Correlation of trauma scoring systems with abdominal septic complications in abdominal trauma.

INTRODUCTION: Anatomical trauma scoring systems can predict the occurrence of postoperative abdominal septic complications (ASC) after major abdominal trauma; however, this has not been validated in any Indian study. We attempted such an evaluation in patients attending a teaching hospital in central India. METHOD: A retrospective analysis of data from 169 patients who had undergone emergency laparotomy for penetrating or blunt abdominal injury between August 1996 and July 2001 was done. Every patient was scored using three trauma severity indices and the occurrence of ASC was identified. RESULTS: Patients who developed ASC had higher trauma severity scores than those who did not. Thirty-eight patients had isolated small bowel injury; trauma scores underestimated the occurrence of ASC in these patients. CONCLUSIONS: Trauma severity indices may serve as useful tools to predict the occurrence of postoperative ASC in patients with abdominal trauma, except in those with isolated small bowel injury. There is thus a need to modify the weight of small bowel injury in these scoring systems.     

Expanding role of capsule endoscopy in inflammatory bowel disease

Capsule endoscopy has been shown to detect small bowel inflammatory changes better than any other imaging modality. Selection criteria have been optimized to increase the yield of capsule endoscopy in patients suspected to have Crohn＇s disease. Capsule endoscopy allows for earlier diagnosis of Crohn＇s disease of the small bowel and improved diagnosis of colitis in patients where it is unclear if they suffer from Crohn＇s or ulcerative colitis. A test capsule is available to assess for small bowel strictures and thus avoid capsule retention. A common language has been developed and a new scoring index will be added to capsule software. It is envisioned that the manner in which we treat Crohn＇s disease in the future will change, based on earlier diagnosis and treatment aimed at mucosal healing rather than symptom improvement.     

Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report

Rationale:The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention.Patient concerns:A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain.Diagnoses:The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing.Interventions:The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed.Outcomes:The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery.Lessons:Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.     

QUANTITATIVE ANALYSIS OF LOW‐DOSE ASPIRIN‐ASSOCIATED SMALL BOWEL INJURY USING A CAPSULE ENDOSCOPY SCORING INDEX

Aim: The major limitation of capsule endoscopy (CE) has been the lack of a standardized and validated severity scale for mucosal injury. The aim of the present study was to verify the usefulness of quantifying small bowel mucosal changes associated with giving low‐dose aspirin (LDA) using a CE scoring index. Methods: The CE score for small bowel mucosal injury was investigated to evaluate the severity of mucosal injury. Healthy volunteers and patients suspected of having small bowel disease were recruited for this study. The short‐term LDA group (V + S‐LDA group) consisted of volunteers who took low‐dose aspirin for 14 days; this group was then compared with healthy volunteers who did not receive LDA treatment (V‐Control group). The long‐term LDA group (L‐LDA group) consisted of patients with at least a 3‐month history of daily LDA use; this group was compared with non‐users of LDA (P‐Control group). Results: The CE score was significantly higher in the V + S‐LDA group than in the V‐Control group. In the V‐Control group, almost all the subjects were categorized as exhibiting a ‘normal’ change. ‘Mild’ changes were observed significantly more frequently in the V + S‐LDA group than in the V‐Control group. The CE score was significantly higher in the L‐LDA group than in the P‐Control group. ‘Mild’ or ‘moderate or severe’ changes were observed significantly more frequently in the L‐LDA group than in the P‐Control group. Conclusion: The CE scoring system was useful for evaluating LDA‐associated small bowel mucosal disease activity and for objectively scoring the small bowel inflammatory disease state.     

Spontaneous free perforation of the small intestine

In western cultures, spontaneous free perforation of the small intestine in adults is rare. The vast majority of published reports are of isolated cases. A review of 19 patients treated at the Lahey Clinic over the past 23 years is presented. All patients presented with an acute onset of peritoneal signs, and free perforation subsequently was documented at operation or at autopsy. Causes of the perforations were malignancy, six; inflammatory small bowel disease, four; combinations of radiotherapy, chemotherapy, or steroids, four; mechanical, three; and iatrogenic, two. Of the 19 patients, 15 had a history of previous abdominal surgery or recent steroid use, chemotherapy, or radiation therapy. Although the underlying disease may be of prime importance in causing perforation, these treatment modalities may be important factors in enhancing predisposition to perforation. Of the 16 patients operated on, ten had intestinal resection with primary anastomosis, and six had primary closure of the perforation. Four major complications included two deaths, and five minor complications occurred. In general, earlier operative intervention decreased mortality. A population of patients who may be at risk for small bowel perforations is identified. A review of the pertinent literature is presented. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Francisco, California, May 2 to 6, 1982.     

Frequency of small bowel polyps in patients with duodenal adenoma but without familial adenomatous polyposis

INTRODUCTION: It is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis (FAP) are at greater risk for small bowel neoplasia. We therefore conducted a study to determine the frequency of small bowel polyps in patients with non-papillary duodenal adenomas using capsule endoscopy for small bowel examination. PATIENTS AND METHODS: 14 patients (8 women, 6 men; mean age 67 +/- 10 years; range: 49 - 77 years) with non-papillary duodenal adenomas without FAP were included. All patients underwent wireless capsule endoscopy. The results were compared with an age- and sex-matched cohort of patients undergoing capsule endoscopy for suspected small bowel disease. RESULTS: Overall, 15 polyps ranging between 1 and 8 mm in diameter were detected in eight patients of the study group, whereas no polyps could be identified in the control group. Natural excretion of the capsule within 24 hours was always reported and no complications were reported by any of the patients. Other pathological findings were multiple angiodysplasias in two patients of the study group. In the control group capsule endoscopy detected angiodysplasias in 5 patients with the indication obscure gastrointestinal bleeding, and inflammatory lesions in 2 patients with suspected Crohn's disease. CONCLUSIONS: Based on the results of this prospective study, the frequency of small bowel polyps in patients with duodenal adenomas without familial adenomatous polyposis appears to be increased compared with a control group undergoing capsule endoscopy for other reasons. In none of the patients was the management altered. Follow-up data of these patients will be needed.     

Explosion from argon cautery during proctoileoscopy of a patient with a colectomy

We report a unique case of a 70-year-old woman with Gardner's syndrome who had a subtotal colectomy with ileoproctostomy. Since then, she has undergone 12 uncomplicated proctoileoscopies, each time with argon plasma coagulation ablation of small polyps without any bowel preparation. However, during the most recent procedure, when we attempted to cauterize some rectal polyps, an immediate explosion occurred, leading to multiple rectal and ileal perforations that required surgical repair with a temporary end ileostomy. This event suggests that bacterial fermentation of colonic content or visible feces is not necessary for combustion because we observed a cautery-related explosion in the absence of a colon. This case shows the need for adequate bowel preparation if cautery is to be used, even in patients who have undergone a colectomy.     

Comparison of scoring systems in predicting the severity of acute pancreatitis

AIM:To investigate the prognostic usefulness of several existing scoring systems in predicting the severity of acute pancreatitis(AP).METHODS:We retrospectively analyzed the prospectively collected clinical database from consecutive patients with AP in our institution between January 2011 and December 2012.Ranson,Acute Physiology and Chronic Health Evaluation(APACHE)-Ⅱ,and bedside index for severity in acute pancreatitis(BISAP)scores,and computed tomography severity index(CTSI)of all patients were calculated.Serum C-reactive protein(CRP)levels were measured at admission(CRPi)and after 24h(CRP24).Severe AP was defined as persistent organ failure for more than 48 h.The predictive accuracy of each scoring system was measured by the area under the receiver-operating curve(AUC).RESULTS:Of 161 patients,21(13%)were classified as severe AP,and 3(1.9%)died.Statistically significant cutoff values for prediction of severe AP were Ranson≥3,BISAP≥2,APACHE-Ⅱ≥8,CTSI≥3,and CRP24≥21.4.AUCs for Ranson,BISAP,APACHE-Ⅱ,CTSI,and CRP24 in predicting severe AP were 0.69(95%CI:0.62-0.76),0.74(95%CI:0.66-0.80),0.78(95%CI:0.70-0.84),0.69(95%CI:0.61-0.76),and0.68(95%CI:0.57-0.78),respectively.APACHE-Ⅱdemonstrated the highest accuracy for prediction of severe AP,however,no statistically significant pairwise differences were observed between APACHE-Ⅱand the other scoring systems,including CRP24.CONCLUSION:Various scoring systems showed similar predictive accuracy for severity of AP.Unique models are needed in order to achieve further improvement of prognostic accuracy.     

Complicaciones intestinales graves en pacientes SARS-CoV-2 recibiendo manejo protocolizado

Introduction and aimsA case series of ten patients that received protocolized care for SARS-CoV-2 infection and developed severe gastrointestinal complications, is presented. The aim of our study was to contribute to the ongoing discussion regarding gastrointestinal complications related to SARS-CoV-2 infection. After reviewing the current literature, ours appears to be the first detailed case series on the topic.Materials and methodsA retrospective filtered search of all patients admitted to our hospital for SARS-CoV-2 infection, who developed severe gastrointestinal complications, was performed. All relevant data on hospital patient management, before and after surgery, were collected from the medical records.ResultsOf the 905 patients admitted to our hospital due to SARS-CoV-2 infection, as of August 26, 2020, ten of them developed severe gastrointestinal complications. Seven of those patients were men. There were four cases of perforation of the proximal jejunum, three cases of perforations of the ascending colon, one case of concomitant perforation of the sigmoid colon and terminal ileum, one case of massive intestinal necrosis, and one preoperative death. Three right colectomies, four intestinal resections, one Hartmann's procedure with bowel resection, and one primary repair of the small bowel were performed. The mortality rate of the patients analyzed was 50%.ConclusionSpontaneous bowel perforations and acute mesenteric ischemia are emerging as severe, life-threatening complications in hospitalized SARS-CoV-2 patients. More evidence is needed to identify risk factors, establish preventive measures, and analyze possible adverse effects of the current treatment protocols.     

Peritonitis in patients over the age of 50 years: 98 cases managed surgically

Generalized peritonitis in patients over the age of 50 years is a common surgical emergency. This is a retrospective analysis of 98 cases managed surgically. Duodenal ulcer perforations, necrotizing enteritis, acute cholecystitis with perforation and small bowel perforations were the common causes. Most of them presented late, and many had associated conditions. Re-look laparotomies had a definite role to play. While there is significant decrease in the number of typhoid and tubercular peritonitis, there appears to be an increase in the incidence of necrotizing enteritis and acute cholecystitis.     

A simplified prognostic scoring system for peptic ulcer perforation in developing countries.

BACKGROUND: Several complex prognostic scoring systems are available for abdominal sepsis. We constructed and assessed a simplified scoring system for peptic perforation, which can be easily used in developing countries. METHODS: One hundred and forty consecutive patients with perforated pre-pyloric or duodenal ulcer undergoing Graham's patch omentopexy closure were studied prospectively. Each factor was given a score based on its severity in accordance with the APACHE-II scoring system to construct the simplified prognostic (Jabalpur) scoring system, and multiple regression analysis was used to identify risk factors. This system was prospectively validated in the next 50 consecutive patients and compared to existing systems. RESULTS: The factors associated with mortality were age, presence of co-morbid illness, perforation-to-operation interval, preoperative shock, heart rate, and serum creatinine. The mean score in survivors (4.9) was less than that in those who died (12.5; p<0.0001). This scoring system compared favorably with other scoring systems. CONCLUSIONS: The Jabalpur scoring system is effective for prognostication in cases of peptic perforation. It is simple and user-friendly as it uses only six routinely documented clinical risk factors.     

Endoscopic scoring systems for inflammatory bowel disease: pros and cons

Endoscopy plays a pivotal role for diagnosis and assessment of disease activity and extent in patients with inflammatory bowel diseases. International guidelines recommend the use of endoscopic scoring systems for evaluation of the prognosis and efficacy of medical treatments. Ideal scoring systems are easy to use, reproducible, reliable, responsive to changes, and validated in different clinical settings in order to guide therapeutic strategies. However, currently available endoscopic scoring systems often appear as complex for routine endoscopy and suffer from insufficient interobserver agreement and lack of formal validation which often limit their use in clinical trials. Here, we describe the role of endoscopic scoring systems in inflammatory bowel diseases focusing on pros and cons in the era of advanced endoscopic imaging and mucosal healing.     

Obesity increases the severity of acute pancreatitis: performance of APACHE-O score and correlation with the inflammatory response.

BACKGROUND: Obese patients appear to be at risk for complications of acute pancreatitis (AP). APACHE-O score has been suggested to improve APACHE-II accuracy in predicting severe outcome in AP. AIMS: To determine if APACHE-O adds any predictive value to APACHE-II score and to test the hypothesis that obese patients are at increased risk of severe AP (SAP) because of a more intense inflammatory response to pancreatic injury. METHODS: 102 AP patients were prospectively studied. Using a body mass index (BMI) >30, 28% of the subjects were obese. Nineteen patients developed organ dysfunction and were classified as SAP. Receiver-operating curves for prediction of SAP were calculated using admission APACHE-II and APACHE-O scores. Binary logistic regression was performed to assess if obesity is a risk for SAP and to determine the clinical factors associated with severe disease. Serum levels of IL-6, MCP-1 and CRP as well as Ranson's scores were compared between obese and non-obese patients. RESULTS: Admission APACHE-O (area under the curve AUC 0.895) and APACHE-II (AUC 0.893) showed similar accuracy in predicting severe outcome. BMI was identified as a significant risk for SAP (OR 2.8, p = 0.048) and mortality (OR 11.2, p = 0.022). CRP levels were significantly higher in obese AP patients (p = 0.0001) as well as Ranson's score (p = 0.021). IL-6 and MCP-1 levels were higher in obese patients but did not reach statistical significance. CONCLUSIONS: Obesity is an independent risk for SAP. Admission APACHE-O score is not more accurate than APACHE-II. Our study results suggest that obesity increases the severity of AP by amplifying the immune response to injury.     

Effect of glycemic gap on short term outcome in critically ill patient: In zagazig university hospitals

Both admission Blood glucose and previous glycemic state may affect critically ill patients; So Glycemic gap may be a good indicator of ICU outcomes. This study investigated the effect of glycemic gap on short term outcome in critically ill patient and the value of incorporation of the Glycemic Gap into the APACHE-II on its discriminative performance.Subjects and MethodsThis cross sectional study was conducted in medical ICU of Zagazig University Hospitals, March 2018 to September 2018; total numbers of 240 critically ill patients admitted to ICU were enrolled in. All of them were subjected to: full history taking, clinical examination, routine investigations, random blood sugar, hemoglobin A1c. ADAG, Glycemic Gap and APACHE II were calculated.ResultsElevated glycemic gap was associated with an increased ICU mortality and APACHE-II score was a good predictor of ICU mortality in critically ill patients.ConclusionsElevated glycemic gap was significantly associated with an increased ICU mortality that the glycemic gap can be used to assess the severity and prognosis of critically ill patients and their incorporation into the APACHE II score has increased its performance as a predictor of mortality.     

Small Bowel Enteroscopy and Intraoperative Enteroscopy for Obscure Gastrointestinal Bleeding

Intraoperative endoscopy (IOE) is accepted as the ultimate diagnostic procedure for completely evaluating the small bowel in patients with obscure gastrointestinal (GI) bleeding. Small bowel enteroscopy (SBE) has been reported useful in the nonsurgical evaluation of the small intestine in these patients, but findings may be limited because of incomplete small bowel intubation and a lack of tip deflection. Twenty-three patients underwent 25 SBE exams and subsequently had 25 IOE exams during surgical exploration for continued bleeding. Patients' bleeding histories averaged 2 yr, with an average transfusion requirement of 27 units. Findings on IOE were the same as with SBE in 17/22 (77%) of examinations. We conclude that SBE and IOE are comparable in depth of insertion and ability to detect small vascular ectasias. Both procedures missed pathology due to limited visibility and the evanescent nature of ectasias. Long-term success in abolishing bleeding with these combined techniques can be expected in 55% of these patients. SBE should precede surgery, since the finding of diffuse ectasias precludes any benefit from operative intervention.     

Risk factors and a simple scoring system for predicting bowel resection in infants with NEC

Background and aimsWe intended to investigate the predictors for bowel resection in infants with necrotizing enterocolitis (NEC). We further developed a scoring system for better predicting bowel resection.MethodsA total of 207 infants who underwent surgical management at Children's Hospital, Chongqing Medical University between April 2008 and December 2020 were identified for the following investigation. Bowel resection was reviewed among the infants who underwent the procedure. Potential parameters related to bowel resection were explored using a multiple logistic regression method, and then a scoring system was developed.ResultsAmong the 207 patients who underwent operative intervention that were reviewed, 109 infants underwent bowel resection. Multivariate logistic regression analysis showed that birth weight, hypotension, neutropenia, pneumoperitoneum, acidosis, and intestinal wall thickness were predictors related to the occurrence of bowel resection. A 6-point scoring system was further developed based on the obtained total coefficient, and the infants could be divided into low-, moderate- and high-risk groups according to cut values of 7 and 13.ConclusionThe results of this study demonstrated that severe NEC features and low birth weight were associated with bowel resection. The risk scoring system could accurately separate infants that were suspected to have bowel loss during surgery.     

Functional bowel disease: malabsorption and abdominal distress after ingestion of fructose, sorbitol, and fructose-sorbitol mixtures

Twenty-five patients with functional bowel disease were given fructose, sorbitol, fructose-sorbitol mixtures, and sucrose. The occurrence of malabsorption was evaluated by means of hydrogen breath tests and the gastrointestinal symptoms, if any, were recorded. One patient could not be evaluated because of lack of H2 production. Based on a cut-off level of 10 ppm rise of H2 concentration, malabsorption was apparent in 13 patients, in 7 of which the calculated absorption capacities were below 15 g. In contrast, in patients given 50 g of sucrose, malabsorption could not be detected. Ingestion of fructose caused marked abdominal distress in patients with demonstrable malabsorption. Ingestion of sucrose in these patients gave less pronounced symptoms of abdominal distress. Malabsorption of a 5-g dose of sorbitol could be detected in 8 of 13 patients. Mixtures of 25 g of fructose and 5 g of sorbitol caused significantly increased abdominal distress, and more than additive malabsorption was found in several cases. The present study shows that pronounced gastrointestinal distress may be provoked by malabsorption of small amounts of fructose, sorbitol, and fructose-sorbitol mixtures in patients with functional bowel disease. The findings may have direct influence on the dietary guidance given to a major group of patients with functional bowel disease and may make it possible to define separate entities in this disease complex.     

Multiple spontaneous small bowel perforations due to systemic cholesterol atheromatous embolism.

A-65-year-old man was admitted for coronary and peripheral angiography to evaluate angina pectoris and peripheral vascular disease. Following angiography, he suffered from blue toes, livedo reticularis and progressive renal failure. The patient's condition continued to deteriorate, including the development of malnutrition. Four months later he suddenly developed panperitonitis, went into shock and died. The autopsy verified multiple perforations of the small bowel with disseminated cholesterol atheromatous embolism. The other organs including kidney were also invaded by atheroembolism. This was a rare case of multiple spontaneous perforations of small bowel due to systemic cholesterol atheromatous embolism.     

Role of capsule endoscopy in inflammatory bowel disease: where we are and where we are going

Capsule endoscopy (CE) is an innovative technological breakthrough that for the first time provides a noninvasive method to obtain high-resolution imaging of the entire small bowel. Since its recent inception, the diagnostic utility of CE has become well established for the evaluation of diverse ulcerative and inflammatory disorders of the jejunum and ileum. The incredible resolution of its lens (0.1 mm) detects focal villous edema or atrophy, denuded, as well as ulcerated mucosal lesions missed by other imaging techniques. CE has been shown by meta-analysis to be a more sensitive method to investigate patients for small bowel Crohn's disease, with an incremental yield above 30% versus other imaging modalities. In patients with indeterminate colitis, CE is useful in distinguishing between ulcerative and Crohn's colitis. Among patients with established Crohn's disease, CE may be employed to determine: (1) the extent and severity of small bowel involvement, (2) postoperative recurrence, (3) post-therapy mucosal healing, and (4) whether active small bowel inflammatory lesions exist in the clinical setting of functional bowel disorder. Complications are rare and include capsule retention at stricture sites. The new patency capsule can diminish the risk of the latter problem in at-risk patients. CE can also serve as a guide to sites that require biopsies or dilatation by push or double-balloon enteroscopy. However, other causes of small bowel lesions may mimic Crohn's disease. A standard terminology system has thus been developed, and a CE Crohn's disease severity scoring index is currently undergoing validation studies.     

Causes of acute peritonitis in 1188 consecutive adult patients in Ghana

In a five-year prospective study, 1188 consecutive adult patients were admitted and treated for acute generalized peritonitis at the Surgical Emergency Unit of the Komfo Anokye Teaching Hospital, Kumasi, Ghana. Appendicitis and typhoid ileal perforation were the commonest causes, occurring in 43.1% and 35.1% of patients, respectively. Other conditions (gastroduodenal perforations, ruptured abscesses, traumatic bowel perforations and amoebic colonic perforations) accounted for fewer than 25% of cases.