Small Bowel Obstruction Secondary to a Spontaneous Intramural Jejunal Hematoma

N/a.

[Rapunzel syndrome: Radiological diagnosis]

Background

Rapunzel syndrome is a rare presentation of trichobezoar, secondary to the ingestion of hair known as trichophagia. This bezoar has been found mainly in women, it invades the stomach and extends to the small intestine. Clinically, patients present weight loss and chronic obstructive symptoms at the intestinal level. A case of Rapunzel syndrome is presented.

Clinical case

A 13-year-old female presented with a weight loss of 10kg in two months, chronic constipation, predominantly nocturnal vomiting, and abdominal pain of seven days' duration. Physical examination revealed decreased peristalsis and a palpable mass in the epigastrium. Laboratories taken on admission: normal blood count, kidney function tests, and liver function tests. The abdominal X-ray showed opacity in the fundus, body and gastric antrum, the abdominal ultrasound showed non-specific findings in the epigastrium, later an abdominal tomography was performed with a swallow of water-soluble contrast medium and showed occupation in the gastric lumen. She underwent exploratory laparotomy and the finding was a trichobezoar in the stomach with extension to the duodenum and part of the jejunum, which was removed without complications. The evolution of the patient was favorable.

Conclusions

For the diagnosis of Rapunzel Syndrome, the use of contrast imaging studies is necessary, and the treatment of choice is surgical.

Fluoroscopic Stent Placement as a Bridge to Surgery for Malignant Colorectal Obstruction: Short- and Long-Term Outcomes

Purpose

To assess the outcomes of single-stage surgery following fluoroscopic stent placement for malignant colorectal obstruction.

Materials and Methods

This retrospective study included 46 patients (28 male and 18 female; mean age, 67.2 years) who had undergone fluoroscopic stent placement followed by laparoscopic resection (n = 31) or open surgery (n = 15) for malignant colorectal obstruction. The surgical outcomes were analyzed and compared. After a mean follow-up of 38.9 months, the recurrence-free and overall survival were estimated, and prognostic factors were evaluated.

Results

The mean interval between stent placement and surgery was 10.2 days. Primary anastomosis was possible in all patients. The mean postoperative length of hospitalization was 11.0 days. Bowel perforation was detected in six patients (13.0%). During the follow-up, ten patients (21.7%) developed recurrence; these included five of the six patients with bowel perforation. Bowel perforation had a significant effect on recurrence-free survival (p = 0.010).

Conclusion

Single-stage surgery following fluoroscopic stent placement may be effective for treating malignant colorectal obstruction. Stent-related bowel perforation is a significant predictive factor for tumor recurrence.

Brunner's Gland Adenoma-An Uncommon Cause for Intussusception and Gastric Outlet Obstruction

Brunner's gland adenoma is extremely uncommon small bowel tumors with an incidence of <0.01% and account for less than 1% of all gastrointestinal tumors. They are branched acinotubular glands found within the submucosal layer and located between the pyloric ring and the major duodenal papilla. Brunner's glands produce an alkaline secretion containing viscous mucin to protect the duodenum from acidic gastric chyme. Although these lesions are usually asymptomatic and are incidentally discovered on upper gastrointestinal endoscopy, they may occasionally present with symptoms of upper gastrointestinal hemorrhage, duodenal obstruction, and more rarely with biliary fistulation or intussusception. We present an atypical case of a large 9-cm Brunner's gland adenoma causing duodenojejunal intussusception in a 44-year-old Chinese man, who presented with long-standing epigastric pain, nausea, and vomiting.

A Late Presentation of COVID-19 Induced Bowel Ischemia

Introduction

Infection with COVID-19 may lead to extrapulmonary pathologies secondary to the systemic inflammatory effects of the virus.

Case Description

This case report discusses a 55-year-old female patient who presented with small bowel obstruction (SBO) several months after resolution of a COVID-19 infection. The patient was surgically treated with a small bowel resection, and eventually made a full recovery.

Discussion

The pathophysiology of COVID-19-induced SBO can be explained by the prolonged inflammation and coagulation activation in the bowel's vasculature system. Under these circumstances, microthrombosis occurs in the bowel's microvasculature; the affected intestinal tissue becomes ischemic and infarcted. The damaged bowel is eventually replaced with fibrotic scar tissue, thus promoting bowel stricture and subsequent obstruction.

Conclusion

COVID-19 can be responsible for both acute and chronic embolic and thrombotic events in the mesenteric vasculature, which acts as a risk factor in the manifestation of SBO.

[Cecal volvulus: one case and literature review]

BACKGROUND

Cecal volvulus is a rare disease that causes intestinal obstruction. It has various congenital and acquired risk factors. It is frequently associated with abnormal cecal fixation, and it is caused by torsion of the cecum in one of its three axes. It is not different from other causes of intestinal obstruction, but a delay in its diagnosis can lead to ischemia, necrosis and colon perforation. Its management depends on the viability of the tissues, ranging from untwisting and cecopexy to hemicolectomy with or without anastomosis. We present a case of caecal volvulus (caecal bascule) and review the literature as well.

CLINICAL CASE

43-year-old female, who was admitted to an emergency department with data of intestinal obstruction. A simple tomography of the abdomen was performed, where a dilated colon and an image that resembles an inverted coffee bean were identified. An exploratory laparotomy was performed, identifying a bascule-type cecal volvulus, without vascular compromise. Devolvulation, decompression through appendectomy, and caecopexy were performed. After the surgical event, the patient recovered without incident and was discharged with adequate controls by external consultation.

CONCLUSIONS

Cecal volvulus is a cause of intestinal obstruction with a low incidence, which is why early recognition and treatment are key to avoiding the complications that its evolution entails. This type of disease should be among our differential diagnoses, since treatment is surgical and delay leads to a high mortality rate.

Diagnostic Accuracy of Ultrasonography by Emergency Medicine Resident in Detecting Intestinal Obstruction; a Pilot Study

Introduction

There are many ambiguities regarding the application of ultrasound in detection of intestinal obstruction. This study aimed to evaluate the diagnostic accuracy of ultrasound in diagnosis of intestinal obstruction.

Methods

This cross-sectional study was performed on patients with symptoms and signs of bowel obstruction between November 2019 and July 2020 in Shohadaye-Tajrish and Imam Hossein General Hospitals, Tehran, Iran. After a brief explanation and getting verbal consent, the patients underwent ultrasound examination in the emergency department by the emergency medicine resident. The results of ultrasound were compared with the surgical findings as the gold standard.

Results

24 patients with the mean age of 57.50±18.26 (range: 28 - 81) years were studied (58.3% male). Ultrasonography findings revealed the lumen diameter ≥ 2.5 cm in 21 (87.5%) cases, wall thickness ≥ 3 mm in 3 (12.5%) cases and inter-loop free fluid in 3 (12.5%) cases. Sensitivity, positive predictive value, and accuracy of ultrasound in detection of intestinal obstruction were found to be 85.00% (95%CI: 61.13 - 96.03), 80.95% (95%CI: 57.42 - 93.71), and 70.83% (95%CI: 48.91 - 87.38), respectively.

Conclusion

It seems that point-of-care ultrasound has good sensitivity and accuracy in detection of intestinal obstruction when performed in the emergency department by a trained emergency medicine resident.

The Oncological Emergency of Intestinal Obstruction: ED Recognition and Treatment Outcomes

OBJECTIVES

Gastrointestinal complications, like blockage, are among the most common oncological emergencies. We investigated whether individuals with cancer presenting at the emergency department (ED) with intestinal obstruction were triaged accurately, and we further evaluated the triage decisions' effect on their ED treatment outcomes.

DATA SOURCES

A retrospective review was completed on all available records of adult cancer patients who were admitted with intestinal obstruction to a tertiary referral hospital. Over 3 years, 46 cancer patients were admitted from the ED with a provisional diagnosis of intestinal obstruction, confirmed by radiological examination. More than half the patients were undertriaged, which often resulted in these patients experiencing a series of risky time delays in the ED. Patients were significantly delayed in reaching five treatment outcomes: first assessment with a physician, initiation of treatment, decision to admit, length of ED stay, and length of hospital stay.

CONCLUSION

The application of triage in practice was inconsistent, inaccurate, and had a significant negative impact on patient treatment outcomes.

IMPLICATIONS FOR NURSING PRACTICE

The study results indicated the need to critically analyze current triage training and policies to increase their effectiveness. Improvement strategies are identified in the literature, and several are discussed. Involving triage nurses in this work is essential.

Encapsulating peritoneal sclerosis in liver transplant

Encapsulating peritoneal sclerosis occurs due to chronic irritation of the peritoneal surface resulting in inflammation and fibrosis. Encapsulating peritoneal sclerosis usually occurs in patients requiring peritoneal dialysis (PD); however, it may also occur in liver transplant patients. The fibrosis in encapsulating peritoneal sclerosis could be severe enough to cause small bowel obstruction (SBO). Herein, we report a case of encapsulating peritoneal sclerosis secondary to liver transplantation that presented with SBO. The patient was started on Tamoxifen for encapsulating peritoneal sclerosis and evaluated at follow-up without any other intestinal obstruction episodes. This case demonstrates that encapsulating peritoneal sclerosis can occur as a liver transplant complication and present with small bowel obstruction.

Gallstone ileus: a rare type of intestinal obstruction in Ghana

Gallstone ileus is an uncommon cause of intestinal obstruction in Ghana. A patient with gallstone ileus that was diagnosed intra-operatively after being treated conservatively as adhesive small bowel obstruction for ten days is reported to highlight the importance of the clinical information in this condition. A 60-year-old Chinese male with recurrent intestinal obstruction who was initially being managed at a primary healthcare facility was subsequently referred to a tertiary hospital on account of computer tomography diagnosis of an intraluminal object obstructing the bowel. He had hypokalaemia that was corrected before surgery. Intra-operatively, a 4.5cm in diameter gallstone was removed from the terminal ileum. Gallstone ileus is rare in Ghana. A high index of suspicion is required to avoid a delay in diagnosis due to the low incidence of cholelithiasis in Ghana.

Funding

None declared.

Cecal bascule herniation through the foramen of Winslow

Bowel obstructions can have a variety of causes, including impacted feces, adhesions, volvulus, non-internal hernias, and in rare cases internal hernias. We report a 63-year-old woman who presented to the emergency department with severe abdominal pain, nausea, vomiting, and obstructive symptoms that had started 12 hours earlier. A computed tomographic scan of the abdomen and pelvis showed a right internal hernia with a cecal bascule traversing through the foramen of Winslow, concerning for a closed-loop obstruction. The patient underwent an exploratory laparotomy with cecal bascule reduction and cecopexy. Given the increased mortality risk if undiagnosed, it is important to remain aware of internal hernias. Patient outcomes are markedly improved with early diagnosis and surgical intervention.

Network Pharmacology and Bioactive Equivalence Assessment Integrated Strategy Driven Q-markers Discovery for Da-Cheng-Qi Decoction to Attenuate Intestinal Obstruction

BACKGROUND

Intestinal obstruction (IO) is a kind of acute abdomen with high morbidity and mortality. Patients suffer from poor quality of life and tremendous financial pressure. Da-Cheng-Qi decoction (DCQD), a classical purgation prescription, has clinically been proven to be an effective treatment for IO.

PURPOSE

Network pharmacology integrated with bioactive equivalence assessment was used to discover the quality marker (Q-marker) of DCQD against IO.

METHODS

As there is hardly any targets recorded in database, thus the collection of IO targets was conducted by searching those of alternative diseases which have similar pathological symptoms with IO. In order to improve the reliability of the obtained targets, IO metabolomics data was introduced. Active compounds combination (ACC) was focused as potential Q-markers via component-target network analysis and function query from the identified components corresponding to the common targets. Bioequivalence between ACC and DCQD was assessed from the aspects of intestine motility (somatostatin secretion), inflammation (IL-6 secretion) and injury (wound healing assay) in vitro and was further validated in ileus rat model. PPI network analysis of core targets followed by gene pedigree classification and experimental validation confirmed the potential intervention pathway.

RESULTS

A combination of 11 ingredients, including emodin, physcion, aloe-emodin, rhein, chrysophanol, gallic acid, magnolol, honokiol, naringenin, tangeretin, and nobiletin was finally confirmed bioequivalence with DQCD to some extent and could serve as Q-markers for DCQD to attenuate IO. PI3K/AKT was verified as a possible affected pathway that DCQD exerted the effectiveness against IO.

CONCLUSION

For the disease with few recorded targets, searching those of alternative diseases which have similar pathological symptoms could be a feasible and effective approach. The proposed network pharmacology integrated bioactive equivalence evaluation paradigm is efficient to discover Q-marker of herbal formulae.

Small Bowel Obstruction by Broad Ligament Hernia: Three Case Reports, Management and Outcomes

Internal hernias are a rare cause of bowel obstruction (1%) and can be caused by broad ligament defects in 4% to 7% of the cases. These defects may be congenital or acquired and are classified according to its anatomical location. This paper reports three cases of small bowel obstruction by broad ligament hernia. The patients, three women aged from 35 to 51 years old, were admitted to the emergency department with small bowel obstruction. An exploratory laparotomy was performed during which an internal hernia through a broad ligament defect was identified. In all cases the hernia content was reduced and the defect closed. One of the patients required a segmental enterectomy. All patients had a favorable outcome. This paper aims to raise awareness about the broad ligament hernia as a cause of bowel obstruction, namely in middle-aged women with no surgical history.

Incidental diagnosis of breast cancer in the pursuit of the treatment of intestinal obstruction

Intestinal lipomatosis is rare and often asymptomatic but can present with intestinal obstruction. Occasionally, metastatic breast cancer is identified in the ovary before a breast primary is discovered. We report the case of a 50-year-old woman diagnosed with synchronous intestinal obstruction due to lipomatosis, and incidental ovarian metastases from breast cancer. The patient presented with a 12-day history of nausea, diffuse abdominal pain, and constipation. An abdominal x-ray showed air-fluid levels, and computed tomography documented small bowel distention. An explorative laparotomy was performed, which revealed small bowel distention, an obstructive lesion of the ileocecal valve, three terminal ileum lesions, ascites, and heterogeneous ovaries. Right ileocolic resection and left oophorectomy were performed. The pathological diagnosis revealed lipomatous submucosal lesion of the ileocecal valve and ileum, and 17 lymph nodes, which were all negative for malignant cells. The oophorectomy revealed ovarian metastasis from breast carcinoma. Ascitic fluid was positive for malignant cells. Mammography and breast/axillary ultrasonography showed a solid nodule of the left breast, ductal carcinoma, and multiple enlarged left axillary lymph nodes, which were positive for neoplastic cells. Immunohistochemical evaluation showed hormonal receptor positivity and C-erb2 negativity. Breast magnetic resonance imaging showed a 14 mm left nodule and a positron emission tomography scan revealed ¹⁸F-FDG uptake in the left breast, left axillary lymph nodes, right ovary, and peritoneum. The tumor was staged as stage IV ductal breast carcinoma, cT1N1M1, Grade 2, Luminal B-like. The multidisciplinary oncological meeting proposed chemotherapy, and a re-staging breast MRI after chemotherapy, which showed a complete response. The patient started treatment with letrozole and remains disease-free 22 months after finishing chemotherapy.

Ileosigmoid knotting: One of the largest single-center series

Ileosigmoid knotting (ISK) is the wrapping of the ileum or sigmoid colon around the base of the other structure, causing a double-loop intestinal obstruction. The disease generally presents as an intestinal obstruction with volvulus triad, including abdominal pain/tenderness, distention, and obstipation. Abdominal X-ray findings are not pathognomonic, and computerized tomography (CT) and magnetic resonance imaging (MRI) are more useful in the diagnosis. A patient with ISK generally requires an emergency laparotomy following resuscitation. Based on the viability of the ileum and sigmoid colon, different resectional or non-resectional surgical techniques may be used. In this report, one of the largest single-center ISK series in the world, an eighty-case series, is concisely presented.

Self-Expandable Metal Stents for Colorectal Cancer: From Guidelines to Clinical Practice

INTRODUCTION

Colonic self-expandable metal stent placement is widely used for palliation of obstructive colorectal cancer. The European recommendations for stent placement as a bridge to elective surgery in obstructive colorectal cancer were recently reviewed. The aim of this study was to evaluate the efficacy and safety of stent placement in obstructive colorectal cancer and to discuss these recent guidelines.

MATERIALS AND METHODS

Demographic characteristics, procedure indications, complications and final outcome in patients with obstructive colorectal cancer who underwent endoscopic stent placement between January 2012 and June 2015 were retrospectively analyzed. Statistical analysis was performed with SPSS V22.

RESULTS

Thirty-six patients were included, 20 (56%) women, mean age 70.6 ± 10.9 years. Stent placement as a bridge to elective surgery was performed in 75% (n = 27) of patients and with palliation intent in 25% (n = 9). In 94% (n = 34) of procedures, technical and clinical success was achieved. A total of eleven (11%) complications were observed: 2 migrations and 9 perforations. No procedure related death was recorded. When stents were placed as a bridge to surgery, average time between endoscopic procedure and surgery was 11.7 ± 9.4 days (excluding three patients who underwent neoadjuvant chemotherapy). Six perforations were recorded in this group: one overt and five silent (three during surgery and two after histopathological examination of the resected specimen). Twenty-one patients underwent adjuvant chemotherapy. During the follow-up period of 14.7 ± 10.9 months recurrence was observed in five patients. None of the recurrence occurred in the group of patients with perforation.

CONCLUSIONS

In this study, stent placement was an effective procedure in obstructive colorectal cancer. It was mainly used as a bridge to elective surgery. However, a significant rate of silent perforation was observed, which may compromise the oncological outcome of these potentially curable patients. Prospective real life studies are warranted for a better definition of actual recommendations.

Sclerosing Encapsulating Peritonitis: Review

Sclerosing encapsulating peritonitis (SEP) is a rare chronic inflammatory condition of the peritoneum with an unknown aetiology. Also known as abdominal cocoon, the condition occurs when loops of the bowel are encased within the peritoneal cavity by a membrane, leading to intestinal obstruction. Due to its rarity and non-specific clinical features, it is often misdiagnosed. The condition presents with recurrent episodes of small bowel obstruction and can be idiopathic or secondary; the latter is associated with predisposing factors such as peritoneal dialysis or abdominal tuberculosis. In the early stages, patients can be managed conservatively; however, surgical intervention is necessary for those with advanced stage intestinal obstruction. A literature review revealed 118 cases of SEP; the mean age of these patients was 39 years and 68.0% were male. The predominant presentation was abdominal pain (72.0%), distension (44.9%) or a mass (30.5%). Almost all of the patients underwent surgical excision (99.2%) without postoperative complications (88.1%).

Rapunzel Syndrome: Rare 'Tale' of a Broken 'Tail'

BACKGROUND

Rapunzel syndrome is a rare and unique form of trichobezoar, in which a cast of hairs is formed in the stomach with its 'tail' extending up to varying lengths into the small bowel. Almost all cases described in literature are of 'classic' and more common form of Rapunzel. Sometimes however, the tail of bezoar is broken into smaller fragments. There is not much literature available on this rarer subset of Rapunzel syndrome.

CASE REPORT

In this report we present the ultrasound (USG) and CT findings of a case of Rapunzel syndrome in which the tail had broken into five separate fragments. The patient presented clinically with intestinal obstruction due to the impaction of the distal- most fragment in the ileum.

CONCLUSIONS

Our case highlights the fact that although USG features may be suggestive, a careful evaluation of CT images is essential for a confidant preoperative diagnosis of Rapunzel syndrome. In cases of this syndrome with a broken tail, CT is essential for precise count and localization of the separated fragments to ensure their complete removal at the time of surgery. We also propose to name the fragments of the broken tail as 'bezoarlets'. This word aptly describes the tail fragments as it suggests their origin from the larger gastric bezoar and the suffix 'lets' conveys they are smaller in size.

Efficacy of Endoscopically Created Bypass Anastomosis in Treatment of Afferent Limb Syndrome: A Single-Center Study

Afferent limb syndrome is a postoperative complication of gastrointestinal surgery, resulting from obstruction of a biliary-enteric limb. Surgery has been the cornerstone of treatment for this condition, but advances in endoscopic and percutaneous techniques could offer less-invasive options. Creation of an internal endoscopic anastomosis between the obstructed afferent limb and an adjacent gastrointestinal lumen can relieve symptoms and might provide a long-term solution. We report the efficacy of endoscopic treatment of afferent limb syndrome using lumen-apposing self-expandable metal stents to create 3 types of enteric anastomoses: a jejunojejunostomy, 2 gastrojejunostomies, and a duodenuojejunostomy in patients who developed afferent limb obstruction following a resection for pancreaticobiliary cancer.

Reevaluation of Self-Expanding Metal Stents as a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction: Six Years Experience

Introduction

Self-expanding metal stents (SEMS) as a bridge to surgery have been used as an alternative for acute malignant left-sided colonic obstruction. However, the benefits are uncertain. The European Society of Gastrointestinal Endoscopy no longer recommends their use in patients with low surgical risk because of the risk of tumor recurrence.

Methods

Patients admitted for acute malignant left-sided colonic obstruction who underwent SEMS as a bridge to elective surgery or urgent surgery were retrospectively evaluated. Postoperative morbidity/mortality, stent complications and survival were recorded. Our aim was to compare the outcome between preoperative SEMS and direct emergent surgery in acute left-sided malignant colonic obstruction.

Results

42 patients were included (SEMS group: 27 and surgery group: 15). There were no differences between groups in relation to age, ASA classification and tumor stage. The technical success of SEMS was 88.9% and the clinical success was 85.2%. There were three SEMS related perforations. In the surgery group, the stoma rate was higher (86.7% vs 25.9%, p < 0.001) and there was a trend for a lower length of hospital stay (18.9 days vs 26.3 days, p = 0.051).

SEMS verses surgery group: There were no differences in the rate of temporary stoma (57.1% vs 61.5%, p = 0.84), definitive stoma (42.8% vs 38.5%, p = 0.84), success of primary anastomosis (86.7% vs 66.7%, p = 0.22) and Clavien–Dindo classification (≥III: 36% vs 58.2% p = 0.24). Overall survival at 1/5 years was identical in the two groups 100%/56% in the SEMS group vs 93%/43% in the surgery group, p = 0.14), as well as tumor recurrence at 3/5 years (24%/50% vs 20%/36% respectively, p = 0.68).

Conclusions

SEMS are associated with a lower overall stoma rate and a higher primary anastomosis rate. However, there are no differences in complications, overall survival and recurrence between the groups.

Acute Treatment of Malignant Colorectal Occlusion: Real Life Practice

Introduction

Colorectal cancer presents itself as acute bowel occlusion in 10–40% of patients. There are two main therapeutic approaches: urgent surgery and endoluminal placement self-expandable metallic stents (SEMS).

Aims and Methods

This study intended to better clarify the risk/benefit ratio of the above-mentioned approaches. We conducted a retrospective longitudinal multicenter study, including 189 patients with acute malignant colorectal occlusion, diagnosed between January 2005 and March 2013.

Results

Globally (85 patients – 35 bridge-to-surgery and 50 palliative), SEMS's technical success was of 94%. Palliative SEMS had limited clinical success (60%) and were associated with 40% of complications. SEMS occlusion (19%) was the most frequent complication, followed by migration (9%) and bowel perforation (7%). Elective surgery after stenting was associated with a higher frequency of primary anastomosis (94% vs. 76%; p = 0.038), and a lower rate of colostomy (26% vs. 55%; p = 0.004) and overall mortality (31% vs. 57%; p = 0.02). However, no significant differences were identified concerning postoperative complications. Regarding palliative treatment, no difference was found in the complications rate and overall mortality between SEMS and decompressive colostomy/ileostomy. In this SEMS subgroup, we found a higher rate of reinterventions (40% vs. 5%; p = 0.004) and a longer hospital stay (14, nine vs. seven, three days; p = 0.004).

Conclusion

SEMS placement as a bridge-to-surgery should be considered in the acute treatment of colorectal malignant occlusion, since it displays advantages regarding primary anastomosis, colostomy rate and overall mortality. In contrast, in this study, palliative SEMS did not appear to present significant advantages when compared to decompressive colostomy.

Avicenna's View on the Etiologies of Intestinal Obstruction

Context:

Bowel obstruction is one of the most common causes of acute abdomen. Because of heterogeneity of patients’ population and variety of causes, therapeutic strategies are not standardized, so treatment of intestinal obstruction is a surgical challenge in many cases. A traditional medicine approach could help detect some issues that were ignored by modern medicine. One of the major schools of medicine, with a history of several thousand years, is Iranian traditional medicine. In this regard, Avicenna, who lived in the medieval period, has had a great influence on the medical knowledge of the world by writing an encyclopedia of medicine entitled “Qanun of Medicine.”

Evidence Acquisition:

The aim of this study was to investigate Avicenna’s views on the causes of intestinal obstruction and comparing them to modern medicine views. This is a review study on an Iranian traditional textbook of medicine by Avicenna, entitled “Qanun of Medicine” (in short “Qanun”). We used Qanun in its original language (Arabic) along with its Persian translation. It consists of 5 books. Part 16 of the third book talks about intestinal anatomy and introduces some intestinal diseases such as “qoolinj” and “ilavos.” Intestinal obstruction can be a kind of “qoolinj” or “ilavos” disease. All intestinal obstruction etiologies in Qanun are searched in international and Iranian databases (Scopus, ISI, SID, and Iranmedex) and similar causes in modern medicine will be discussed in this article.

Results:

According to Qanun, 16 causes are involved in intestinal etiologies of bowel obstruction such as “reeh,” mucoid phlegm, abdominal hot and dry distemperament, decreased bile secretion, job, and so on while modern medicine considers some of them, for instance, volvulus, intestinal herniation, worm, intestinal pseudo-obstruction, and opiate.

Conclusions:

Attention to the similar causes of intestinal obstruction in modern medicine and traditional medicine is the starting point for investigation of noninvasive diagnostic and therapeutic methods that have been mentioned in Qanun. In addition, etiologies which are missed in modern medicine can open new doors to the researchers and gastroenterologists for the study, diagnosis, and prevention of the disease.

Impacted Foreign Body Causing Acute Malignant Colonic Obstruction

Malignant colorectal obstruction is a serious complication of advanced cancers. The obstruction can be caused by colorectal cancer, adjacent organ cancer or distant metastases. Rectal metastases from gastric cancer are rare. Foreign body ingestion is not a rare event and the majority of them causes no symptoms or complications. Nevertheless, they are likely to stop at any narrowing or angulation of the intestinal lumen. The authors describe a rare clinical presentation of an impacted foreign body in a pathological narrowing secondary to rectal metastasis of a gastric neoplasia that caused an acute malignant colonic obstruction. After endoscopic removal of the foreign body, there was complete resolution of symptoms avoiding surgery or palliative stenting. This case report highlights the need of careful inspection of colonic malignant strictures before stenting to exclude other causes of colonic obstructions, as an impacted foreign body.

Intestinal Obstruction Due to Idiopathic Sclerosing Encapsulating Peritonitis: A Case Report

INTRODUCTION

Sclerosing encapsulating peritonitis (SEP) is characterized by partial or complete encasement of small intestine by a thick fibrocollagenous membrane. Depending on underlying causes, SEP is divided into primary and secondary forms. Idiopathic SEP is also called idiopathic or abdominal cocoon syndrome. Herein we presented a case of idiopathic SEP.

CASE PRESENTATION

A 90-year-old male patient presented to our emergency department with signs and symptoms of intestinal obstruction and dehydration. Physical examination findings, patient's age and plain abdominal radiography were consistent with tumoral obstruction or viscus perforation. Explorative laparotomy revealed a fibrous capsule encasing intestines as well as dense adhesions between intestinal loops. Since the overall condition of the patient was not well enough to allow a wide dissection and membrane excision, the operation was terminated after performing a limited loop ileostomy. Unfortunately, the patient was lost due to organ failure at the postoperative period.

CONCLUSIONS

Despite advances in radiological techniques, the exact diagnosis in many cases is still made according to intraoperative findings and histopathological properties of the excised membrane. While some cases of SEP remain asymptomatic for years, most cases are characterized by recurrent bouts of acute, subacute or chronic intestinal obstruction. To our knowledge, the case presented here is the oldest patient with idiopathic SEP in the literature.

Short and hypertrophic ligament of treitz: a rare cause of superior mesentric artery syndrome

Superior mesenteric artery syndrome (SMAS) is a rare form of upper intestinal obstruction in which the third part of the duodenum is compressed between the superior mesenteric artery and the aorta, secondary to any condition decreasing the angle between these two arteries. We recently cared for a young male who came with features of proximal small bowel obstruction. On investigation, there was extrinsic duodenal obstruction. Exploratory laparotomy was done which revealed a short and hypertrophic ligament of treitz leading to compression of 3(rd) part of duodenum. Release of the ligament with doudenojejunostomy was done. Postoperatively, patient recovered well. This case report highlights the occurrence and importance of hypertrophic and contracted ligament of treitz as a rare cause of SMAS.

Da-cheng-qi decoction, a traditional Chinese herbal formula, for intestinal obstruction: systematic review and meta-analysis

BACKGROUND

This study was aimed at determining the effects and safety of Da-Cheng-Qi decoction (DCQD) or DCQD combined with conservative therapy in patients with intestinal obstruction.

MATERIALS AND METHODS

PubMed, EMBASE, Cochrane Controlled Trials Register, and several other databases were searched. Randomised controlled trials (RCTs) of DCQD or DCQD plus conservative therapy in patients with intestinal obstruction were eligible. Therapeutic effect was estimated by the improvement of clinical manifestations and diagnostic imaging; dichotomous/ordinal data assessment of overall response to therapy, adverse effects; or continuous variable were identified, including time to first bowel movement, time to first flatus, length of hospital stay.

RESULTS

Sixty eligible RCTs including 6,095 patients were identified. Response rate: (1) DCQD versus conservative therapy (6 RCTs, 361 patients, RR of respond =1.13; 95% CI 0.97 to 1.31). (2) DCQD plus conservative therapy versus conservative therapy (48 RCTs, 4,916 patients, RR of respond =1.25 which favoured DCQD plus conservative therapy; 95% CI 1.20 to 1.30). Treatment effect remained similar when RCTs at high risk of bias were excluded. Time to first flatus postoperatively: (1) DCQD versus conservative therapy (2 RCTs, 240 patients, SMD=-3.65; 95% CI -8.17 to 0.87). (2) DCQD plus conservative therapy versus conservative therapy (11 RCTs, 1,040 patients, SMD=-2.09 which favoured DCQD plus conservative therapy; 95% CI -3.04 to -1.15).

CONCLUSION

DCQD combined with conservative therapy may increase the success rate of conservative therapy for intestinal obstruction significantly and can shorten the duration of postoperative ileus in patients undergoing abdominal surgery compared with conservative therapy alone.

Resolution of gallstone ileus with spontaneous evacuation of gallstone: a case report

Gallstone ileus is an infrequent complication of cholelithiasis. The formation of a fistula between the gallbladder and duodenum may allow a gallstone to enter the gastrointestinal (GI) tract. Gallstone ileus generally occurs in the elderly patients and is associated with significant mortality. Spontaneous resolution of gallstone ileus after passage of gallstone per rectally, though rare, has been reported Farooq et al. (Emerg Radiol 4(6):421-423, 2007). We describe a 60-year-old woman who presented with a 3-day history of vomiting, pain, distension and constipation .Radiological investigations revealed dilatation of small bowel loops with multiple air fluid levels with a large lamellated radio-opaque density measuring 4.4 cm × 4 cm seen in the right iliac fossa. A possibility of gallstone ileus was kept. Because of co-morbid conditions (post-myocardial infarct with cardiac failure), surgery could not be done and patient was kept on conservative management. Three days later patient had sudden relief of her symptoms after passing a large calculus per rectally suggesting a spontaneous evacuation of gallstone. This case highlights the possibility of spontaneous resolution of gallstone ileus after the passage of gallstone. It has been reported in stones less than 2.5 cm. However, to the best of our knowledge, this is the first time in which a large stone measuring 4 cm × 3.8 cm passed spontaneously.

Hirschsprung's Disease: a Clinical and Pathologic Study in Iranian Constipated Children

OBJECTIVE

Hirschsprung's disease (HD) is a complex disorder resulting from absence of ganglion cells in the bowel wall leading to functional obstruction and bowel dilatation proximal to the affected segment. The aim of our study was to evaluate rectal biopsies from constipated children in different age groups to see in which age it is more likely to encounter HD to avoid unnecessary rectal biopsy.

METHODS

Records of all children with chronic constipation undergoing a rectal biopsy to exclude HD were obtained from the files of Children's Medical Center in Tehran, Iran. A detailed retrospective demographic review, including age of beginning of signs and symptoms was made of all cases.

FINDINGS

Totally, 172 biopsies were taken from 168 children in a five year period, of which 127 cases (75%) had HD. The mean age of constipated patients at biopsy was 39 months and the mean age of patients with proven HD was 18 months. Males were affected more than females. Congenital anomalies associated with HD were found in 9.6%. In 85 (91%) cases constipation had begun in neonatal period.

CONCLUSION

Our data supports previous studies that if constipation begins after the neonatal period, the child is unlikely to have HD. In neonates delay in meconium passage is the most important clinical sign of HD.

Abdominal hernias: Radiological features

Abdominal wall hernias are common diseases of the abdomen with a global incidence approximately 4%-5%. They are distinguished in external, diaphragmatic and internal hernias on the basis of their localisation. Groin hernias are the most common with a prevalence of 75%, followed by femoral (15%) and umbilical (8%). There is a higher prevalence in males (M:F, 8:1). Diagnosis is usually made on physical examination. However, clinical diagnosis may be difficult, especially in patients with obesity, pain or abdominal wall scarring. In these cases, abdominal imaging may be the first clue to the correct diagnosis and to confirm suspected complications. Different imaging modalities are used: conventional radiographs or barium studies, ultrasonography and Computed Tomography. Imaging modalities can aid in the differential diagnosis of palpable abdominal wall masses and can help to define hernial contents such as fatty tissue, bowel, other organs or fluid. This work focuses on the main radiological findings of abdominal herniations.