Unusual causes of small-bowel obstruction

From Blocking Shots to Blocking GI Transit, This Professional Basketball Player Does It All: A Case Report on Small Bowel Obstruction

Small bowel obstructions (SBO) are a commonly encountered diagnosis within emergency departments. Typically, these patients have evident risk factors including, but not limited to, prior abdominal surgery, personal or family history of gastrointestinal disorders, femoral and inguinal hernias, or neoplasm. In this case, we describe an SBO in a female, professional athlete whose swift, severe symptom onset, rapid resolution with conservative treatment, lack of identifiable risk factors, and prompt return to high level competition without recurrence are certainly unique. A female professional basketball player in her mid-20's with no past medical history presented with a seven-hour history of worsening abdominal pain beginning in the epigastric region and migrating to the right lower quadrant. Physical exam did not reveal abdominal distension, tympany to percussion, or high-pitched bowel sounds. Initial differential diagnosis included appendicitis, ruptured ectopic pregnancy, and other genitourinary pathology. Computed tomography with contrast revealed distended loops of small bowel with wall thickening, enhancement, and decompressed loops of bowel distally, consistent with an SBO. Symptoms resolved after 24 hours with conservative treatment, including decompression with a nasogastric tube. The athlete returned to full participation five days after initial presentation without recurrence of symptoms. Outpatient gastroenterology workup was negative for predisposing conditions. This presentation is rare in the absence of bowel pathology, family history, or prior abdominal surgery. Perhaps, her profession as an athlete, with frequent air travel and extensive exercise, may have contributed to this unique presentation. This case report should serve as a reminder to all providers that SBOs can occur in young, active patients devoid of risk factors. Even in the absence of typical signs on physical examination, providers should use imaging as adjuncts based on their clinical gestalt and utilize conservative management, when appropriate, to maximize chances of recovery with minimal morbidity.

Peach pit impaction presenting as gallstone ileus

Small bowel obstruction (SBO) secondary to fruit pit impaction is rare. The presence of an ovoid, stony body in the bowel lumen on radiologic imaging in a patient presenting with signs and symptoms of SBO is likely to raise concern for gallstone ileus. We report the case of a 56-year-old man who presented with a 1-day history of intermittent left-sided abdominal pain and nausea associated with a single episode of vomiting. CT scan of the abdomen and pelvis revealed a 3.3 cm impacted stony mass in the terminal ileum resulting in high-grade partial SBO. The mass had a hypodense centre encased within a hyperdense, ridged outer layer. The diagnostic impression was gallstone ileus. The object was removed via enterotomy and was found to be a peach pit.

Praxagoras of Cos (4th Century BC) and His Innovative Method of a Diverting Enterocutaneous Fistula to Relieve Small Bowel Obstruction

Born in an island with huge medical tradition in ancient Greece, Praxagoras of Cos became an esteemed medico-philosopher and surgeon. The evolution made by the Hippocratic School of Medicine further boosted his talent and helped him perform surgical operations, which were believed impossible for his era. Praxagoras introduced an innovative surgical technique to confront small bowel obstruction, by creating an enterocutaneous fistula. This historical review connects all available data to present the life and work of an important medical figure of the ancient Hellenic School.

A rare case of small bowel obstruction secondary to activated charcoal administration

Intestinal obstruction is a rare complication of the administration of activated charcoal. We describe a 22-year-old patient who had received multiple-dose activated charcoal for carbamazepine intoxication. The patient presented with sudden-onset abdominal pain after discharge from the emergency room, and abdominal imaging examinations revealed findings consistent with small bowel obstruction. Laparoscopic-assisted exploration of the abdomen was offered, and a hard obstructing charcoal mass was found in the small bowel. Clinicians should be aware of the rare occurrence of gastrointestinal complication or obstruction following the administration of multiple-dose activated charcoal, especially in patients who ingested a drug that is potentially antiperistaltic.

Obstructive ileus caused by metal staples 6 years after the initial surgery: A case report

RATIONALE

Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands installed after a surgical procedure. However, SBO caused by surgical staples used in a previous operation is unusual. Herein, we report a rare case of adhesive ileus induced by surgical staples.

PATIENT'S CONCERNS

A 58-year-old woman visited our Emergency Department with right lower quadrant (RLQ) pain and vomiting. The patient had undergone laparoscopic total hysterectomy with the Endo GIA stapler for uterine myoma 6 years prior.

DIAGNOSES

Computed tomography (CT) revealed a closed-loop obstruction with volvulus involving the distal ileum.

INTERVENTIONS

After suspected failure of conservative therapy with fluid resuscitation and Levin tube decompression, emergency laparoscopic surgery was performed. A fibrous band around the surgical staples considered to have been used in a previous operation was observed which extended to the greater omentum, through which a segment of the bowel formed a closed-loop obstruction around the right ovary.

OUTCOMES

The patient's symptoms resolved and a follow-up on post-operative day 14 showed no symptoms.

LESSONS

Surgeons using surgical staples should be aware that adhesion may occur when the staples are exposed to the abdominal cavity, which can lead to the risk of SBO several years after surgery. Thus, staples should not be exposed to the abdominal cavity, or anti-adherent substances should be used to minimize the possibility of such complications.

Small bowel obstruction caused by vas deferens: a first documented report

Small bowel obstruction (SBO) is one of the most common causes for an acute surgical admission. Most of the time SBO is a result of common causes such as postoperative adhesions. However, rare and unusual causes of SBO do exist which can be challenging for surgeons. We report a first documented case of SBO caused by a remnant of the vas deferens in a 24-year-old patient with a history of gastroschisis and left orchidectomy. Clinical presentation, investigations, imaging and management of this case are described. To summarise, clinicians should keep an open mind in dealing with patients with intestinal obstruction due to the rare and atypical causes.

When a cure becomes the pathology: mechanical bowel obstruction due to herbal pharmacobezoar. A case report with review of literature

Bezoars are intra-luminal concretions of ingested material which accumulate within the bowel. They are termed pharmacobezoars when the constituent material is drugs. We report a 64-year-old female with abdominal pain and obstipation for 3 days. Patient had completed anti-tuberculous combination therapy for suspected abdominal tuberculosis 25 years ago. She exhibited features of shock with a right iliac fossa lump. Abdominal X-ray displayed multiple air-fluid levels with densely cluttered radio-opacities in the right lower quadrant. Laparotomy revealed a palpable mid-ileal intra-luminal lump, adherent to the ascending colon and proximal ileum necessitating resection. Ex vivo examination of resected specimen revealed numerous tablets aggregating proximal to an ileal stricture. The patient post-operatively confirmed the tablets resembled the herbal laxatives she had been consuming. Pharmacobezoars can lead to subacute intestinal obstruction. Numerous drugs have been implicated. Patients with partial gastrectomy and vagotomy are at risk. CT is the pre-eminent diagnostic modality. The treatment options for pharmacobezoars include lavage, endoscopic retrieval, in addition to surgery. Pharmacobezoars need a high index of suspicion for pre-operative diagnosis. A detailed history and correlation with radioimaging can offer important cues. One can prevent pharmacobezoars by abstaining from unwarranted medications and identifying those at risk.

Food ileus secondary to citrus fruit associated with a Meckel's diverticulum: a case report and review of the literature

The case of an 11-year-old boy with an orange-associated ileus in the setting of a mesodiverticular band from a Meckel’s diverticulum is reported herein. Computed tomography showed a small bowel feces sign. He underwent laparoscopic-assisted surgery, and intraoperative findings revealed a Meckel’s diverticulum associated with a mesodiverticular band distal to dilated small bowel. After resection of the Meckel’s diverticulum and inspection of the intestinal contents proximal to the obstruction, it was apparent that undigested food material was impacted proximal to the obstruction. Upon questioning postoperatively, it was revealed that the patient ate two citrus fruits with locular membranes several days prior to his clinical presentation. It was speculated that the combination of the citrus fruit impaction with the Meckel’s band led to his obstruction. He was discharged uneventfully on postoperative Day 13. It is important to avoid eating large quantities of fruit rich in fiber and also to masticate well.

Intestinal obstruction caused by a strangulating adnexa: a rare complication of ovarian sparing hysterectomy

Intestinal obstruction caused by a remnant fallopian tube from previous hysterectomy is a rare entity that has been reported once in the literature. We report the case of a 61-year-old woman who presented with both small and large bowel obstructions caused by a strangulating remnant fallopian tube. She had an ovarian sparing hysterectomy 16 years ago and was diagnosed with antiphospholipid syndrome. Our case report will discuss the clinical presentation, imaging and outcome of the patient. It will also briefly tackle other rare causes of bowel obstruction.

Osteoid bezoar: a rare case causing small bowel obstruction

Acute intestinal obstruction due to foreign bodies or bezoar is a rare occurrence in an adult. We report an unusual case of a 27-year-old male patient with no previous history of abdominal surgery or other medical disease, who presented with an acute episode of intestinal obstruction due to ingestion of a bone piece which was managed surgically by enterotomy, and the patient had an uneventful postoperative course. He was advised regular follow-up once in 2 weeks initially and once a month subsequently. He had no problems at the end of 6 months.

[Volvulus of the small bowel due to ascaris lumbricoides package: about a case]

Nous rapportons un cas exceptionnel de volvulus nécrosé de l'intestin grêle dû à des ascaris adultes chez un enfant de 7 ans. A l'admission, l'enfant présentait le tableau d'occlusion intestinale qui évoluait depuis deux jours avec altération de l'état général. La radiographie de l'abdomen sans préparation retrouvait des niveaux hydroaériques de type grêlique et un aspect tigré évoquant le diagnostic d'une occlusion intestinale haute sur masse abdominale. Après la réanimation, le traitement chirurgical consistait en une laparotomie qui avait retrouvé un volvulus nécrosé de l'iléon terminale contenant des ascaris adultes. Une résection du grêle sur environ un mètre emportant le segment nécrosé suivie d'une iléostomie était réalisée. L'évolution a été favorable, l'anastomose iléo-colique fut réalisée quatre semaines plus tard. Au recul de deux ans l'enfant est indemne de tout symptôme.

Ingested Sharp Bone Fragment: An Unusual Cause of Acute Bowel Obstruction- Case Report

Acute bowel obstruction due to ingested foreign body (FB) like sharp bone fragment is a rare entity. As preoperative diagnosis was uncertain due to lack of proper history, diagnosis is usually done intraoperatively. Even though it is rare, we should consider it as differential diagnosis in patients with recent dietary history. Herein, we are reporting a 38-year-old man, without any psychiatric illness or previous surgery presenting to emergency department with the features of acute bowel obstruction. CT scan shows high density object in ileum suspicious of foreign body. Patient underwent exploratory laparatomy which reveals dilated small bowel with sharp bony object in ileum, which was retrieved with enterotomy.

Repeated Small Bowel Obstruction Caused by Chestnut Ingestion without the Formation of Phytobezoars

A small number of cases of small bowel obstruction caused by foods without the formation of phytobezoars have been reported. Repeated small bowel obstruction due to the ingestion of the same food is extremely rare. We present the case of 63-year-old woman who developed small bowel obstruction twice due to the ingestion of chestnuts without the formation of phytobezoars. This is the first reported case of repeated small bowel obstruction caused by chestnut ingestion. Careful interviews are necessary to determine the meal history of elderly patients and psychiatric patients.

A Comparative Analyses of Granulometry, Mineral Composition and Major and Trace Element Concentrations in Soils Commonly Ingested by Humans

This study compared the granulometric properties, mineralogical composition and concentrations of major and trace element oxides of commonly ingested soils (geophagic soil) collected from different countries with a view of understanding how varied they may be in these properties and to understand the possible health implications of ingesting them. Soil samples were collected from three different countries (South Africa, Swaziland and Democratic Republic of Congo (DRC)) and their granulometric properties, concentrations of major and trace element oxides as well as mineralogical composition determined. Differences were observed in the granulometric properties of geophagic soil from the three different countries with most of them having <20% clay content. The soils also showed varied degrees of weathering with values of Chemical Index of Alteration (CIA) and Chemical Index of Weathering (CIW) being between 60% and 99.9% respectively. The mineral assemblages of the soils from South Africa and Swaziland were dominated by the primary minerals quartz and feldspar whereas soils from DRC had more of kaolinite, a secondary mineral than primary minerals. Soils from DRC were associated with silt, clay, Al₂O₃, and CIA unlike most samples from South Africa which were associated with SiO₂, sand, K₂O, CaO, and MgO. The soils from Swaziland were closely associated with silt, H₂O and Fe₂O₃(t). These associations reflect the mineralogy of the samples. These soils are not likely to serve as nutrient supplements because of the low concentrations of the nutrient elements contained. The coarse texture of the samples may also result in dental destruction during mastication. Sieving of the soils before ingestion to remove coarse particles is recommended to reduce the potential health threat associated with the ingestion of coarse-textured soils.

Intestinal obstruction in a mentally retarded patient due to pica

A 40-year-old mentally retarded Japanese man was admitted at rehabilitation facility for handicapped persons and found dead in his bed. His neonatal period was complicated by seizures, and he had a medical history of schizophrenia. A postmortem computed tomography scan suggested an intestinal obstruction, but the cause was unknown. To clarify the cause of death, a medicolegal autopsy was carried out. The gastrointestinal tract was found to contain copious amounts of cloth pieces. A diagnosis of intestinal obstruction secondary to pica of clothes was made. Despite still being an essentially neglect condition; mental retardation is cause to significant burden to the patient, his relatives and caregivers and the whole society. Moreover, people with mental retardation may be at increased risk for potentially self-injury due to ingestion of non-eating substance or incongruent intake of eating substances, which may on turn lead to severe or even life-threatening medical and surgical complications as herein reported. Specific attention also to pica in mentally-retarded patients with sudden, severe, gastrointestinal events, should therefore be placed in order to prevent potential death or otherwise severe chronic consequences, ideally aiming at enhancing the early recognition and multi-disciplinary management of those psychological stressors or triggers potentially responsible for pica too.

Bowel hath no fury like a gallbladder inflamed

Gallstone ileus is a well-established phenomenon in which a large gallstone leads to mechanical small bowel obstruction. This case, however, reports the novel finding of a patient presenting with suprapubic pain and guarding caused by paralytic ileus of the small bowel and a duodenal perforation secondary to a necrotic gallbladder. It highlights the importance of distinguishing between gallstone ileus and paralytic ileus and how the management of the two conditions differs. Furthermore, this article discusses how paralytic ileus caused by intra-abdominal inflammatory conditions such as cholecystitis can mask the typical clinical findings making the diagnosis difficult.

Influence of physico-chemistry and mineralogy on the occurrence of geohelminths in geophagic soils from selected communities in the Eastern Cape, South Africa, and their possible implication on human health

Geophagic soils from selected communities in Eastern Cape, South Africa were characterised to determine their properties and geohelminth content. The soils were coarse-textured with cation exchange capacity values ranging from 6.35 to 18.94 cmol (+)/kg. Quartz was the dominant mineral in the samples with SiO2, Al2O3, and Fe2O3(t) having the highest concentrations among major element oxides. The soil properties, mineralogical composition, and low amounts of particle binding substances may favour the survival of geohelminth ova in the soils. Seven of the samples contained at least one of the following geohelminths: Ascaris lumbricoides, Trichuris trichiura, Necator americanus, Ancylostoma duodenale and Strongyloides stercoralis. The presence of these geohelminths in the soils was attributed to agricultural and sanitary practices inherent in the communities and the soil properties. Communities need to be sensitised on the importance of safe sanitary and animal husbandry practices to reduce the prevalence of helminth infection among geophagists.

Bowel obstruction from wild bananas: a neglected health problem in Laos

We investigated the significance and risk factors of bowel obstruction caused by the consumption of wild bananas (BOWB) in Laos. Of six patients with BOWB in Luang Namtha, North Laos, five required enterotomy for phytobezoars. All had eaten wild banana (WB) seeds.

Of 227 other patients/relatives: 91.2% had eaten WB; 46.3% had also eaten the seeds and 45.4% knew of complications resulting from eating WB; 42.3% were aware of the complications of ingesting the seeds (constipation [37.9%], appendicitis/abdominal pain/vomiting [2.6% each] and bloated stomach/death [1.3% each]). Middle/highland Lao ethnicity was associated with WB and seed consumption (odds ratio [OR] 9.91 and 2.33), male sex with WB consumption and unawareness (OR 4.31 and 1.78).

At all surgically-equipped hospitals in Laos, 33/44 doctors knew of BOWB, describing patients as young adults (16/30), male (24/30) and from middleland Lao (18/30). Countrywide, 46/48 patients with BOWB required laparotomy in 2009 (incidence 0.8/100,000). All consumed WB seeds. BOWB is widespread in Laos, especially among young middleland Lao men consuming WB seeds on an empty stomach.

Bizarre behaviour, bizarre intruder and bizarre bowel obstruction

An 82-year-old woman, with previous history of hiatal hernia, cholecystectomy and depression, has been admitted for worsening diffuse abdominal pain with constipation and vomiting for 4 days. She lived alone, without signs of dementia or cognitive impairment. The abdomen was distended and tender in middle quadrants. Abdominal x-ray revealed concentric distension of bowel loops. CT scan confirmed mechanical small bowel obstruction with a transition point in the right iliac fossa. At laparotomy, the obstruction was caused by an intraluminal mass. After enterotomy, a 5.5 cm large phytobezoar was extracted; immediately after, a small live insect jumped out from the vegetable mass crawling onto the surgical area. The specimen was sent for parasitology and identified as a crustacean isopod, terrestrial arthropod, classified in the phylum Arthropoda, subphylum Crustacea and order Isopoda. They usually live in humid, moist conditions, obtaining their nourishment from decomposing vegetable matter. They often colonise in greenhouse pot plants. No cases of parasitisation in vertebrate species have been reported to date.

Unusually late presentation of lactobezoar leading to necrotising enterocolitis in an extremely low birthweight infant

The present report concerns a case of unusually late presentation of lactobezoar, or inspissated milk curd obstruction, leading to necrotising enterocolitis (NEC) in an extremely low birthweight (ELBW) boy infant, born at 26 weeks gestation with a birth weight of 750 g. He deteriorated acutely on day 84 of postnatal age (corrected age 38 weeks) needing intermittent positive pressure ventilation (IPPV). Over the next 3 days he developed signs of NEC, though a radiograph showed no diagnostic features. In view of increasing abdominal distension, silent abdomen and increasing ventilatory requirements, an emergency exploratory laparotomy was performed. The laparotomy revealed inspissated milk curd obstruction in the terminal ileum. There was also a small area of NEC at the ileocaecal valve. A limited hemicolectomy was performed with creation of an ileostomy and mucous fistula. Following this procedure his clinical status improved. Feeds were reintroduced after 7 days and he was on full enteral feeds by 14 days.

Acute small bowel obstruction due to impacted bone: a case report

A 71-year-old man was admitted with features of intestinal obstruction. His past surgical history included an appendicectomy as a child and three laparotomies. A CT scan of the abdomen revealed a high attenuation foreign body impacted in the distal ileum, associated with small bowel obstruction. At laparotomy, a bone was removed from the terminal ileum.

Ume (Japanese apricot)-induced small bowel obstruction with chronic radiation enteritis

Stricture formation is recognized as one of the complications of chronic radiation enteritis. Here, we present a case of a 73-year-old woman who presented with small bowel obstruction 16 years after pelvic irradiation for uterine cancer. Computed tomographic (CT) scan of the abdomen demonstrated a 1-cm foreign body in the terminal ileum. Laparotomy revealed a stone of ume (Japanese apricot) stuck in an ileal stricture, leading to complete impaction and perforation. She was successfully treated with ileocecal resection and ileocolic anastomosis without any complication. Pathological study revealed that the low compliance caused by fibrosis of the bowel wall prevented the small ume stone from passing through the irradiated ileum. Our case implies the specific risk of food-induced small bowel obstruction in patients with a history of pelvic irradiation.

Multiple jejuno-jejunal fistulae of uncertain origin: a case report

A 43 year-old male patient presented with small bowel obstruction while being treated for cervical tuberculous lymphadenopathy. Laparotomy revealed multiple adhesions and multiple jejuno-jejunal fistulae. Absence of previous abdominal surgery or other abdominal insult favoured an 'idiopathic' origin of these unusual lesions, although treated tuberculosis may have been the underlying cause. To the best of our knowledge this intestinal condition has never previously been reported in the medical literature.

An apricot story: view through a keyhole

BACKGROUND

Very few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy.

CASE PRESENTATION

A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy.

DISCUSSION

Small bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods.

CONCLUSION

Generally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach.

A videolaparoscopia no diagnóstico e tratamento da obstrução intestinal

A obstrução intestinal constitui complicação freqüente, de etiologia multifatorial, apresentação clínica variável e alta morbidade. Uma vez esgotados os recursos conservadores em casos específicos, a laparotomia exploradora é empregada para o diagnóstico final e tratamento em grande número de pacientes. Apesar do sucesso da via laparoscópica no manuseio de diversas afecções, a utilização desta via na abordagem inicial da obstrução do intestino delgado tem sido bastante limitada e alvo de numerosas críticas. Entretanto, o acúmulo de experiência com o método nos últimos anos, aliado ao avanço tecnológico e instrumental, têm permitido tratar número cada vez maior de pacientes obstruídos por meio do acesso laparoscópico. Assim, o surgimento de novos instrumentos como grampeadores laparoscópicos, pinças e trocáteres menos traumáticos ajudaram a tornar a videolaparoscopia factível e segura nestes pacientes. Neste artigo, os autores apresentam uma revisão sobre o papel da vídeo-cirurgia em casos selecionados de obstrução intestinal, ressaltando a contribuição dos métodos minimamente invasivos para o arsenal diagnóstico e terapêutico desta importante complicação.

Small bowel obstruction caused by snail's shell: radiographic and CT findings

We report a case of small bowel obstruction in a 74-year-old woman presenting with abdominal pain due to the accidental swallowing of a snail shell. A diagnosis of obstruction was made by abdominal radiograph, and its etiology was found after abdominal CT was performed. This is an unusual case of small bowel obstruction due to a foreign body that was preoperatively diagnosed with imaging.