Mechanical small bowel obstruction precipitated by colonoscopy

Mechanical small bowel obstruction (SBO) is rare complication of colonoscopy. We present a patient who developed SBO 24 h after surveillance colonoscopy. Four years prior to this procedure, he had undergone augmentation cecocystoplasty with continent ileal conduit. He subsequently underwent laparotomy and lysis of a band adhesion that caused extrinsic compression of the ileum proximal to ileotransverse colostomy. We further review the literature, describe the salient features of colononoscopy-induced bowel obstruction, and identify the risk factors for this unusual complication.     

Small bowel obstruction caused by appendiceal tourniquet

True mechanical small bowel obstruction because of appendicitis is extremely rare. A case is presented, and diagnosis and treatment principles are discussed.     

Trichobezoar: A rare cause of bowel obstruction

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. A trichobezoar is a bezoar made up of hair and is a rare cause of bowel obstruction of the proximal gastrointes-tinal tract. They are seen mostly in young women with trichotillomania and trichotillophagia and symptoms include epigastric pain, nausea, loss of appetite and bowel or gastric outlet obstruction. We herein describe a case of a trichobezoar that presented as a gastric outlet obstruction and was subsequently successfully removed via a laparotomy.     

A peculiar cause of bowel obstruction

INTRODUCTIONGallstone disease is one of the most common surgical problems necessitating intervention. It is estimated that approximately 15% of people in the western world will develop gallstones. Of these patients, 35% of patients initially diagnosed with gallstones will later develop a complication which will eventually result in cholecystectomy.²One of these complications is gallstone ileus, which is a rare complication associated with high morbidity and mortality, and the diagnosis is often missed.³PRESENTATION OF CASEA 66 year old female presented with an acute onset of “colicky” abdominal pain accompanied with vomiting. She had known gallstones diagnosed previously by ultrasound. Her abdomen was generally tender with guarding of the right hypochondrium and absent bowel sounds.DISCUSSIONGallstone ileus accounts for 0.5–4% of all cases of small bowel obstruction, and typically affects females over the age of 65.3, 4 The pathophysiological basis of the disease involves fistulation of the gallstone through the wall of the gallbladder into the bowel, where it becomes impacted and leads to obstruction. Mortality of the condition is not sufficiently reported, but surgical intervention in itself conveys significant morbidity, and mortality has been reported to be 18%.3, 9CONCLUSIONWe report a single large gallstone, which we believe to be one of the largest documented in recent literature, resulting in gallstone ileus. We also present a brief synopsis of the diagnosis and management of the condition, which although rare, should be considered by the astute surgical trainee.     

A laparoscopic approach to small bowel obstruction secondary to endometriosis

The complications of endometriosis are well recognized and extend beyond the pelvis. Gastrointestinal manifestations of this disease have been well described; however, reports of small bowel obstruction are rare. We describe the case of a 44 year-old-woman who presented with high-grade small bowel obstruction secondary to an endometrioma. We review the epidemiology and pathology associated with this condition and describe a laparoscopic approach to its management.     

A rare cause of small bowel obstruction: Abdominal cocoon

INTRODUCTIONThe clinical manifestations of abdominal ‘cocoon’ are non-specific and hence its diagnosis is rarely made preoperatively and the management is often delayed. Surgery remains the main stay of treatment with satisfactory outcome and comprises excision of the fibrous membrane, meticulous adhesionolysis and release of the entrapped small bowel.PRESENTATION OF CASEA 45-year-old male patient presented with 6-month history of progressive subacute small bowel obstruction. After initial radiological investigations, he underwent diagnostic laparoscopy and was misdiagnosed as abdominal tuberculosis. He was started on anti-tuberculous therapy, but exploratory laparotomy was carried out after failure to respond to anti-tuberculous therapy. At laparotomy, the abdominal ‘cocoon’ which was encapsulating the entire small bowel was excised, and the adhesions were carefully lysed. The patient remained well and without recurrence at 1-year follow-up.DISCUSSIONAbdominal ‘cocoon’ is a rare cause of subacute, acute and chronic small bowel obstruction. Its diagnosis is rarely made preoperatively.CONCLUSIONAbdominal ‘cocoon’ should be thought of as a rare cause of small bowel obstruction. It may be mistaken with abdominal tuberculosis. Surgery remains the mainstay of curative treatment.     

Small bowel obstruction after laparoscopic donor nephrectomy

Background: Laparoscopic live donor nephrectomy has become the procedure of choice for kidney procurement at many centers worldwide. A decrease in postoperative pain and length of stay, a faster return to work, and no difference in morbidity and mortality compared to open nephrectomy have all been reported. However, few data exist regarding the complication of postoperative internal hernia and small bowel obstruction, which is unique to a laparoscopic/transperitoneal approach. Methods: We present three case reports of patients who developed small bowel obstruction from an internal hernia and mesenteric defect after laparoscopic donor nephrectomy. Results: A total of 635 patients underwent laparoscopic donor nephrectomy between March 1996 and August 2001 at our institution. Small bowel obstruction developed in three patients (0.47%) within 1 week postoperatively. Each case involved an internal hernia through a left colon mesenteric defect at the site of nephrectomy. Reoperation was necessary in each case and was associated with a prolonged hospital stay (mean, 22.3 days; range, 6–37). Two patients were managed with laparotomy; one patient underwent a laparoscopically assisted exploration. One patient required an additional open exploration for intraabdominal sepsis and cholecystectomy. Conclusions: Small bowel obstruction from internal hernia following laparoscopic donor nephrectomy is a rare event, but it can lead to significant morbidity in an otherwise healthy patient. These patients may be at higher risk for bowel obstruction given the soft tissue defect remaining after nephrectomy. Vigilance is required when mobilizing the colon to ensure that mesenteric defects are recognized and repaired.     

Management of rectosigmoid obstruction due to severe bowel endometriosis

Bowel obstruction is a rare complication of intestinal endometriosis. The aim of this work was to evaluate outcomes after colorectal resection for bowel obstruction due to endometriosis. Of 720 patients who underwent colorectal resection for bowel endometriosis, 12 (1.7 %) presented with bowel obstruction. Preoperative work-up, management, perioperative and long-term outcomes were analyzed. All lesions were localized in the rectosigmoid tract. All patients underwent colorectal resection, which was carried out laparoscopically in 4 (33 %). Rate of low or ultra-low colorectal anastomoses was 83 %. Four patients (33 %) required blood transfusions. Two patients developed rectovaginal fistulas. After a median follow-up of 38 months, there were no cases of disease recurrence and dyschezia improved in 75 % of patients. Bowel endometriosis should be considered in the differential diagnosis of young women with bowel obstruction. Despite challenging operations, colorectal resections are associated with good outcomes.     

Small bowel obstruction caused by congenital mesocolic hernia: case report

Transmesocolic hernias are extremely rare. Their exact incidence is still unknown. A strangulated hernia through a mesocolic opening is a rare operative finding. Preoperative diagnosis still is difficult in spite of imaging techniques currently available. This is the case of a 4-month-old boy with transmesocolic internal hernia and coincident intestinal malrotation and volvulus of small bowel.     

An undigested cherry tomato as a rare cause of small bowel obstruction

Small bowel obstruction due to undigested fibre from fruits and vegetables is a rare but known medical condition. We report a case of small bowel obstruction caused by a whole cherry tomato in a patient without a past medical history of abdominal surgery. A 66-year-old man presented to the emergency department complaining of lower abdominal pain with nausea and vomiting. His last bowel movement had occurred on the morning of presentation. He underwent abdominal computed tomography (CT), which showed a sudden change of diameter in the distal ileum with complete collapse of the proximal small bowel segment. Laparoscopy confirmed a small bowel obstruction with a transition point close to the ileocaecal valve. An enterotomy was performed and a completely undigested cherry tomato was retrieved. To our knowledge, this is the first reported case of a small bowel obstruction caused by a whole cherry tomato.     

Left paraduodenal hernia: a rare cause of large bowel obstruction and gangrene

Internal hernias are a rare cause of intestinal obstruction. Paraduodenal hernias are the most common type of internal hernias. Although small bowel obstruction is associated with internal hernias, large bowel obstruction is unique. The authors here report a case of left para duodenal hernia with simultaneous small and large bowel obstruction and gangrene. The patient underwent emergency laparotomy and generous resection of gangrenous small and large bowel was carried out and stoma was created. Postoperatively, the patient had a smooth recovery and was discharged after a few days.Reversal of stoma was carried out after 2 months.     

Viral small bowel intussusception: a rare cause of intestinal obstruction

Representing a rare cause of bowel obstruction, the ileal intussusception is commonly met in the pediatric surgery. Even if in children's cases the symptoms can mimick a multitude of abdominal syndromes, usually in adult cases the symptoms fit the pattern of the intestinal obstruction. This paper presents 2 clinical cases of small bowel intussusception in adult, the particularity of cases being that the pathogenesis couldn't be established first hand; the pathology exam revealed only minor inflammatory responses,including modest reactive lymph nodes in the vicinity of lesions, without further alterations. The etiology of bowel intussusception was finally attributed to viral infection with gastroenteritis, based on clinical and pathological criteria.     

Rare small bowel obstruction: Right paraduodenal hernia. Case report

INTRODUCTIONParaduodenal hernia (paramesocolic hernia), a rare congenital anomaly due to a midgut malrotation during fetal development, is recognized as the most frequent internal hernias. Two variants have been described: left and right, the latter less common than the first one.PRESENTATION OF CASEWe report a right paraduodenal hernia case in a 86 years old female patient who developed an acute bowel obstruction syndrome. Final diagnosis was achieved by imaging techniques as abdomen X-ray and CT and confirmed only after surgical operation.DISCUSSIONSurgical approach was via median laparotomy, consisting in hernia reduction, replacement and stitching of the bowel in its anatomical orientation, and fixing of the posterior wall defect. At 15 months follow-up from surgical procedure the patient is asymptomatic.CONCLUSIONParaduodenal hernia is a rare pathology but its involvement in bowel obstruction syndrome should be always taken into account during diagnostic process.     

Ileal fecalomas causing small bowel obstruction: A case report

IntroductionFecaloma is an accumulation of feces that has formed a mass and has failed to be expelled spontaneously. Because fecal matter is harder and firmer in the left side of colon, and the diameter of the bowel is smaller compared to the right, fecalomas mostly form in recto-sigmoid area. Small bowel fecaloma formation is an extremely rare condition.Case presentationWe report a 49 years old man who presented with small bowel obstruction due to ileal fecalomas for whom enterotomy and removal of fecaloma was done with good outcome.DiscussionFecal matter can accumulate in the intestinal lumen to form a mass separate from other intestinal contents which eventually becomes fecaloma. Formation is usually related to chronic constipation, conditions causing intestinal motility disorder, or in psychiatric patients who could have ingested extraordinary substances. Fecaloma can present as abdominal mass, stercoral colitis, urinary retention or intestinal obstruction. Treatment options include conservative management with bowel rest, laxatives, endoscopic removal, laparotomy and removal via enterotomy.ConclusionFecaloma can be considered in patients who present with small bowel obstruction without any risk factors. Initial noninvasive management should be considered. Failed conservative treatment can be followed by laparotomy and fecaloma removal.     

恶性肠梗阻的处理与治疗

恶性肠梗阻常见于肠管肿瘤或妇科肿瘤患者.手术治疗对于大部分患者是首选,但对于预后极差的患者并不适用.鼻胃管减压仅用于短期治疗,自膨胀金属支架适用于胃出口梗阻及近端小肠梗阻.     

Small bowel obstruction caused by a solitary metastasis from carcinoma of the breast

Solitary gastrointestinal metastases from breast cancers are rare and are diagnosed late. This paper describes a small bowel breast metastasis discovered at laparotomy for small bowel obstruction. A higher index of clinical suspicion in these cases may lead to earlier detection and improved patient outcome.     

Small bowel obstruction

Background: This is a retrospective review of our experience using a laparoscopic approach in the treatment of acute and chronic small bowel obstruction (SBO). Materials and methods: Of 136 patients hospitalized in our institutions for acute (94 cases: 69.1%) and chronic (42 cases: 30.8%) SBO, from January 1994 to March 1998, 63 (46.3%) were approached laparoscopically. The etiology was accurately diagnosed in 58 cases (92%), and it was possible to treat it laparoscopically in 82.5% (52 of 63 cases). In the remaining 11 cases (17.4%), a formal laparotomy was needed for bowel resection, due to an ischemic small bowel or for malignant disease. Results: Overall, 82.5% of our cases were successfully treated laparoscopically. Conclusions: We conclude that, in experienced hands, laparoscopy is an excellent diagnostic and, in the majority of cases, a therapeutic surgical approach in selected patients with acute or chronic SBO. Received: 30 June 1998/Accepted: 12 February 1999     

The incidence and risk of early postoperative small bowel obstruction. A cohort study

Early postoperative small bowel obstruction is a rare (0.69 percent incidence) but serious postoperative complication with a relatively high mortality rate (17.8 percent). Operations performed below the transverse mesocolon impose an increased risk, whereas those limited to the upper abdomen are virtually free of risk. The clinical picture of a patient who initially manifests a return of gut function and advances to a diet, but then has loss of bowel function with distention and pain is most characteristic of early postoperative small bowel obstruction. Any patient in the high-risk group demonstrating this clinical picture should be presumed to have a mechanical small bowel obstruction, and early operation should be considered.     

Small bowel obstruction secondary to Meckel diverticulum detected and treated laparoscopically--case report

A 13-year-old man with no history of abdominal surgery was admitted to Saisei Kai Sendai Hospital complaining of acute abdominal pain. Abdominal computed tomography revealed distal small bowel obstruction of unknown etiology. Abdominal symptoms worsened and emergency surgery was performed. To determine the cause of bowel obstruction, laparoscopy was performed. At Trendelenburg position using endoscopic bowel forceps, the focus of the obstruction was explored. The dilated ileum was incarcerated at 10 cm proximal to the ileocecal region. Laparoscopic exploration revealed that the appendix was tightly attached to Meckel diverticulum (MD) and comprised an internal hernia orifice, in which the small bowel was incarcerated. Intra-abdominal surgical space was insufficient to release the bowel obstruction intracorporally. After a 5 cm of midline incision was made in the lower abdomen, a LAP-Disc (Hakko Co, Japan) was applied. Opening of the internal hernia orifice, normograde appendectomy, and resection of MD with a suturing instrument were performed. The hernia orifice between MD and the appendix was released and the incarcerated bowel was normalized. The patient was discharged without postoperative complications. Laparoscopic procedures are useful in identifying rare causes of bowel obstruction and to determine an appropriate access point for treatment.     

Causes of small bowel obstruction after laparoscopic gastric bypass

Background Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass is not a rare complication, occurring in approximately 3% of patients. The goal of this study was to review the causes and timing of small bowel obstruction as an aid to diagnosis, treatment, and prevention. Methods The records of consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass at the authors' center from 4/99 to 7/03 were retrospectively reviewed. All the patients had a laparoscopic handsewn gastrojejunostomy and a stapled jejunojej-unostomy. The Roux limb was placed retrocolically in the first 405 patients and antecolically in the next 1,310 patients. Results Altogether, 1,715 patients underwent a total laparoscopic Roux-en-Y gastric bypass at the authors' bariatric center. In 51 patients, 55 small bowel obstructions occurred (3%) during a median follow-up period of 21 months (range 1–52 months). Small bowel obstruction developed in 27 (7%) of the retrocolic patients, as compared with 24 (2%) of the antecolic patients (p<0.001, chi-square). The cause of small bowel obstruction were adhesive bands (n=14), obstruction at the jejunojejunostomy from kinking or narrowing (n=13), internal hernia or external compression at the transverse mesocolon (n=11), internal hernia through the jejunal mesentery (n=8) incarcerated abdominal wall hernia (n=4), and other (n=5). For patients in whom small bowel obstruction developed in the first 3 weeks after their bypass surgery bowel resection was required in 19 of 24 patients, as compared with 6 of 31 patients in whom obstruction develop after 3 weeks (p<0.001, chi-square). Conclusions Early small bowel obstructions tend to result from technical problems with the Roux limb and require revision of the bypass or small bowel resection significantly more often than late obstructions. The latter group of obstructions usually result from adhesions or hernias, which could be handled laparoscopically without bowel resection. The position of the Roux limb (retrocolic vs antecolic) appeared to influence the incidence of small bowel obstruction. In the current series, changing the position of the jejunal bypass limb from retrocolic to antecolic significantly decreased the overall incidence of small bowel obstruction because it eliminated one of the most common sites for obstruction: the mesocolon. Online publication: 13 October 2004