Facing the unexpected: unusual causes of mechanical small bowel obstruction in adults

Fecaloma causing small bowel obstruction in the absence of risk factors: a case report

BACKGROUND

Small bowel obstruction is a common surgical emergency typically caused by adhesions, hernias, and malignancies. However, ileal fecalomas represent an exceptionally rare etiology, with few cases reported in literature. This case study and literature review aim to highlight an unusual cause of small bowel obstruction, emphasizing the diagnostic challenges and management strategies.

CASE PRESENTATION

A 60-year-old Middle Eastern female patient from Syria with a 1-year history of chronic constipation presented with abdominal pain, vomiting, and an inability to pass feces. Diagnostic imaging confirmed small bowel obstruction, which was caused by a fecal mass proximal to the ileocecal junction. Surgical extraction successfully resolved the obstruction.

CONCLUSION

This case underscores the importance of considering fecal impaction as a differential diagnosis in patients with chronic constipation and highlights the effectiveness of surgical intervention in resolving such obstructions. A comprehensive review of literature on unusual causes of small bowel obstruction, including imaging characteristics and management approaches, is also provided to enhance clinical awareness and improve patient outcomes.

Exploring Early Complications in Paraumbilical Hernia Mesh Repair: A Rigorous Six-Month Prospective Study and In-Depth Analysis

Introduction When an organ, such as the colon, pushes through the wall of the abdominal cavity, a hernia results. After femoral and inguinal hernias, umbilical hernias account for the third most common kind of abdominal hernia in adults precipitated by conditions such as obesity, ascites, and repeated pregnancies. A subtype of umbilical hernias called paraumbilical hernias is more likely to cause problems such as rupture, skin ulceration, and obstruction. Seroma, hematoma, and infection are the reported post-repair consequences but data regarding early complications is limited. High-quality data assessing early complications is necessary to improve mesh repair outcomes. Materials and methods This cross-sectional study was carried out in the Department of General Surgery at Medical Teaching Institute (MTI) Lady Reading Hospital, Peshawar over one year, from January to December 2022. A total of 167 patients were selected using simple random sequential selection. Patients aged 20-60 years of both genders who were diagnosed with paraumbilical hernia in the emergency department were included. To prevent bias, those with uncontrolled diabetes or existing complications from hernia were excluded. Following informed consent, data were gathered using pre-designed proformas. Patients underwent open mesh repair during each surgery, and they were monitored at one and three months following the procedure. Complications such as seroma, hematoma, and wound infection were documented. Data were analyzed using SPSS version 20 (IBM Corp., Armonk, NY) with chi-square tests for categorical variables and a significance level of p < 0.05. Results The study included a total of 167 patients, with a mean age of 42 years (SD ±8.77). The majority of patients (40%) ranged in age from 41 to 50 years old, with 33% aged 31 to 40. Gender distribution revealed that 63 (38%) of the patients were male and 104 (62%) were female. Early complications included 25 (15%) wound infections, 32 (19%) seromas, and 63 (38%) hematomas. The occurrence of wound infections, seromas, and hematomas did not differ significantly by age or gender (p > 0.05). Conclusion Early complications from paraumbilical hernia mesh repair include wound infections (15%), seromas (19%), and hematomas (38%). Postoperative monitoring is critical to reducing these complications.

Management of small bowel obstruction in the third trimester

Small bowel obstruction (SBO) in pregnancy is exceedingly rare. Management of SBO in the third trimester may pose particular challenges, as clinicians must determine whether or not the delivery of the fetus is indicated. In this report, we review the case of a patient in her mid-20's with no prior surgical history who presented with nausea and vomiting at 34 weeks of gestation and was ultimately diagnosed with an SBO. Following expectant management during the initial 4 days of inpatient admission, the patient subsequently underwent an exploratory laparotomy at 35 weeks without concurrent delivery. She was monitored for the remainder of her pregnancy with non-stress tests to evaluate fetal status and eventually underwent induction of labour at 39 weeks, resulting in a successful vaginal delivery. Herein, we review the challenges related to the diagnosis and management of SBO in pregnancy, as well as the maternal-fetal outcomes in the setting of SBO in the third trimester.

Management of small bowel obstruction and therapeutic role of contrast media: A multicenter study

Background

Adhesive small bowel obstruction (SBO) accounts for 55-75% of mechanical small bowel obstructions [1,2]. According to guidelines, water-soluble contrast media (CM) is suggested in the diagnostic work-up of adhesive SBO [3], [4], [5]. However, there is currently no consensus on the therapeutic role of water-soluble CM in adhesive SBO [6] or a generally approved protocol as to when CM should be administered, how often should radiographs be taken and how long conservative management can safely be pursued.

Material and methods

The data of patients who were hospitalized for SBO in two regional hospitals of Estonia between January 2015 and December 2019 were retrospectively collected from the hospitals' electronic databases.

Results

Of 1,008 patients with mechanical SBO included in analysis, 140 (13.9%) were operated on immediately. In the case of conservative management, 575 (66.2%) patients received CM. Resolution occurred in 75.8% of the patients who received CM and in 68.9% of the patients who did not (p = 0.037). Resolution rate was the highest (78.8%) in the group that received CM within 12 h of admission. The duration of symptoms was longer in patients who needed surgical intervention compared to conservatively treated patients (31 h vs 15 h, p<0.001). For patients with a history of a single previous abdominal/pelvic operation, the likelihood of surgical intervention was higher compared to patients whom resolution was achieved with conservative measures (50.9% vs 38.5%). In patients with three or more previous operations SBO resolved more often with conservative treatment compared to patients who required surgical intervention (22.7% vs 11.4%; p<0.001).

Conclusion

The significantly higher rate of SBO resolution in the CM group suggests that CM may have a therapeutic role in SBO treatment, especially when it is administered within 12 h of admission. Patients with longer duration of symptoms and a history of one previous abdominal surgery need more likely surgical treatment.

An Unusual Small Bowel Phytobezoar Successfully Resolved by Double-balloon Enteroscopy

We herein report a very unusual case of small bowel obstruction caused by phytobezoar in a 69-year-old woman who consumed a large amount of bracken. The patient presented with nausea and vomiting. Computed tomography revealed an air-filled foreign body in the jejunum that had likely caused the small bowel obstruction. A fibrous foreign body diagnosed as a phytobezoar was detected using double-balloon enteroscopy. The obstruction was successfully resolved by crushing the phytobezoar repeatedly using a snare. Small bowel obstructions caused by phytobezoars are often treated with surgical interventions. However, endoscopic fragmentation using a snare is a minimally invasive treatment alternative.