Imaging of Uncommon Causes of Large-Bowel Obstruction

Bowel obstruction: signs indicating the need for urgent surgery

Bowel obstruction is common in emergency departments. Obstruction is more common in the small bowel than in the large bowel. The most common cause is postsurgical adhesions. Nowadays, bowel obstruction is diagnosed with multidetector computed tomography (MDCT). MDCT studies for suspected bowel obstruction should focus on four points that need to be mentioned in the report: confirming the obstruction, determining whether there is a single transition point or whether the obstruction is found in a closed loop, establishing the cause of the obstruction, and seeking signs of complications. Identifying signs of ischemia is important in the management of the patient because it enables patients at higher risk of poor outcomes after conservation treatment who could benefit from early surgical intervention to avoid greater morbidity and mortality associated with strangulation and ischemia of the obstructed bowel loop.

Cecal perforations due to descending colon obstruction (closed loop): a case report and review of the literature

BACKGROUND

Cases of large bowel closed-loop phenomenon with cecal perforation are extremely rare, especially when extracolonic epiploic appendage and peritoneal bands are the cause. However, sporadic cases exist in the literature with various presentations, but very few occur in patients in the abdomen without a previous scar.

CASE PRESENTATION

An 89-year-old Sudanese farmer was admitted to the emergency department with 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. Given his clinical presentation and assessment, he was diagnosed with peritonitis due to a perforated viscus in a virgin abdomen. Operative exploration revealed an extraluminal left-sided omento-epiploic band that resulted in closed-loop colonic obstruction with secondary multiple cecal perforations. Standard right hemicolectomy with adhesiolysis was done. Postoperative wound infection and hypoalbuminemia were treated, and the patient was discharged on postoperative day 9 on a regular oral diet.

CONCLUSIONS

Although this condition is rare, it can be extremely dangerous, requiring prompt investigation and surgical intervention. It usually occurs secondary to raised intraluminal pressure with subsequent ischemia of the cecal wall. Through this case report, we aim to reflect on this rare experience, shedding light on the benign, extracolonic pathologies that can be life threatening or even fatal.

Large-bowel obstruction secondary to Enterobius vermicularis pseudotumour

Enterobius vermicularis infection is typically observed in paediatric patients and manifests with perianal pruritus, but other manifestations or ectopic presentations have been reported in the literature. We present the case of a man in his 60ss with a large-bowel obstruction with symptoms including a 4-day history of progressive abdominal pain, distension, vomiting and absolute constipation. On examination, his abdomen was distended with tinkling bowel sounds on auscultation. Cross-sectional imaging demonstrated an obstructing mass in the distal descending colon. An emergency laparoscopic Hartmann's procedure was performed and the patient made an uneventful recovery. An intraoperative colonoscopy demonstrated numerous white threadworms in the colon. Histological analysis demonstrated a pseudotumour related to Enterobius vermicularis infection. This case represents a rare differential diagnosis for a large-bowel obstruction.

Overview of the Large Bowel Assessment Using Magnetic Resonance Imaging: Different Techniques for Current and Emerging Clinical Applications

Radiological assessments of the small and large bowel are essential in daily clinical practice. Over plain film X-ray and ultrasound, cross-sectional techniques are considered the most comprehensive imaging modalities. In fact, computed tomography and magnetic resonance imaging take great advantage of the three-dimensional appraisal and the extensive evaluation of the abdominal cavity, allowing intestinal evaluation as well as detection of extra-intestinal findings. In this context, the chief advantage of computed tomography is the fast scan time, which is crucial for emergency cases. Nonetheless, it is undeniably impaired using ionizing radiation. As the awareness of radiation exposure is a topic of increasing importance, magnetic resonance imaging is not only becoming a mere alternative but also a primary imaging technique used in assessing intestinal diseases. Specifically, the evaluation of the large bowel through MRI can be still considered relatively uncharted territory. Although it has demonstrated superior accuracy in the assessment of some clinical entities from inflammatory bowel disease to rectal carcinoma, its role needs to be consolidated in many other conditions. Moreover, different technical methods can be applied for colonic evaluation depending on the specific disease and segment involved. This article aims to provide a thorough overview of the techniques that can be utilized in the evaluation of the large bowel and a discussion on the major findings in different colonic pathologies of primary interest.

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

Diagnosis and Management of Colonic Volvulus

An 88-year-old man with no significant medical history, and in a good state of health, presented to the emergency department with 4 days of obstipation, progressive abdominal pain, and bloating. Examination revealed abdominal distension and generalized tenderness without signs of peritonitis. Laboratory values, including lactate and complete blood count, were within normal limits. Computed tomography imaging of the abdomen and pelvis revealed radiological signs of sigmoid volvulus and no evidence of bowel perforation (Fig. 1). Flexible sigmoidoscopic examination revealed no evidence of mucosal ischemia and enabled detorsion of the colon. The patient's symptoms resolved after the detorsion. He was seen in consultation by a surgeon who advised surgical treatment only if the volvulus recurred. After hospital discharge, the patient self-educated about sigmoid volvulus and sought a second surgical opinion. Five weeks after his initial presentation and 1 week after complete colonoscopy, he underwent laparoscopic sigmoidectomy with colorectal anastomosis. His postoperative course was uneventful. At 6-month follow-up, he remained well with no bowel-related concerns.