchings of air-filled cysts were found throughout the small bowel's external surface, leading to the diagnosis of PCI. Distinguishing free intraperitoneal air from PCI on imaging presents a challenge to clinicians. Contrast-enhanced abdominal CT is the preferred imaging modality, but PCI remains difficult to diagnose on imaging alone. Spreading awareness of the typical benign nature of PCI alongside the common presentation on imaging may lead to earlier detection, better treatment outcomes, and prevention of unnecessary surgical intervention.