Right paraduodenal hernia successfully treated with laparoscopic surgery

A 23‐year‐old Japanese man presented with a history of sudden‐onset right abdominal pain accompanied by nausea and vomiting. Contrast‐enhanced CT showed a large cluster on the right side of the retroperitoneum, with most of the small bowel incarcerated. The patient was diagnosed with small bowel obstruction caused by a right paraduodenal hernia, and emergency laparoscopic surgery was performed. The large retroperitoneal cluster on the right side contained almost all segments of the small bowel, although the incarcerated bowel showed no evidence of volvulus or ischemia. The bowel was reduced, and the hernia orifice was closed. The patient made good progress and was discharged 7 days after surgery. We herein report an acute case of right paraduodenal hernia with small bowel obstruction that was successfully treated with emergency laparoscopic surgery. With an early preoperative diagnosis, laparoscopic surgery is appropriate for the treatment of right paraduodenal hernia.     

Small Bowel Obstruction from Potato and Broccoli Phytobezoar Mimicking Mesenteric Ischemia

Background

Bezoars are concretions of undigested foreign material that form in the gastrointestinal tract. Rare in humans, they are nonetheless a well-documented cause of intraluminal bowel obstruction.

Objectives

The objectives of this case report include describing an unusual presentation of small bowel obstruction due to phytobezoar, which mimicked mesenteric ischemia, and highlighting the risk factors, presentation, and management of bezoars, in addition to covering historical beliefs regarding bezoars.

Case Report

Here we report a 64-year-old man who presented to the Emergency Department with chest pain, vomiting, and hypotension. Initial work-up was directed at ruling out cardiac causes and aortic catastrophe such as aortic dissection or ruptured abdominal aortic aneurysm. Computed tomography angiography of the chest and abdomen showed findings suggestive of mesenteric ischemia and small bowel obstruction. However, exploratory laparotomy revealed intraluminal small bowel obstruction from a phytobezoar consisting of undigested chunks of potato, brussels sprouts, and broccoli.

Conclusions

Although rare in humans, bezoars are a documented cause of small bowel obstruction, and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction require surgical treatment.     

Combined laparoscopic resection of intestinal stenosis of Garré and open preperitoneal mesh repair for irreducible femoral hernia

Intestinal stenosis of Garré is a rare condition caused by a benign fibrous bowel stricture due to complicated strangulated hernia. We present a case of intestinal stenosis of Garré associated with right femoral hernia in an 85‐year‐old woman. The patient visited our hospital with a 2‐day history of vomiting. Her abdomen was slightly distended. A mass was palpated in the right groin region. CT showed prolapse of the small intestine in the right groin region. An incarcerated right femoral hernia was diagnosed and manually reduced. Thirteen days later, the patient complained of abdominal pain. CT revealed dilatation and caliber change in part of the small bowel, indicating a small bowel obstruction due to intestinal stenosis of Garré. Laparoscopic release of the bowel obstruction and femoral hernia repair via an anterior approach were performed simultaneously. No recurrence of femoral hernia or bowel obstruction was noted at the 15‐month follow‐up.     

Small bowel obstruction caused by endometriosis in a postmenopausal woman

We report a rare case of small bowel obstruction (SBO) caused by endometriosis in a postmenopausal woman. A 54‐year‐old postmenopausal woman presented with severe abdominal pain and vomiting. Before menopause, she sometimes had abdominal pain associated with menses. Axial multi‐dimensional CT images revealed a SBO with small nodules near the terminal ileum. The obstruction was diagnosed as being caused by small bowel endometriosis. Curved planar reconstruction images showed a complicated obstruction of the small intestine 15 cm from the terminal ileum. Based on the stenotic lesion, a SILS procedure was performed. The patient's SBO diagnosis was histologically confirmed as being caused by small bowel endometriosis. SILS was deemed to be a safe, feasible procedure for treating this bowel obstruction. Curved planar reconstruction images were useful in preoperative imaging and diagnosis of SBO, especially as they were able to highlight the constricting legion.     

Small bowel obstruction and previous gynecologic surgery

We reviewed the cases of women admitted to LSU Medical Center in Shreveport with the diagnosis of "small bowel obstruction" from Jan 1, 1975 to June 30, 1981. Review of the charts of patients who had exploratory laparotomy for relief of the obstruction showed that 83% of them had had previous abdominal surgery. Furthermore, 67% of the patients had had an abdominal hysterectomy. In 100% of the cases of obstruction after abdominal hysterectomy, there were adhesions to the site of reperitonealization or to the anterior abdominal wall. This study shows a higher incidence of small bowel obstruction after gynecologic surgery than has been previously reported.     

Point-of-care procalcitonin may predict the need for surgical treatment in patients with small bowel obstruction

BackgroundThe early identification of patients with small bowel obstruction who require surgical treatment could potentially lead to improved patient outcomes. We evaluated the efficacy of point-of-care procalcitonin for predicting surgical treatment among patients with small bowel obstruction.MethodsThis was a prospective observational study. We measured serum procalcitonin levels in patients who presented to the emergency department and were diagnosed with small bowel obstruction from April 1, 2018 through March 31, 2019. Patients were grouped into two groups: the elevated procalcitonin and normal procalcitonin groups. Our primary outcome was surgical treatment.ResultsA total of 53 patients with small bowel obstruction were included in the study, and 11 patients (20.8%) were treated operatively. Baseline characteristics were similar, except for age, between the elevated procalcitonin (≥0.12 ng/ml) and normal procalcitonin groups. The elevated procalcitonin level was significantly correlated with surgical treatment and hospital length of stay (p < 0.05). The sensitivity, specificity, and positive likelihood of procalcitonin for the former were 45.5%, 85.7%, and 5.0 respectively.ConclusionThe patients with small bowel obstruction who had elevated procalcitonin levels on presentation showed significantly higher rate of surgical treatment than those who had normal procalcitonin levels. Point-of-care procalcitonin might predict the need for surgical treatment in patients with small bowel obstruction and could be used as an additional diagnostic test. Further studies with more patients are needed to investigate the predictive value of point-of-care procalcitonin for surgical treatment.     

Heal mucosal diaphragm causing small bowel obstruction

A case of small bowel obstruction in an adult due to ileal mucosal diaphragm is reported. This unusual cause of small bowel obstruction to the best of our knowledge has not been previously reported. The cause of intestinal diaphragm remains uncertain.     

小肠机械性肠梗阻的CT诊断

目的 探讨小肠机械性肠梗阻病因的CT表现和诊断价值。方法 对53例小肠机械性肠梗阻的CT表现与手术、病理和临床随诊结果对照分析。结果 53例小肠机械性肠梗阻病因中，肠粘连18例，炎症10例，肠肿瘤8例，腹外疝6例，腹内疝3例，异物4例，肠套叠3例，肠扭转1例，CT诊断小肠机械性肠梗阻病因的符合率5％(49／53)。结论 CT对小肠机械性肠梗阻病因有较高的诊断价值。     

Early diagnosis of bowel obstruction and strangulation by computed tomography in emergency department

BACKGROUND:

Closed loop bowel obstruction is a specific type of mechanical obstruction with a high risk of strangulation and bowel infarction, especially in the small bowel. It is associated with a high mortality rate. Hence, it is important for emergency physicians to identify the presence of strangulation, while making the diagnosis of closed loop small bowel obstruction.

METHODS:

We reported three patients with strangulated closed loop small bowel obstruction associated with severe abdominal pain, who had been treated at the emergency department. Urgent computerized tomography was performed in the patients.

RESULTS:

Two patients were discharged with stable conditions, and one patient died after hemodialysis.

CONCLUSION:

Urgent computerized tomography of the abdomen serves as an important diagnostic tool in view of its ability to detect the site, level and cause of obstruction along with the distinctive CT appearance of closed loop small bowel obstruction and signs of ischemia. Early definitive diagnosis will guide subsequent management and improve outcomes.KEY WORDS: Closed loop small bowel obstruction, Computed tomography, Ischemia, Strangulation     

多层螺旋 CT 对小肠梗阻的诊断价值

目的：探讨多层螺旋C T对小肠梗阻的诊断价值。方法对36例小肠梗阻患者进行多层螺旋C T平扫和增强扫描,并利用工作站对C T图像进行多平面重建,将C T诊断结果与手术病理结果相对照。结果36例小肠梗阻患者均通过多层螺旋C T扫描明确诊断,诊断准确率为100．0％,均表现为小肠扩张、积液和积气;梗阻原因中肠粘连16例,肿瘤性病变5例,炎症性病变5例,腹疝5例,肠套叠3例,粪石2例,病因诊断准确率为94．4％。结论多层螺旋CT结合三维重建能够准确诊断小肠梗阻,并且在确定梗阻病因方面具有优越性。     

Pelvic organ prolapse: An unusual cause of small bowel obstruction

We present the rare case of a small bowel obstruction secondary to pelvic organ prolapse (POP). A 77-year-old female presented with four days of abdominal pain, nausea, and vomiting. She had a history of abdominal hysterectomy with bilateral salpingo-opherectomy and a mildly symptomatic cystocele. She was found to have an enterocele causing small bowel obstruction. The enterocele was manually reduced and subsequently managed non-operatively with a pessary. Prior case reports of small bowel obstructions secondary to POP required emergent surgical intervention. Post-menopausal women should be asked about symptoms or presence of pelvic organ prolapse and in the correct patient population, pelvic examination can be important for diagnosis and treatment of small bowel obstruction. If the enterocele is manually reduced non-operative management can be safe and effective.     

Delayed diagnosis of small bowel obstruction following laparoscopic lymph node dissection

Laparoscopic surgical procedures are infrequently complicated by bowel herniation through unsutured trocar sites. Nevertheless, there is a risk of this complication in patients presenting with symptoms of small bowel obstruction after laparoscopy. We present a case of delayed small bowel obstruction due to a Richter's hernia, a rare type of hernia that involves incomplete protrusion of bowel wall through a surgical defect. Knowledge of this potential complication of laparoscopic procedures may prevent the significant morbidity that results from mechanical small bowel obstruction with necrosis.     

一例疑似小肠梗阻患者的循证CT诊断

目的针对急诊收治的一例疑似小肠梗阻(SBO)患者,检索当前最佳证据,为临床合理诊断提供依据。方法计算机检索MEDLINE/PubMed (1978～2006．4)、SUMsearch(1978～2006．4)、CNKI(1978～2006．4),查找有关计算机体层摄影术(CT)诊断小肠梗阻的系统评价、横断面研究等,并对所获证据进行评价。结果临床证据表明,与参考标准小肠造影及外科手术诊断相比较,CT诊断小肠梗阻的敏感度和特异度均较高,并能在早期明确梗阻的类型及病因,提高临床医师正确处理小肠梗阻的能力。据此临床证据,结合患者意愿,对患者进行CT检查,CT结果提示绞窄性小肠梗阻,需立即进行手术治疗。结论CT是诊断小肠梗阻敏感性及特异性均较高的影像学检查方法。     

急诊CT对小肠植物性粪石梗阻的诊断价值

目的探讨植物性粪石致急性小肠梗阻的CT表现及诊断价值。方法回顾性分析经外科手术证实的19例植物性粪石致急性小肠梗阻的临床资料及术前CT表现。结果本组19例术前CT影像均显示粪石呈边缘清楚的卵圆形或圆形,其内密度不均或夹有小气泡影的软组织包块影。手术证实14例(73.7%)为单发粪石,5例(26.3%)为多发粪石;共取出粪石27枚,其中位于回肠16枚(59.3%),空肠8枚(29.6%),胃2枚(7.4%),十二指肠1枚(3.7%)。结论小肠植物性粪石CT影像具有特征性表现,可明确粪石数量及部位,是诊断植物性粪石致急性小肠梗阻的有效方法。     

肠镜在肠梗阻病因和部位诊断中的作用探讨

【目的】了解结肠镜在肠梗阻病因诊断中的应用价值。【方法】2000年6月至2004年6月间．对43例部位和原因不明的肠梗阻进行电子肠镜检查,以判断肠梗阻的部位和病因。【结果】结肠镜检查结果与手术结果比较发现,33例结直肠梗阻者中有31例明确了梗阻病因和梗阻部位,仅2例出现梗阻部位判断错误;10例小肠梗阻者,结肠镜检查可以帮助排除结直肠梗阻。【结论】结肠镜检查在发现肠梗阻病因和部位的诊断过程中具有十分重要的应用价值。     

The use of MRI in bowel obstruction

Nine patients with clinical or radiographic evidences of bowel obstruction were examined by magnetic resonance imaging. Retrograde insufflation of 1000–1200 ml of air through a Foley catheter placed in the rectum was employed. Scopolamine was used to inhibit bowel peristalsis and possibly relax the ileocecal valve. The administered air successfully distended the colon and the small bowel distal to the obstruction in seven of the nine cases. The air-filled small bowel loops were useful in delineating the obstruction sites and adjacent lesions in these seven cases. The diagnosis was established by means of surgery in six cases and by clinical course in three cases. The causes of obstruction included four peritoneal carcinomatoses, and one each of supravesical hernia, intussusception, adhesive band, benign granulomatous stricture, and radiational stricture. The site of obstruction was the distal small bowel in eight cases, and the rectosigmoid colon in one case.     

Small bowel obstruction in rats: diagnostic accuracy of sonography versus radiography.

Our purposes were to determine whether sonography can distinguish between obstructed and nonobstructed rats and to compare the diagnostic accuracy of sonography and radiography in the diagnosis of small bowel obstruction. Nonstrangulating small bowel obstruction was created in 19 rats; sham laparotomies were performed in 18 controls. Serial radiographs and sonograms, including duplex Doppler sonography, were obtained. Bowel diameter and bowel wall thickness were evaluated retrospectively. Bowel diameter, bowel wall thickness, and resistive indices increased in the animals with obstruction; controls remained unchanged (P = 0.002). Sonography demonstrated a significantly higher diagnostic accuracy than radiography at 24 hours and beyond (P = 0.023). Ultrasonography is sensitive and more accurate than radiography in diagnosing small bowel obstruction using objective criteria in the animal model.     

Sonographic detection of transient gas in the portal vein in an infant following abdominal surgery: a possible sign of adhesive small bowel obstruction

We present a case of sonographically detected transient gas in the portal vein in a 4.5-month-old infant who had a history of two consecutive jejunectomies due to jejunal stenoses and was admitted to our hospital with clinical and laboratory findings consistent with a subacute small bowel obstruction and dehydration. Sonography excluded other pathologies and the patient was treated conservatively with success. The presence of gas in the portal vein could be a sign of an underlying mechanical obstacle, as another episode of small bowel obstruction 1 month later required surgical treatment of adhesive intestinal obstruction.     

植物粪石性小肠梗阻的多层螺旋CT(256层)诊断

目的:探讨植物粪石性小肠梗阻的多层螺旋CT(256层)诊断。材料与方法:回顾性分析经手术证实15例植物粪石性小肠梗阻MSCT(256层)表现及临床资料。结果:植物粪石性小肠梗阻位于空肠3例,回肠10例,1例合并胃石,1例回盲部肿瘤并肠套叠。粪石CT表现为蜂窝状气泡征。其中5例MSCT增强检查,粪石不强化,周围肠壁明显强化。结论:蜂窝状气泡征为植物粪石性小肠梗阻特征性MSCT表现。全腹部CT检查是本病术前定位定性诊断重要检查方法。     

Chronic intermittent intestinal obstruction from a seat belt injury

Most patients with intestinal obstruction have had previous surgery. Rarely, the development of adhesions and resulting small bowel obstruction is attributed to previous intra-abdominal trauma. We present the case of a young man, without a history of surgery, who had been a restrained driver in a motor vehicle crash. Seven years later, the patient had an intermittent partial small bowel obstruction that recurred over the next 5 years. We review the pathophysiology and epidemiology of similar occurrences, as well as diagnostic options.