Small intestinal obstruction

Small intestinal obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding operative delay whenever surgery is indicated, not every patient is always best served by immediate operation. Certain entities, such as SBO secondary to incarcerated abdominal wall hernia, and patients with clinical signs and symptoms suggestive of strangulation do require prompt operative intervention. Other conditions, however, such as postoperative adhesions and neoplastic-associated SBO, particularly in patients with numerous previous abdominal procedures, concomitant medical problems, or incomplete or partial obstruction, often justifiably benefit by a trial of nonoperative management. The risk of strangulation with adhesive and neoplastic SBO is relatively low as compared with incarcerated hernia and small bowel volvulus. Close and careful clinical evaluation, in conjunction with laboratory and radiologic studies, will usually dictate the proper course of management in any given case. If any uncertainty exists, prompt operative intervention is indicated. Because over 50 per cent of all cases of SBO are the direct result of postoperative adhesions, it is probably just as important as the actual management of SBO for all practicing abdominal surgeon to familiarize themselves with the widely accepted "ischemic theory" of adhesion formation. A number of intraoperative measures, many of which go against established surgical principles, are now encouraged during routine elective abdominal surgery to reduce the incidence of detrimental adhesions that might subsequently produce SBO. At the same time, surgeons should continue their aggressive attitude towards elective repair of any and all abdominal hernias, which continue to account for close to 15 per cent of all cases of small intestinal obstruction and still remain the most common cause of strangulation.     

Primary intestinal posttransplant T-cell lymphoma

There have been only five reported cases of primary posttransplant T-cell lymphoma. We report the first case associated with the use of sirolimus (Rapamycin, Wyeth-Ayerst, Philadelphia, PA). The patient, receiving prednisone, cyclosporine, and sirolimus treatment, developed ascites, diarrhea, and weight loss 7 months after his second renal transplant. Tissue obtained at laparotomy established the diagnosis of primary T-cell lymphoma. Latent membrane protein-1 for Epstein-Barr virus was negative, but in-site hybridization test for Epstein-Barr-encoded RNA was positive. Despite aggressive chemotherapy, the patient died 8 months posttransplant. This is the sixth reported case of primary intestinal posttransplant T-cell lymphoma, but it is the first case associated with the use of sirolimus. The incidence of posttransplant lymphoproliferative disease in patients receiving sirolimus should be studied.     

Small intestinal mucosa-associated lymphoid tissue lymphoma with deep ulcer and severe stenosis: A case report

IntroductionAlthough eosinophils are commonly present on the mucosa of the gastrointestinal tract, various pathological conditions may cause a secondary increase in eosinophil quantity.Presentation of caseA 78-year-old man was referred to our hospital due to abdominal pain. Examinations revealed an ulcerative lesion with white moss in the terminal ileum and severe stenosis on the oral and anal sides. Tissue biopsies obtained from the ulcer margins showed a predominance of chronic inflammatory cells and abundant eosinophils in addition to lymphocytes/plasma cells. Secondary causes of tissue eosinophilia were suspected; however, the diagnosis could not be confirmed because of atypical endoscopic findings. Partial resection of the ileum was performed for therapeutic and diagnostic purposes. Histopathology of the resected specimen identified a lymphoepithelial lesion with an invasive tendency. While CD20 staining was positive, MUM-1 and Bcl-6 staining were negative. Based on these findings, the lesion was diagnosed as a small intestinal mucosa-associated lymphoid tissue lymphoma (Lugano staging, stage II₁).DiscussionHypereosinophilia in this lesion was suggested to be secondary to chronic inflammation due to tumor growth or impaired transit.ConclusionThere is a type of gastrointestinal MALT lymphoma showing an invasive tendency. In such cases, it may demonstrate atypical findings and hypereosinophilia in gastrointestinal tissues.     

Enteropathy-type T-cell lymphoma after intestinal diffuse large B-cell lymphoma

A rare case of enteropathy-type T-cell lymphoma (ETL) developed in a 47-year-old Chinese male 6 years after the diagnosis of diffuse large B-cell lymphoma (DLBCL) in the small intestine. The patient initially presented with vague gastrointestinal complaints. Work-up demonstrated an ulcerated mass in the small intestine. Partial resection and histologic examination of the intestine showed a DLBCL, positive for CD20 and Bcl-2, involving the jejunum transmurally. Further staging work-up demonstrated mesenteric and retroperitoneal lymphadenopathy, splenomegaly, and ascites. The patient was treated aggressively with radiotherapy, chemotherapy, and autologous bone marrow transplant, and complete remission was obtained. Six years later, the patient presented with diarrhea and dehydration. Clinical work-up revealed thickening of the small intestinal wall, and biopsies demonstrated ETL based on morphology, immunohistochemistry, and polymerase chain reaction analysis. Celiac disease was diagnosed concurrently. The patient responded to chemotherapy, received allogeneic peripheral blood stem cell transplantation from an HLA-matched sibling donor, and remains in remission. To our best knowledge, this is the first reported case of metachronous ETL and DLBCL. Possible associations between the 2 types of lymphoma are discussed.     

Small intestinal obstruction from peritoneal carcinomatosis

Small intestinal obstruction from peritoneal carcinomatosis was reviewed at the Ellis Fischel State Cancer Hospital. The outlook is poor for survival and conservative management is warranted as a trial because strangulation obstruction is rare. Reobstruction after either nonoperative or operative management is common, and if surgery is performed, a permanent tube jejunostomy should be considered.     

Small intestinal transplantation in nonhuman primates

Small intestinal transplantation represents a potentially therapeutic procedure for individuals with short gut syndrome. The purpose of this study was to develop a model for small intestinal transplantation in primates that is: technically feasible without microsurgery; consistent in the prevention of allograft rejection; functional in terms of nutrient absorption; and compatible with harvest for multiple organ procurement. First, autotransplantations on four rhesus monkeys were performed in order to study a variety of harvesting techniques and vascular anastomoses. Then, a study was performed with 14 heterotopic allotransplants in 4 baboons and 10 rhesus primates. The successful donor model consisted of division of the pancreas, harvesting the small bowel with a superior mesenteric artery and portal vein pedicle. The allograft vascular pedicle was anastomosed to the recipient's common iliac vessels in end-to-side fashion. The graft was transplanted as an out-of-continuity loop, both ends being exteriorized as stomas providing access for absorption studies and biopsy. Three immunosuppressive regimens were tested: (1) cyclosporine A (CyA) 20 mg/kg/d, solumedrol (SML) 2 mg/kg/d, and graft irradiation (150 rad) (n = 4); (2) CyA 20 mg/kg/d and SML 2 mg/kg/d (n = 3); and (3) CyA 40 mg/kg/d, SML 2 mg/kg/d, and azathioprine 5 mg/kg/d (n = 3). There were 4 deaths due to technical error in the first 24 hours. Weekly graft biopsy, serum CyA levels, complete blood count, and automated 24-channel serum analysis were performed. Grafts surviving greater than 14 days underwent absorption study via luminal perfusion with sucrose, maltose, dextrose, Pregestimil, xylose, and cyclosporine.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intestinal perforation secondary to intestinal Burkitt lymphoma

Introduction and importanceSmall intestinal perforation in patients with Burkitt lymphoma is extremely rare. We present the first report of such a case.Case presentationA 53-year-old woman was admitted with abdominal pain and vomiting. Abdominal examination revealed rigidity and tenderness in the upper abdomen.Computed tomography scan showed thickening of the wall of the jejunum, intra-abdominal free gas, and ascites; the patient was diagnosed with small intestinal perforation, and underwent emergency surgery on the same day. Laparoscopic findings were a 50 mm jejunal perforation and perforation in the transverse mesocolon. A partial jejunal resection of the perforated area, partial transverse colectomy, temporary colostomy, and intra-abdominal drainage were performed. Histological examination showed diffuse infiltration of medium-sized atypical lymphocytes in the perforated area, exhibiting a “starry sky” appearance.Immunostaining results showed that the atypical lymphocytes were CD20 and virtually 100% Ki-67 positive, and CD56, CD30, and EBER negative. The lesion was identified as Burkitt lymphoma (BL). The postoperative course was favorable. On postoperative day 18 the patient began chemotherapy through the hematology department. Currently, the patient is in remission.Clinical discussionThe majority of the malignant lymphomas occurring in the digestive tract are identified in the stomach; over 90% are B-cell lymphomas and mucosa-associated lymphoid tissue lymphoma Nakamura et al. BL originating from the small intestine accounts for only about 9%.ConclusionThe incidence of BL in the small intestine is low. Pretreatment BL can lead to bowel perforation. Prompt involvement of the hemato-oncologist after definitive diagnosis, and commencing chemotherapy as early as possible after surgery, are thought to improve prognosis.     

Small intestinal perforation following minor trauma.

Small intestinal perforation occurred in two patients aged 70 years and 88 years who had experienced minor trauma by tripping or falling on the pavement. They both developed signs of generalized peritonitis and at laparotomy were found to have perforated the mid ileum. There was no sign of direct abdominal trauma but they had suffered minor facial trauma as a result of the fall.     

Small intestinal angiosarcoma masquerading as an appendiceal abscess

Angiosarcomas of the small intestine are rare and present non-specifically. They usually manifest with abdominal discomfort, altered bowel habits, anaemia and gastrointestinal bleeding. Diagnosis is often challenging and occurs at an advanced tumour stage. We describe a case of a terminal ileum angiosarcoma masquerading as an appendiceal abscess, and discuss salient clinicopathological features in diagnosing and managing this disease.     

Small intestinal obstruction complicating ileal pouch-anal anastomosis.

Small bowel obstruction remains the most common complication after proctocolectomy with ileal pouch-anal anastomosis. Of 626 patients who underwent this operation between January 1981 and October 1986 for ulcerative colitis (544 patients), familial adenomatous polyposis (72 patients), or indeterminate colitis (ten patients), 17% developed small bowel obstruction, 7.5% of whom required surgical intervention. The obstruction occurred either before or after closure of the temporary ileostomy. Patients who had a temporary Brooke ileostomy were more likely to develop obstruction (four of 32 patients, 12.5%) than those who had a loop ileostomy (25 of 564 patients, 4.6%) (p = 0.07). Also, patients who had had previous operations were at greater risk of obstruction (8.5%) than those who had not (2.2%) (p less than 0.04).     

Small intestinal volvulus caused by loose surgical staples

Small intestinal volvulus beyond infancy is rare and usually has an iatrogenic cause. The authors describe an adolescent boy with small bowel volvulus secondary to the presence of free intraperitoneal surgical staples after a laparoscopic appendectomy.     

Small intestinal submucosa intracardiac patch: an experimental study

In this experimental study, small intestinal submucosa was implanted as an atrial prosthesis in calves. Echocardiography and histology showed this to be an impermeable prosthesis that develops a neointimal nonthrombogenic surface making it safe for repair of defects in a low-pressure system. Further study with small intestinal submucosa in an intracardiac position is warranted.