Mechanical obstruction of the small bowel and colon

The Role of Procalcitonin in Predicting Failure of Non-operative Management in Bowel Obstructions

Procalcitonin has been investigated as a marker for bowel ischemia. This study examined the role of procalcitonin in predicting failure of non-operative management (NOM) in bowel obstructions. Patients with bowel obstructions at a single center from August 2022 to January 2023 were prospectively enrolled (n = 79). Lactic acid (LA) and procalcitonin were collected after surgical consultation. The primary outcome was success or failure of NOM. Univariate analysis, multivariable logistic regression, and performance measures of procalcitonin and LA in predicting bowel ischemia was performed. Of 79 patients included, 48 (61%) required operative intervention during index admission. There were no significant differences in demographics, comorbidities, procalcitonin, nor LA between groups. Time from last bowel movement was associated with failure of NOM (OR 1.03 [95% CI 1.01-1.06]; P = .008), though initial procalcitonin or LA was not. Procalcitonin >.3 ng/mL had acceptable sensitivity in screening for bowel ischemia.

Bowel Obstruction as the Initial Presentation of Urothelial Carcinoma

Bowel obstructions are one of the main causes of hospital admissions for acute abdominal pain. In addition, bladder cancer is one of the most common cancers in the world. This said, bowel obstruction and bladder cancer are very frequent diseases but the same cannot be said about the association between these two pathologies. We report a unique case of an 80-year-old patient admitted to the emergency room with a bowel obstruction caused by a urothelial carcinoma with adrenal metastasis. The patient underwent an urgent laparotomy, and intraoperative inspection of the peritoneal cavity confirmed a large tumorous mass suspected of gastrointestinal etiology. The mass infiltrated the ileum and sigmoid colon and was apparently in contact with the bladder wall. An en-bloc resection of the lesion was performed. An R0 excison was not possible and fragments of the lesion were excised from the bladder wall for separate analysis. Histopathological examination of the resected specimen described a high-grade, undifferentiated urothelial carcinoma that originated in the bladder and invaded the ileum and sigmoid colon. The presence of an invasive urothelial carcinoma presenting with bowel obstruction represents an unexpected diagnosis and, although rare, the surgeon must be aware of this possibility. This case should serve as a reminder that a broad differential diagnosis should be considered when investigating an abdominal tumor.

Evaluation of clinical profiles, surgical experience and outcomes of ileosigmoid knotting in low-resource setup: A retrospective cohort study at Jimma University Medical Center

BACKGROUND

Bowel obstruction is a mechanical or functional blockade of intestinal contents from evacuation to the adjacent distal bowel or external environment. It poses significant morbidity and mortality in both high-income and low-to-middle-income countries. Ileosigmoid knotting is a special form of obstruction where the small bowel often ileum wraps around the sigmoid colon or vice versa. It is the severest form of bowel obstruction, involving both the small and large bowels in a compound manner. It is common where sigmoid volvulus is common and geographic areas with a bulky diet.

METHODS

An institution-based retrospective cohort study was employed among purposively selected 40 surgical patients with ileosigmoid knotting records from July 2020 to July 2023 at Jimma University Medical Center. To estimate and compare the survival probabilities, the Kaplan-Meir method and log-rank test were used. A Cox-regression analysis was fitted to identify independent predictors of time to death.

RESULTS

Among a cohort of 40 patients followed for 347 person-days at Jimma University Medical Center, 11 (27.5%) had died. The overall incidence rate of death was 3.2 (95% CI 1.8, 5.7) per 100 person-days. In multivariable Cox-regression analysis, age (AHR = 1.15; 95% CI: 1.04-1.28), shock at presentation (AHR = 30.50: 95% CI 1.25-742.54), comorbidities (AHR = 5.81; 95% CI 1.19-28.23), pulse rate intraoperatively (AHR = 1.19; 95% CI: 1.01-1.40), postoperative pulse rate (AHR = 1.07; 95% CI: 1.01-1.14) were independently associated with time to death.

CONCLUSION

The incidence of death among surgical patients with ileosigmoid knotting was high and also had a shorter median survival time. Age, shock at presentation, comorbidities, pulse rate intraoperatively, and postoperative pulse rate were found to be statistically significant predictors of time to death and outcome among surgical patients with Ileosigmoid knotting.

Metastatic Urothelial Cancer Presenting as Small Bowel Obstruction: A Case Report

Neoplasms are among the common causes of small bowel obstruction (SBO). Metastatic disease is the most common cause of neoplastic SBO and is most commonly the result of colon, ovarian, pancreatic, and gastric neoplasms. Metastatic SBO secondary to metastatic urothelial carcinoma is exceedingly rare, with only a few cases described in the literature. It is important for physicians to be aware of urothelial carcinoma as a potential etiology of SBO.

Malignant Acute Colonic Obstruction: Multidisciplinary Approach for Endoscopic Management

Patients presenting with acute colonic obstruction are usually evaluated in the emergency department and multiple specialties are involved in the patients' management. Pre-treatment evaluation is essential in order to establish the correct endoscopic indication for stent implantation. Contrast-enhanced imaging could allow the exclusion of benign causes of colonic obstruction and evaluation of the length of malignant stricture. Endoscopic stenting is the gold standard of treatment for palliative indications whereas there are still concerns about its use as a bridge to surgery. Different meta-analyses showed that stenting as a bridge to surgery improves short-term surgical outcomes but has no role in improving long-term outcomes. Multidisciplinary evaluation is also essential in patients that may be started on or are currently receiving antiangiogenic agents because endoscopic stenting may increase the risk of perforation. Evidence in the literature is weak and based on retrospective data. Here we report on how to correctly evaluate a patient with acute colonic malignant obstruction in collaboration with other essential specialists including a radiologist, surgeon and oncologist, and how to optimize the technique of endoscopic stenting.

Outcomes for sigmoid volvulus managed with and without early definitive surgery: 20-year experience in a tertiary referral centre

BACKGROUND

Sigmoid volvulus is rare in Western countries. Patients at risk of sigmoid volvulus are often older with significant co-morbidity. Without sigmoid colectomy there is a high recurrence rate, but indications for surgery are controversial.

METHODS

A retrospective observational study was conducted by reviewing clinical records of patients admitted to Waikato Hospital 1 January 2000 to 1 January 2020 with a diagnosis of sigmoid volvulus. Patient characteristics, clinical features, investigations, management, and outcomes were recorded.

RESULTS

One hundred and thirty-two patients (87 male) were included with 203 volvulus episodes. Median age 76 years, median Charlson co-morbidity index (CCI) 4. Median follow-up 11 years. 44/132 (33.3%) had surgery during the index admission, two had elective surgery and the remainder had planned non-operative management. 73/132 (55.3%) had surgery at any stage. 42/86 (48.8%) patients managed non-operatively recurred; 66.7% of recurrences were within 6 months. Forty-three (32.6%) died within 12 months of index admission; 28 (21.2%) died during an admission for volvulus. On univariate analysis higher age and abnormal vital signs were associated with inpatient and 12-month mortality; higher CCI was associated with 12-month mortality. On multi-variate analysis increasing age in years was associated with increased risk of death (HR 1.089 [1.052-1.128, P < 0.001]). Normal vital signs at presentation were associated with decreased risk of death (HR 0.147 [0.065-0.334, P < 0.001]).

CONCLUSION

Sigmoid colectomy should be considered at index presentation with sigmoid volvulus. Half of patients managed non-operatively recurred, with two-thirds recurring within 6 months. The mortality rate remains high for subsequent volvulus episodes.

Colonic stent as a bridge to surgery versus emergency rection for malignant left-sided colorectal obstruction: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The role of self-expanding metal stent (SEMS) implantation as a bridge to surgery in malignant left-sided colorectal obstruction (MLCO) remains controversial.

OBJECTIVE

To evaluate the safety of SEMS implantation versus emergency surgery (ER) in the treatment of MLCO.

METHODS

Four major literature databases (Cochrane Library, Embase, PubMed, and Web of Science) were searched to collect articles published before April 20, 2023. After determining random or fixed-effect models based on heterogeneity tests, odds ratios (RR) or standardized mean differences (SMD) with their respective 95% confidence intervals (CI) were calculated.

RESULTS

Nineteen randomized controlled studies were included. The main outcomes included overall tumor recurrence rate, 30-day mortality rate, and overall incidence of complications. Secondary outcomes included mortality-related indicators, tumor recurrence-related indicators, surgery-related indicators, and other relevant indicators. The study found that there was no significant difference in the 30-day mortality rate between the SEMS group and the er group. However, the SEMS group had a lower overall incidence of complications (RR = 0.787, P = .004), lower incision infection rate (RR = 0.472, P = .003), shorter operation time (SMD = -0.591, P = .000), lower intraoperative blood loss (SMD = -1.046, P = .000), lower intraoperative transfusion rate (RR = 0.624, P = .021), lower permanent stoma rate (RR = 0.499, P = .000), lower overall stoma rate (RR = 0.520,P = .000), shorter hospital stay (SMD = -0.643, P = .014), and more lymph node dissections during surgery (SMD = 0.222, 95% CI: 0.021-0.423, P = .031), as well as a higher primary anastomosis rate (RR = 0.472, 95% CI: 0.286-0.7 77, P = .003), among other advantages. However, the SEMS group had a higher overall tumor recurrence rate (RR = 1.339, P = .048).

CONCLUSION

SEMS has significant advantages over er in relieving clinical symptoms and facilitating postoperative recovery in MLCO, but does not reduce the tumor recurrence rate. Neoadjuvant chemotherapy combined with SEMS may provide a new approach to the treatment of MLCO.

Does the use of computed tomography scenogram alone enable diagnosis in cases of bowel obstruction?

BACKGROUND

Ileus is a pathological condition of the abdomen that presents as a medical emergency. It is characterized by potential complications such as perforation and ischemia, which can lead to significant morbidity and mortality if not promptly addressed. The successful management of ileus relies heavily on the timely and precise identification of the condition. While conventional radiography (CR) is commonly used as the primary diagnostic tool, its accuracy in identifying obstructions ranges from 46% to 80%. Furthermore, the diagnostic accuracy of identifying the location and etiology of intestinal obstruction by CR is limited, therefore making computed tomography (CT) the ideal imaging modality in this regard.

AIM

To determine the presence of acute bowel obstruction (BO) on abdominal CT scenogram images and the accuracy of determining its possible location, taking into account the experience of the observers.

METHODS

A retrospective screening was conducted on an ensemble of 46 individuals who presented to the emergency department between January 2021 and January 2022 with severe abdominal pain and were subsequently monitored for suspected ileus. The abdominal CT scans of these patients were assessed by three radiologists with varying levels of experience (1, 3, and 10 years) at different intervals (1 mo apart). The evaluation focused on determining the presence or absence of BO, as well as identifying the potential location of the obstruction (small bowel or large bowel). The study employed Kappa statistics to assess inter-observer variances, while the McNamer test was used to evaluate obstruction and segmentation discrepancies between observations. A significance level of P < 0.05 was determined to indicate statistical significance.

RESULTS

Out of the total sample size of 46 patients, 15 individuals (32.6%) were identified as female, while the remaining 31 individuals (67.4%) were identified as male. The ultimate diagnosis of 42 instances (91.3%) indicated ileus resulting from mechanical obstruction (MO). Among these patients, 14 (33%) experienced obstruction in the large bowel (LB), while 28 (66%) experienced obstruction in the small bowel (SB). The initial evaluation yielded sensitivity rates of 76.19%, 83.31%, and 83.33%, and diagnostic accuracy rates of 69.56%, 76.08%, and 80.43% for the detection of BO among the three observers. The initial study revealed that the average sensitivity of three observers in detecting the presence of ileus caused by MO was 80.94%, while the diagnostic accuracy was 75.35%. Based on the first evaluation, the senior observer demonstrated the highest sensitivity (85.71%), negative predictive value (92.60%), and diagnostic accuracy (80.43%) when accurately estimating the thick and thin segmentation, as per the final diagnosis. There was no statistically significant disparity observed in the sensitivities pertaining to the identification of ileus during the second assessment, as well as the precise determination of the segment level inside the LB or SB, when comparing the second and third observers. Nevertheless, although there was no statistically significant alteration in the detection rate of ileus by the first observer, there was a notable rise in the accuracy rate of segment estimating (73.91%). The senior assessor had a higher level of accuracy in assessing the existence of ileus and segmentation compared to the other evaluators in both evaluations.

CONCLUSION

The findings of our study indicate that the sensitivity and accuracy rates of abdominal CT scenogram scans in diagnosing acute MOs are similar to or greater than those of CR. Additionally, the study revealed that radiologists with more experience demonstrated a higher likelihood of accurately predicting the existence and potential localization of MO compared to their less experienced counterparts.

Endometriosis as an Uncommon Cause of Intestinal Obstruction-A Comprehensive Literature Review

The prevalence of intestinal endometriosis has been estimated to be between 3% and 37% of all endometriosis cases. Cases of intestinal occlusion due to endometriosis foci on the small bowel and on the large bowel are even rarer, with a reported prevalence of 0.1-0.7%. The aim of this literature review was to summarize the available published evidence on the diagnosis, characteristics, and management of intestinal occlusion due to endometriosis. The search on PubMed retrieved 295 records, of which 158 were rejected following a review of the title and abstract. After reviewing the full text, 97 studies met the Population, Intervention, Comparator, Outcomes, and Study (PICOS) criteria and were included in the analysis. The total number of patients with bowel occlusion due to endometriosis included in the studies was 107. The occlusive endometrial foci were localized on the ileum in 38.3% of the cases, on the rectosigmoid in 34.5% of the cases, at the ileocecal junction and the appendix in 14.9% of the cases, and at the rectum in 10.2% of the cases. Only one case reported large bowel obstruction by endometriosis of the hepatic flexure of the colon extending to the transverse colon (0.9%), and in one case the obstruction was caused by an omental giant endometrioid cyst compressing the intestines. We identified six cases of postmenopausal females with acute bowel obstruction due to endometriosis. Malignant degeneration of endometriosis was also identified as a cause of intestinal occlusion. The mechanisms of obstruction include the presence of a mass in the lumen of the intestine or in the wall of the intestine, extrinsic compression, adhesions, or intussusception.

Global, regional, and national burden of intestinal obstruction from 1990 to 2019: an analysis from the Global Burden of Disease Study 2019

BACKGROUND

Intestinal obstruction (IO) is a common surgical acute abdominal condition that places a significant burden on modern health systems. Unfortunately, the global burden and trends of IO remain unknown. Therefore, this study aimed to comprehensively assess its long-term trends and epidemiological features, which will help policymakers to formulate appropriate health policies.

METHODS

We conducted an ecological study using data from the Global Burden of Disease Study (GBD) 2019. Data on IO were analyzed by sex, age, year, sociodemographic index (SDI), and location according to GBD 2019. In addition, joinpoint regression analysis was used to assess temporal trends. Age-period-cohort analysis (APC Analysis) was conducted to evaluate age, period, and birth cohort effects on IO incidence and mortality risk.

RESULTS

Globally, the prevalent and incident cases increased by 56.91% and 86.67% from 1990 to 2019, respectively. Joinpoint regression analysis showed that age-standardized incidence rate (ASIR) and age-standardized prevalence rate (ASPR) increased, but age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life year (DALY) rate decreased over the past three decades. The age effect demonstrated that older people have a higher risk of morbidity and mortality. The period effect of incidence and mortality showed an upward trend from 1990 to 2019. Cohort effect revealed that the incidence and death risk peaked in the earlier-born cohort and was lower in the more recent-born cohort. Notably, we found that the burden of IO was higher in males than in females throughout the study period. There are huge disparities in IO burden among countries.

CONCLUSION

Globally, the reported incidence and prevalence of IO increased from 1990 to 2019. The burden of IO differed markedly by age, sex, country, and region. Middle-aged and elderly people over 50 years old were at high risk. Given the ageing population, the burden of IO will be a major public health challenge. Thus, there is a strong necessity to strengthen prevention and early intervention in the at-risk population.

Gallstone Enteropathy: An Unusual Cause of Bowel Obstruction

Gallstones causing bowel obstruction, known as gallstone ileus, are rare and account for less than 0.5% of small bowel obstruction cases. Additionally, it is a rare complication affecting only 0.3% of patients who have gallstones. Fistula formation between the biliary system, most commonly between the gallbladder and duodenum because of their proximity, facilitates the migration of gallstones into the enteric system with subsequent impaction in the small intestine, usually in the distal ileum close to the ileocecal valve, promoting the development of mechanical small bowel obstruction. Computerized tomography of the abdomen and pelvis is a confirmatory and widely used imaging study when there are two signs of Rigler's triad, which includes pneumobilia, evidence of small bowel obstruction and the presence of radiopaque stones. We report a case of a 75-year-old Caucasian man who presented with abdominal distention with signs of severe dehydration secondary to intractable nausea and vomiting complicated with severe acute kidney injury and was found to have a 4.7-centimeter gallstone-induced small intestinal obstruction.

Comprehensive Diagnosis and Management of Malignant Bowel Obstruction: A Review

Malignant bowel obstruction is a common complication of advanced gastrointestinal, gynecologic, and genitourinary tumors. Patients present with nausea, vomiting, abdominal pain, and constipation. Cross-sectional imaging is essential to make a diagnosis of bowel obstruction. Initial management is conservative with fluid replacement, electrolyte replacement, bowel rest and sometimes nasogastric decompression. Numerous advanced options exist for definitive management, though none are overly promising but nevertheless may improve quality and quantity of life. Surgical bypass, endoscopic stenting, and endoscopic decompression are some of the options with variable efficacy and are employed in select patients. Chemotherapy may be utilized if the bowel obstruction resolves to reduce tumor burden in a limited number of patients. Parenteral nutrition is an option and should typically be used in surgical patients with good functional and nutritional status with limited tumor burden or curative intent. Palliative care and hospice should be discussed in patients with advanced malignancy who present with peritoneal carcinomatosis or multiple levels of obstruction. Overall prognosis of malignant bowel obstruction is poor, and median survival ranges from 26 to 192 days.

Retroperitoneal Aortoaortic Bypass for Treatment of Aortoduodenal Syndrome

Aortoduodenal syndrome is a rare clinical entity characterized by extrinsic compression of the duodenum by an abdominal aortic aneurysm. The current surgical standard involves open aneurysm repair in a transperitoneal fashion. We describe a case of a 69-year-old man diagnosed with this syndrome who underwent successful repair using a retroperitoneal approach. The postoperative outcomes included early initiation of an oral diet, improved nutritional status, and a shorter hospital stay. We also describe the rationale leading to our decision and advocate the use of retroperitoneal surgery as the standard of care for patients presenting with aortoduodenal syndrome.

Practicing Digital Gastroenterology through Phonoenterography Leveraging Artificial Intelligence: Future Perspectives Using Microwave Systems

Production of bowel sounds, established in the 1900s, has limited application in existing patient-care regimes and diagnostic modalities. We review the physiology of bowel sound production, the developments in recording technologies and the clinical application in various scenarios, to understand the potential of a bowel sound recording and analysis device-the phonoenterogram in future gastroenterological practice. Bowel sound production depends on but is not entirely limited to the type of food consumed, amount of air ingested and the type of intestinal contractions. Recording technologies for extraction and analysis of these include the wavelet-based filtering, autoregressive moving average model, multivariate empirical mode decompression, radial basis function network, two-dimensional positional mapping, neural network model and acoustic biosensor technique. Prior studies evaluate the application of bowel sounds in conditions such as intestinal obstruction, acute appendicitis, large bowel disorders such as inflammatory bowel disease and bowel polyps, ascites, post-operative ileus, sepsis, irritable bowel syndrome, diabetes mellitus, neurodegenerative disorders such as Parkinson's disease and neonatal conditions such as hypertrophic pyloric stenosis. Recording and analysis of bowel sounds using artificial intelligence is crucial for creating an accessible, inexpensive and safe device with a broad range of clinical applications. Microwave-based digital phonoenterography has huge potential for impacting GI practice and patient care.

Piezo2 mediates visceral mechanosensation: A new therapeutic target for gut pain?

Mechanical distension/stretch in the colon provokes visceral hypersensitivity and pain. In this issue of Neuron, Xie et al. report that mechanosensitive Piezo2 channels, expressed by TRPV1-lineage nociceptors, are involved in visceral mechanical nociception and hypersensitivity.

Piezo2 channels expressed by colon-innervating TRPV1-lineage neurons mediate visceral mechanical hypersensitivity

Inflammatory and functional gastrointestinal disorders such as irritable bowel syndrome (IBS) and obstructive bowel disorder (OBD) underlie the most prevalent forms of visceral pain. Although visceral pain can be generally provoked by mechanical distension/stretch, the mechanisms that underlie visceral mechanosensitivity in colon-innervating visceral afferents remain elusive. Here, we show that virally mediated ablation of colon-innervating TRPV1-expressing nociceptors markedly reduces colorectal distention (CRD)-evoked visceromotor response (VMR) in mice. Selective ablation of the stretch-activated Piezo2 channels from TRPV1 lineage neurons substantially reduces mechanically evoked visceral afferent action potential firing and CRD-induced VMR under physiological conditions, as well as in mouse models of zymosan-induced IBS and partial colon obstruction (PCO). Collectively, our results demonstrate that mechanosensitive Piezo2 channels expressed by TRPV1-lineage nociceptors powerfully contribute to visceral mechanosensitivity and nociception under physiological conditions and visceral hypersensitivity under pathological conditions in mice, uncovering potential therapeutic targets for the treatment of visceral pain.

Intestinal occlusion due to Burkitt lymphoma: an unusual cause

We present the case of a 37-year-old Caucasian woman, with no history of interest, who came to the emergency room for an occlusive condition of 24 hours' evolution. The patient reported a weight loss of 12 kg in the last month, as well as the appearance of a lump in the left breast in the last week. A chest-abdominal CT scan revealed multiple solid-appearing nodules in the left breast, a metastatic liver lesion, and a tumor-like mass in the right iliac fossa measuring 90x60 mm. A biopsy of the breast lesion revealed a diffuse architectural pattern with destruction of the parenchyma and irregular medium-large cellularity with intense and diffuse expression of CD20, CD10 and Bcl6 and a proliferative index of practically 100%, consistent with lymphoma. Burkitt stage IV. Intestinal obstruction constitutes about 15% of hospital admissions for abdominal pain, representing a significant cause of hospital mortality. Although the most common causes of small bowel obstruction are benign (adhesions, hernias), intraluminal lesions such as inflammatory bowel disease or neoplasms are well-established causes associated with this clinical picture. Lymphomas constitute 25% of cases of intestinal obstruction of neoplastic origin; among them, Burkitt lymphoma is a rare type of B-cell lymphoma characterized by rapid and aggressive cell growth, the most common initial involvement of which is located at the abdominal and extra-nodal level.

Application of acupuncture in the emergency department for patients with ileus: A pilot prospective cohort clinical study

Acupuncture can be conveniently used for pain control in patients with a variety of conditions, and it has obvious effects on various acute pains. In 2018, we implemented a program for emergency treatment with Chinese medicine to promote the integration of Chinese and Western medicine at the Emergency Department (ED). Ileus is a common cause of abdominal pain among patients in the ED, and it is an indication for emergency treatment with Chinese medicine. This study investigated the efficacy of acupuncture as a traditional Chinese medicine (TCM)-based treatment method for the treatment of patients with ileus in the ED. We analyzed data of patients with ileus, who visited ED between January and December 2019, and compared the length of ED stay between the Western medicine group and the Western medicine plus acupuncture group. Furthermore, pain intensity was measured by a visual analogue scale before and after acupuncture. We found that the length of ED stay was 10.8 hours lesser in the Western medicine plus acupuncture group than in the Western medicine group (P = .04), and the visual analogue scale score decreased by 2.0 on average from before to after acupuncture treatment (P = .02). Acupuncture treatment was effective and rapid in relieving the symptoms and discomfort in patients with ileus and in reducing their length of stay in the ED.

Isolated Ascending Colon Gangrene With Persistent Ascending Mesocolon: A Case Report

Persistent mesocolon is a rare embryological anomaly that occurs when the primitive dorsal mesocolon fails to fuse with the posterior lateral parietal peritoneum allowing for volvulus of the cecum and colon. In malrotation of the gut, the normal rotation of the embryonic gut is arrested or disturbed during in-utero development.

To our knowledge, this is the first case of isolated colon gangrene with persistent ascending mesocolon to be reported, although earlier studies have documented cases of persistent mesocolon of both ascending and descending mesocolon. This case had signs of acute intestinal obstruction and peritonitis, and preoperative imaging was suggestive of sigmoid volvulus. Explorative laparotomy revealed a hugely dilated and gangrenous ascending colon; the fixed part of the small intestine was found in the subhepatic space, and the hepatic flexure was at a level below the transpyloric plane in the midclavicular line. Findings were suggestive of isolated colon gangrene with persistent ascending mesocolon and malrotation of the gut. Right hemicolectomy with terminal ileostomy was performed and postoperative follow-up showed no complications.

For a young patient with no prior co-morbidities, a volvulus of ascending mesocolon diagnosis was deemed unlikely because ascending colon is a retroperitoneal organ. The medial position of ascending mesocolon and small bowel loops to the right side was a crucial intra-operative clue for diagnosis. Such cases are difficult to diagnose pre-operatively through imaging alone, hence explorative laparotomy becomes necessary. Intra-operative findings led to performing a right hemicolectomy and ileostomy to relieve the obstruction. Therefore, among other congenital reasons for intestinal obstruction, surgeons should consider persistent mesocolon and volvulus as differential diagnoses when evaluating young patients. Emergent surgery is the only approach to address this.

Mechanisms of lymphoid depletion in bowel obstruction

Background and aims: Bowel obstruction (BO) causes not only gastrointestinal dysfunctions but also systemic responses such as sepsis, infections, and immune impairments. The mechanisms involved are not well understood. In this study, we tested the hypothesis that BO leads to lymphoid depletion in primary and peripheral lymphoid organs, which may contribute to systemic responses. We also sought to uncover mechanisms of lymphoid depletion in BO. Methods: Partial colon obstruction was induced with a band in the distal colon of Sprague-Dawley rats, and wild-type and osteopontin knockout (OPN^-/-) mice. Obstruction was maintained for 7 days in rats and 4 days in mice. Thymus, bone marrow, spleen, and mesenteric lymph node (MLN) were taken for flow cytometry analysis. Results: The weight of thymus, spleen, and MLN was significantly decreased in BO rats, compared to sham. B and T lymphopoiesis in the bone marrow and thymus was suppressed, and numbers of lymphocytes, CD4⁺, and CD8⁺ T cells in the spleen and MLN were all decreased in BO. Depletion of gut microbiota blocked BO-associated lymphopenia in the MLN. Corticosterone antagonism partially attenuated BO-associated reduction of lymphocytes in the thymus and bone marrow. Plasma OPN levels and OPN expression in the distended colon were increased in BO. Deletion of the OPN gene did not affect splenic lymphopenia, but attenuated suppression of lymphopoiesis in the bone marrow and thymus in BO. Conclusions: BO suppresses lymphocyte generation and maintenance in lymphoid organs. Mechanical distention-induced OPN, corticosterone, and gut microbiota are involved in the immune phenotype in BO.

Point-of-Care Abdominal Ultrasonography (POCUS) on the Way to the Right and Rapid Diagnosis

Point-of-Care ultrasound (POCUS) is based on target ultrasound that is performed wherever a patient is being treated, and by a non-radiologist directly involved in the patient’s care. It is used either for quick diagnosis or procedural guidance. Abdominal pain is one of the most common complaints in emergency departments, and POCUS can help in the differentiation of patients who need additional diagnostic tests or hospital treatment, which eventually reduces the overall costs of health care. POCUS has high sensitivity and specificity in abdominal pathology, it can be helpful in the evaluation of biliary, intestinal, and urinary tract, and it is especially used in trauma. Additionally, the gold standard for abdominal aortic aneurysm detection, follow up and screening is precisely this diagnostic procedure. Unfortunately, the quality of ultrasound examination can be affected by the experience of the physician performing it and the patient’s body weight. There is no doubt that POCUS is being increasingly recognized, but all motivated physicians should be provided with dedicated tutors and enough time for learning. This would certainly help to implement this diagnostic method as a routine in emergency and critical care departments, and significantly shorten the time until definitive diagnosis.

Surgical Resection of Metastatic Malignant Small Bowel Obstruction

Small bowel cancer is a rare cause of small bowel obstruction (SBO) that is often discovered too late, leading to a poor prognosis at diagnosis. This case describes an African American patient with a previous history of abdominal surgery who presented to the emergency department with a partial small bowel obstruction (PSBO) that failed to resolve with conservative measures, therefore requiring surgical intervention. An exploratory laparoscopy revealed a firm apple core mass obstructing the lumen of the proximal jejunum 20 cm from the ligament of Treitz. The involved portion of the small bowel was resected with wide margins and sent to pathology. The small bowel was reconstructed by a functional end-to-end anastomosis, and the patient was admitted for observation until the return of bowel function. The pathology report, returned four weeks after the patient's discharge, reported metastatic adenocarcinoma originating from the small intestine. The patient was referred to oncology for further management of his metastatic cancer. Small bowel cancer, although rare, should always be part of the differential diagnosis in the case of small bowel obstruction. If cancer is suspected during exploratory surgery, the entire peritoneal cavity should be explored, and oncologic bowel resection should be performed with adequate margins. Final staging then occurs in the postoperative period.

Point-of-care ultrasound-first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure

OBJECTIVES

Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point-of-care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS-first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS).

METHODS

We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS-first approach for SBO. The model assumes that all patients who require surgery or have non-diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved.

RESULTS

A POCUS-first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths.

CONCLUSIONS

If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.

Prognostic Value of Water-Soluble Contrast Challenge for Nonadhesive Small Bowel Obstruction

BACKGROUND

There is little evidence supporting the use of a water-soluble contrast challenge (WSCC) for conservative management of nonadhesive small bowel obstruction (NASBO). Our objective was to evaluate the prognostic value of the WSCC in a diverse group of patients with NASBO in comparison with patients with adhesive small bowel obstruction (ASBO).

STUDY DESIGN

Retrospective chart review of patients with ASBO or NASBO who underwent a WSCC during a 4-year time period was performed. The primary study endpoint was any intervention for small bowel obstruction during the initial admission or within 30 days of discharge.

RESULTS

A total of 106 patients were included, 53 with ASBO (mean age 64 ± 13 years [SD]; 55% women) and 53 with NASBO (mean age 59 ± 13 years [SD]; 57% women). A higher rate of interventions during admission or within 30 days of discharge was seen in patients with NASBO compared with ASBO (24/53 [45%] vs 12/53 [23%]; p = 0.01), including those with colonic transit times of less than 36 hours (14/41 [34%] vs 5/43 [12%]; p = 0.01). Using multivariate analysis, transit time greater than 36 hours remained an independent predictor of an intervention during admission or within 30 days of discharge (p < 0.001, odds ratio 19.0), after controlling for the type of small bowel obstruction.

CONCLUSIONS

A majority of patients with NASBO were successfully managed conservatively during a 30-day period, supporting the use of WSCC in patients with NASBO; however, patients with NASBO had a higher rate of interventions during admission or within 30 days of discharge.

Non-toxic Megacolon Secondary to High-Grade Large-Bowel Obstruction

A 92-year-old male presented from an outside hospital for treatment of a chronic obstructive pulmonary disease exacerbation (COPD) and subsequently developed worsening abdominal distention with pain during the course of his hospitalization. He was found to have a high-grade large-bowel obstruction with a dilated colon of 20 cm measuring upward. The patient ultimately underwent a hemicolectomy to prevent bowel ischemia and reformation of another volvulus. We present this case to elucidate the need for vigilant monitoring in patients with chronic bowel obstruction due to lack of typical symptoms, to demonstrate a successful management approach, and to exhibit an extreme example of the resulting megacolon.

Surgical treatment of mechanical bowel obstruction: characteristics and outcomes of geriatric patients compared to a younger cohort

PURPOSE

Mechanical bowel obstruction (MBO) is one of the most common indications for emergency surgery. Recent research justifies the method of attempting 3-5 days of nonoperative treatment before surgery. However, little is known about specific characteristics of geriatric patients undergoing surgery compared to a younger cohort. We aimed to analyze patients with MBO that required surgery, depending on their age, to identify potential targets for use in the reduction in complications and mortality in the elderly.

METHODS

Thirty-day and in-hospital mortality were determined as primary outcome. We retrospectively identified all patients who underwent surgery for MBO at the University Hospital of Bonn between 2009 and 2019 and divided them into non-geriatric (40-74 years, n = 224) and geriatric (≥ 75 years, n = 88) patients, using the chi-squared-test and Mann-Whitney U test for statistical analysis.

RESULTS

We found that geriatric patients had higher 30-day and in-hospital mortality rates than non-geriatric patients. As secondary outcome, we found that they experienced a longer length of stay (LOS) and higher complication rates than non-geriatric patients. Geriatric patients who suffered from large bowel obstruction (LBO) had a higher rate of bowel resection, stoma creation, and a higher 30-day mortality rate. The time from admission to surgery was not shown to be crucial for the outcome of (geriatric) patients.

CONCLUSION

Geriatric patients suffering from mechanical bowel obstruction that had to undergo surgery had higher mortality and morbidity than non-geriatric patients. Especially in regard to geriatric patients, clinicians should treat patients in a risk-adapted rather than time-adapted manner, and conditions should be optimized before surgery.

Predictors of mortality in patients with acute small-bowel perforation transferred to ICU after emergency surgery: a single-centre retrospective cohort study

Background

Although small-bowel perforation is a life-threatening emergency even after immediate surgical intervention, studies have rarely investigated surgical outcomes due to its relatively low incidence. This study aimed to investigate the outcomes of emergency surgery for patients with small-bowel perforation transferred to the intensive care unit (ICU) and the risk factors for mortality.

Methods

Consecutive patients with small-bowel perforation who were confirmed via emergency surgery and transferred to the ICU in Zhongshan Hospital, Fudan University (Shanghai, China) between February 2011 and May 2020 were retrospectively analysed. Medical records were reviewed to determine clinical features, laboratory indicators, surgical findings, and pathology.

Results

A total of 104 patients were included in this study, among whom 18 (17.3%), 59 (56.7%), and 27 (26.0%) underwent perforation repair, segmental resection with primary anastomosis, and small-bowel ostomy, respectively. Malignant tumours were the leading cause of perforation in these patients (40.4%, 42/104). The overall post-operative complication rate and mortality rates were 74.0% (77/104) and 19.2% (20/104), respectively. Malignant tumour-related perforation (odds ratio [OR], 4.659; 95% confidence interval [CI], 1.269–17.105; P = 0.020) and high post-operative arterial blood-lactate level (OR, 1.479; 95% CI, 1.027–2.131; P = 0.036) were identified as independent risk factors for post-operative mortality in patients with small-bowel perforation transferred to the ICU.

Conclusions

Patients with small-bowel perforation who are transferred to the ICU after emergency surgery face a high risk of post-operative complications and mortality. Moreover, those patients with malignant tumour-related perforation and higher post-operative blood-lactate levels have poor prognosis.

Targeting Mechano-Transcription Process as Therapeutic Intervention in Gastrointestinal Disorders

Mechano-transcription is a process whereby mechanical stress alters gene expression. The gastrointestinal (GI) tract is composed of a series of hollow organs, often encountered by transient or persistent mechanical stress. Recent studies have revealed that persistent mechanical stress is present in obstructive, functional, and inflammatory disorders and alters gene transcription in these conditions. Mechano-transcription of inflammatory molecules, pain mediators, pro-fibrotic and growth factors has been shown to play a key role in the development of motility dysfunction, visceral hypersensitivity, inflammation, and fibrosis in the gut. In particular, mechanical stress-induced cyclooxygenase-2 (COX-2) and certain pro-inflammatory mediators in gut smooth muscle cells are responsible for motility dysfunction and inflammatory process. Mechano-transcription of pain mediators such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) may lead to visceral hypersensitivity. Emerging evidence suggests that mechanical stress in the gut also leads to up-regulation of certain proliferative and pro-fibrotic mediators such as connective tissue growth factor (CTGF) and osteopontin (OPN), which may contribute to fibrostenotic Crohn's disease. In this review, we will discuss the pathophysiological significance of mechanical stress-induced expression of pro-inflammatory molecules, pain mediators, pro-fibrotic and growth factors in obstructive, inflammatory, and functional bowel disorders. We will also evaluate potential therapeutic targets of mechano-transcription process for the management of these disorders.

Incidence and mortality results of intestinal obstruction in geriatric and adult patients: 10 years retrospective analysis

Objectives

People with ileus is one of the patient groups with the highest admission rates to the emergency departments. In this study, it was aimed to determine the effects of age groups and etiological factors on mortality when evaluated together with gender.

Material and Methods

In our study, patients who were consulted from the Emergency Service to the General Surgery department with a pre-diagno- sis of abdominal pain between 2009 and 2020 were retrospectively screened. Patients hospitalized for ileus were analyzed in terms of age (18-65 years and over 65 years), gender, operation, etiology, incidence, and mortality.

Results

Between 2009 and 2020, 534 (3.03%) of 17.601 patients who received emergency consultation from the general surgery clinic were diagnosed with ileus. While 253 (47.4%) of the patients were operated, 317 (59.4%) patients and 101 (18.9%) patients were diagnosed with brid and malignancy, respectively; and 21 (3.9%) patients died in the complete patient group (Table 1). While the incidence of brid was high in non-operated patients, in operated patients, malignancy and other pathologies was found to be higher (p <0.001) (Table 2). While, in patients 65 years and older, mortality was observed in 10.6% of women and 2.6% of men, it was determined that the mortality rate was higher in women (p= 0.008) (Figure 4).

Conclusion

The mortality rate in patients hospitalized with the diagnosis of mechanical bowel obstruction was found to be statistically significantly higher in female patients aged 65 and over.

Outcomes of management of intestinal obstruction at an urban tertiary hospital in sub Saharan Africa: a cross-sectional study

Background

Intestinal obstruction (IO) is a common cause of acute abdomen globally, it remains challenging as it increases surgical financial expenditure while also causing major morbidity. Clinically it presents with nausea, vomiting, colicky abdominal pain and cessation of bowel movements or passage flatus and stool. Diagnosis, especially in resource limited settings, can be clinical but is usually confirmed radiologically. We studied the current diagnosis, management and outcomes of IO in Mulago Hospital.

Materials and methods

This was a prospective study done at all the surgical units of Mulago from January to May 2014 to assess general diagnosis and management of IO. Ethical approval was got in line with Helsinki declaration, we used pretested and validated questionnaires to collect data. Informed consent was got with eligible and consenting/assenting patients that fitted the inclusion criteria of age and presenting with suspected intestinal obstruction. Uni-variate and bi-variate variables analysis was done plus measures of association.

Results

We enrolled 135 patients, excluded 25 and recruited 110 patient. We had more males than females i.e. 71.8% males and 28.2% females. Colicky abdominal pain, abdominal distension, and vomiting were commonest symptoms, then abdominal distension, increased bowel sounds and abdominal tenderness were the commonest signs. Most patients’ (51%) were diagnosed radiologically with a lesser number clinically diagnosed. “Dilated bowel loops” was the commonest radiological sign. Surgery was the main stay of management at 72.7% while 27.3% were conservatively managed. Postoperatively the bowels opened averagely on the 3rd post-operative day (POD) with return of bowel sounds occurring on 5th POD. Most discharges (73%) occurred by the 7th POD. Unfavourable outcomes were prolonged hospital stay followed by wound sepsis (surgical site infection) and then Mortality.

Conclusion

This study noted that In Mulago we mostly diagnosed patients radiologically with most surgically managed and which is similar to regional practices. Postoperatively bowel opening happening on third POD with return of bowel sounds on fifth POD. Prolonged hospital stay followed by wound sepsis and then mortality were commonest unfavorable management outcomes.

Malignant Large Bowel Obstruction

Large bowel obstruction is a serious and potentially life-threatening surgical emergency which is associated with high morbidity and mortality rate. The most common etiology is colorectal cancer which accounts for over 60% of all large bowel obstructions. Proper assessment, thoughtful decision-making and prompt treatment is necessary to decrease the high morbidity and mortality which is associated with this entity. Knowledge of the key elements regarding the presentation of a patient with a large bowel obstruction will help the surgeon in formulating an appropriate treatment plan for the patient. Comprehensive knowledge and understanding of the various treatment options available is necessary when caring for these patients. This chapter will review the presentation of patients with malignant large bowel obstruction, discuss the various diagnostic modalities available, as well as discuss treatment options and the various clinical scenarios in which they are most appropriately utilized.

Computed Tomography in Emergency Diagnosis and Management Considerations of Small Bowel Obstruction for Surgical vs. Non-surgical Approach

BACKGROUND

Small bowel obstruction (SBO) accounts for 15% of abdominal pain complaints referred to emergency departments and imposes significant financial burdens on the healthcare system. The absence of passage of flatus or stool and abdominal distention are reported as the most common symptom and a sign of SBO, respectively. Patients who do not demonstrate severe clinical or imaging findings are typically treated with conservative approaches. Patients with clinical signs of sepsis or physical findings of peritonitis are often instantly transferred to the operating room without supplementary imaging assessment. However, in cases where symptoms are non-specific, or the physical examination is challenging, such as in cases with loss of consciousness, the diagnosis can be complicated. This paper discusses the key findings detectable on Computed tomography (CT), which are vital for the emergent triage, proper treatment, and decision making in patients with speculated SBO.

METHOD

Narrative review of the literature.

RESULTS AND CONCLUSION

CT plays a key role in emergent triage, proper treatment, and decision making. It provides high sensitivity, specificity, and accuracy in the detection of early-stage obstruction and acute intestinal vascular compromise. It can also differentiate between various etiologies of this entity which is considered an important criterion in the triage of patients into surgical vs. non-surgical treatment. There are multiple CT findings, such as mesenteric edema, lack of the small-bowel feces, bowel wall thickening, fat stranding in the mesentery, and intraperitoneal fluid, which are predictive of urgent surgical exploration.

Radiation risk issues in recurrent imaging

Millions of patients benefit from medical imaging every single day. However, we have entered an unprecedented era in imaging practices wherein 1 out of 125 patients can be exposed to effective dose >50 mSv from a single CT exam and 3 out of 10,000 patients undergoing CT exams could potentially receive cumulative effective doses > 100 mSv in a single day. Recurrent imaging with CT, fluoroscopically guided interventions, and hybrid imaging modalities such as positron emission tomography/computed tomography (PET/CT) is more prevalent today than ever before. Presently, we do not know the cumulative doses that patients may be receiving across all imaging modalities combined. Furthermore, patients with diseases with longer life expectancies are being exposed to high doses of radiation enabling radiation effects to manifest over a longer time period. The emphasis in the past on improving justification of imaging and optimization of technique and practice has proved useful. While that must continue, the current situation requires imaging device manufacturers to urgently develop imaging technologies that are safer for patients as high doses have been observed in patients where imaging has been justified through clinical decision-support and optimized by keeping doses below the national benchmark doses. There is a need to have a critical look at the fundamental principles of radiation protection as cumulative doses are likely to increase in the coming years.

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

Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usually acute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through a systematic review and critical analysis of the available evidence, and summarises the essential intra-operative steps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.

Ultrasound of Small Bowel Obstruction: A Pictorial Review

Small bowel obstruction (SBO) is a common condition requiring urgent attention that may involve surgical treatment. Imaging is essential for the diagnosis and characterization of SBO because the clinical presentation and results of laboratory tests may be nonspecific. Ultrasound is an excellent initial imaging modality for assisting physicians in the rapid and accurate diagnosis of a variety of pathologies to expedite management. In the case of SBO diagnosis, ultrasound has an overall sensitivity of 92% (95% CI: 89–95%) and specificity of 93% (95% CI: 85–97%); the aim of this review is to examine the criteria for the diagnosis of SBO by ultrasound, which can be divided into diagnostic and staging criteria. The diagnostic criteria include the presence of dilated loops and abnormal peristalsis, while the staging criteria are represented by parietal and valvulae conniventes alterations and by the presence of free extraluminal fluid. Ultrasound has reasonably high accuracy compared to computed tomography (CT) scanning and may substantially decrease the time to diagnosis; moreover, ultrasound is also widely used in the monitoring and follow-up of patients undergoing conservative treatment, allowing the assessment of loop distension and the resumption of peristalsis.

Incorporation of a Poly-ε-Caprolactone Scaffold in a ;Circular Stapled End-To-End Small Intestine Anastomosis Does Not Have Any Adverse Effects Within 30 days: A Study in Piglets

Background. Incorporation of a poly-ε-caprolactone (PCL) scaffold in circular stapled anastomoses has been shown to increase the anastomotic tensile strength on postoperative day (POD) 5 in a pig model. The aim of this study was to investigate the effects of incorporation of a PCL scaffold in a circular stapled end-to-end small intestine anastomosis, with stricture formation and anastomotic histology as primary outcomes in a 30-day observation period. Methods. A total of 15 piglets were included. In each piglet, three circular stapled end-to-end anastomoses were made in the small intestines. Two were interventional and one was a control. On POD 10, 20, or 30, the anastomoses were subjected to in vivo intraluminal contrast study, and the index for anastomotic lumen was calculated. The anastomotic segment was resected and subjected to a tensile strength test and histological examination. Results. At POD 10, the mean ± SD value for anastomotic index was .749 ± .065 in control anastomoses and .637 ± .051 in interventional anastomosis (P = .0046), at POD 20, .541 ± .150 and .724 ± .07 (P = .051), and at POD 30, .645 ± .103 and .686 ± .057 (P = .341), respectively. No significant difference was observed in maximum tensile strength and histology at POD 30. Conclusions. The incorporation of a PCL scaffold in a circular stapled end-to-end small intestine anastomosis does not increase the risk of stricture or impair wound healing after 30 days.

A Rare Case of Small Bowel Obstruction Secondary to Pelvic Inflammatory Disease

Small bowel obstruction (SBO) secondary to pelvic inflammatory disease (PID) is a rare complication only reported on a few occasions. We presented a 38-year-old female with an acute abdomen secondary to PID diagnosed via CT and MRI abdomen. The patient was treated in a conservative manner and recovered with no further complications. In our case, the learning point is the consideration of such an etiology in women with no previous surgical history presenting with an acute abdomen.

Hematemesis Secondary to Complex Incarcerated Pantaloon Hernia

Hematemesis with concomitant small bowel obstruction is an uncommon emergency department presentation. We report the case of a patient who presented with hematemesis and an incarcerated pantaloon hernia. While the patient initially had intact bowel movements and flatus, he eventually developed complete obstruction that required open surgical repair. In a patient with an incarcerated hernia and a history of recurrent small bowel obstruction, predicting strangulation or compromised bowel and the need for rapid surgical intervention can be difficult. Hematemesis concurrent with hernia incarceration may be suggestive of impending complete bowel obstruction and ischemia.

Diagnostic accuracy of ultrasound for small bowel obstruction: A systematic review and meta-analysis

PURPOSE

Accurate diagnosis of small bowel obstruction (SBO) remains challenging. The evidence of the diagnostic accuracy of ultrasound varies among studies, with reporting sensitivity ranging from 82 % to 100 % and specificity ranging from 54 % to 100 %. The aim of our study is to perform a systematic review and meta-analysis to investigate the accuracy of ultrasound for diagnosing SBO.

METHOD

The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were searched from database inception to March 2020. Randomized controlled trials, quasi randomized studies, and prospective or retrospective cohort studies that evaluated the diagnostic performance of ultrasound for the diagnosis of bowel obstruction in adult patients (age ≥ 16 years) were eligible. The QUADAS-2 tool was used to assess the quality of the included studies. The pooled sensitivities, specificities were analyzed using a bivariate random-effects model. (PROSPERO ID: CRD42020170010).

RESULTS

Fifteen studies, with most rating as a moderate risk of bias, met the inclusion criteria. The pooled sensitivity and specificity were 92 % (95 % CI: 89%-95%) and 93 % (95 % CI: 85%-97%), respectively. Subgroup analysis revealed no significant differences in sensitivity when ultrasound was performed on different continents, in different settings, and under different reference standards. However, the specificity was significantly lower when ultrasound was performed in the North America, in the emergency department, and when computed tomography was used as the only reference standard.

CONCLUSIONS

Overall, ultrasound is a highly sensitive and specific tool for the diagnosis of SBO. Using ultrasound to rule in patients with SBO should be used with caution, as variations in the specificity were observed in different study setting, operators from different continents and reference standards used.

Non-operative management of small bowel obstruction in virgin abdomen: a systematic review

The aim of this study was to systematically review the feasibility and safety of non-operative management of small bowel obstruction (SBO) in virgin abdomen. A systematic review was performed through December 2019. The primary outcome was the resolution of non-operative management of SBO in virgin abdomen. Secondary outcomes were the etiology of SBO and findings of exploratory laparotomy. Six studies were included in the analysis. Of the 442 patients, 2 with metastatic cancer received palliative care, and the management in 26 was not reported, so these patients were excluded. A total of 414 patients were ultimately analyzed, including 203 patients (49%) who were managed non-operatively and 211 (51%) who underwent surgical management. Of the 203 managed non-operatively, the condition of 194 (96%) was resolved without further intervention. The remaining 9 (5%) patients failed non-operative management and ultimately required surgery. Of the 211 patients who underwent surgical exploration, only 137 had their intraoperative findings reported. Adhesions (n = 67; 49%) were the main cause, followed by malignancy (n = 14; 10%) and others (n = 33; 24%). No cause was found in 23 patients (17%). In highly select cases of SBO with virgin abdomen, non-operative management can be attempted if patients are clinically stable and computed tomography does not demonstrate concerning features or obvious pathology. Further well-designed prospective studies will be required prior to the introduction of this concept in clinical practice, as current evidence remains heterogeneous.

Comparing Surgical Outcomes Among Patients Admitted for Small Bowel Obstruction on Weekend vs. Weekday

INTRODUCTION

Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively.

MATERIALS AND METHODS

Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables.

RESULTS

2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score (P < .0001) and large hospital size (P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income (P = .0022) and weekend admission (P = .048).

DISCUSSION

There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.

Precision Lactobacillus reuteri therapy attenuates luminal distension-associated visceral hypersensitivity by inducing peripheral opioid receptors in the colon

Luminal distension and abdominal pain are major clinical hallmarks of obstructive bowel disorders and functional bowel disorders linked to gut dysbiosis. Our recent studies found that chronic lumen distension increased visceral sensitivity and decreased abundance of gut commensal Lactobacillus reuteri in a rodent model of partial colon obstruction (OB). To establish causation, we performed precision microbial therapy to assess whether recolonization of L. reuteri prevents visceral hypersensitivity in lumen distension, and if so, to identify the gut-microbiota mechanism. Lumen distension was induced in Sprague-Dawley rats by implanting an OB band in the distal colon for up to 7 days. L. reuteri strains or vehicle were gavage ingested 1 × 10 colony-forming units/g daily starting 2 days before OB. L. reuteri rat strains that were able to recolonize obstructed colon significantly improved food intake and body weight in OB rats, and attenuated referred visceral hyperalgesia measured by the withdrawal response to von Frey filament applications to the abdomen. Mechanistically, L. reuteri treatment attenuated hyperexcitability of the dorsal root ganglia neurons projecting to the distended colon by promoting opioid receptor function in affected tissues. The expression of µ, δ, and κ opioid receptors was significantly downregulated in colonic muscularis externae and sensory neurons in OB rats. However, L. reuteri treatment prevented the loss of opioid receptors. Furthermore, administration of peripheral opioid receptor antagonist naloxone methiodide abolished the analgesic effect of L. reuteri in OB. In conclusion, precision L. reuteri therapy prevents lumen distension-associated visceral hypersensitivity by local bacterial induction of opioid receptors.

Strangulated internal hernia due to defect in broad ligament: a case report

Small bowel obstruction is a relatively common disease process accounting for up to 16 percent of surgical admissions and more than 300,000 operations annually in the United States. Approximately 5–8 percent of small bowel obstructions can be attributed to internal hernias. A slightly lower percentage, roughly 4–7 percent, of these internal hernias are noted to originate from a defect in the broad ligament of the uterus. A majority of broad ligaments defects causing a small bowel obstruction are not diagnosed preoperatively due to the equivocal imaging findings as well as the infrequency of this etiology. To date, there are very few case reports describing this disease process. This case report describes a 70-year-old female who was found to have a defect in her broad ligament causing a small bowel obstruction leading to subsequent strangulated bowel.

PREVALENCE, DISTRIBUTION AND DETERMINANTS OF INTESTINAL TUBERCULOSIS IN ADULT INDOOR PATIENTS WITH ACUTE SMALL INTESTINAL OBSTRUCTION IN POPULATION OF PESHAWAR DIVISION, PAKISTAN

Background: Acute small intestinal obstruction (ASIO) is one of the commonest causes of emergency hospital admissions, morbidity and mortality. Intestinal tuberculosis (ITB) is common cause of ASIO in developing countries leading to significant morbidity and mortality. Our objectives were to determine prevalence, distribution and determinants of ITB in adult indoor patients with ASIO in population of Peshawar Division, Pakistan.Materials Methods: This cross-sectional study was conducted at Department of Surgery Peshawar Medical College, Peshawar, Pakistan from January 2019 to June 2020.  The data was collected from its three affiliated hospitals; Mercy Teaching Hospital, Kuwait Teaching Hospital Prime Teaching Hospital, Peshawar. 207 ASIO subjects were selected from population at risk consecutively. Sex, age groups and presence of ITB were variables. Prevalence and distribution were described by count, percentage and confidence intervals for proportion for population. Hypotheses for distribution were tested by chi-square goodness of fit and of association by chi-square test of association.Results: Out of 207 patients with ASIO, 128 (61.84%) were men and 79 (38.16%) women, 87 (42.03%) were in age group 18-40 and 120 (57.97%) in 41-60 years. Out of 207 patients with ASIO, 41 (19.81%) had ITB, while 166 (80.19%) had no ITB. Out of 41 ITB patients, 25 (12.08%) were men and 16 (7.73%) women, 17 (8.21%) in age group 18-40 and 24 (11.60%) in 41-60 years. The prevalence of ITB was similar to expected (p=.5695). The distribution across sex (p=.00001) was different and across age groups (p=.12501) was similar to expected. Presence of ITB was not associated to sex (p=.8992) and age groups (p=.9347).Conclusion: Prevalence of intestinal TB in adult indoor acute small intestinal obstruction (ASIO) population of Peshawar Division, Pakistan was 19.81%. Prevalence was higher in men than women and higher in 41-60 years than 18-40 years age group population. Overall prevalence of intestinal TB was similar to expected. Observed distribution across sex was different and across age groups was similar to expected. Presence of intestinal TB was not associated to sex and age groups respectively.

Large-bowel obstruction: CT findings, pitfalls, tips and tricks

Large bowel obstruction (LBO) is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. MDCT has become the standard of care to identify the site, severity, and etiology of obstruction. The goal of this review is fourfold. The first objective is to give clues to differentiate LBO from colonic pseudo-obstruction. The second objective is to describe CT features in the most common cause of LBO which is colonic cancer by illustrating classical and atypical features of colonic cancer responsible for LBO and by giving the features which must be reported when differentiating malignant from benign: presence of local lymph nodes, other colic localizations, length of involved segment, presence of diverticula, or other. The third objective is to illustrate the various causes of LBO which can mimic a colon cancer by leading to a thickening of the colonic wall: diverticulitis, ischemic colitis, endometriosis, inflammatory disease and to give tips which permit to evoke another diagnosis than a colon cancer in patient with a LBO and a thickening of the colic wall. The fourth objective is to describe the common signs of cecal and sigmoid volvulus and to give tips for a diagnosis sometimes difficult particularly for cecal volvulus: one of two transition points according to the type of volvulus and the presence of a whirl sign with a torsion of the mesenteric vessels.

Small bowel knots

INTRODUCTION

Intertwining of bowel loops to form a knot is very rare cause of intestinal obstruction. Among intestinal knots, ileoileal knotting is the most rare, with only a handful of cases reported in literature. We present a rare case of ileoileal knotting and review of small bowel knots. The aim of this review was to summarise the existing evidence on small bowel knots and to postulate the possible mechanisms for knotting.

METHODS

A systematic search was conducted for literature published up to December 2019 using MEDLINE, PubMed and Google Scholar databases, together with the references of the full-text articles retrieved. Papers with case reports of small bowel knots were considered to be eligible for inclusion in the review.

FINDINGS

A total of 14 case reports were evaluated. There was no clear predilection for age or sex. Mostly cases were from Asia and Africa with no cases from the West. The presenting complaints were abdominal pain (93%), vomiting (64%), abdominal distention (57 %) and obstipation (43%). The bowel was gangrenous in 78% of cases. All underwent exploration, with the majority requiring resection and anastomosis of the involved segment.

CONCLUSION

Ileoileal knotting is a very rare cause of intestinal obstruction. Possible mechanisms include loaded bowel with longer mesentery, vigorous peristalsis, single bulky meal, pregnancy and intussusception. The condition is extremely difficult to diagnose preoperatively and it is usually diagnosed intraoperatively. The standard of treatment is resection of gangrenous part and anastomosis.