Importance of sonography in diagnosis of ileus. A retrospective study of 459 patients]

In a retrospective trial we investigated the significance of ultrasound in the diagnosis of intestinal obstruction in 459 patients. The overall sensitivity was 93.7%. In paralysis the correct diagnosis was obtained in 98% of all. Mechanical obstruction was identified in 91%. In cases of incomplete mechanical obstruction sensitivity was 89%. The corresponding value for complete obstruction was 95%. In all patients with negative findings on abdominal x-ray (10%) the correct diagnosis was established by ultrasound. Only in 71% of cases ultrasound was successful differentiating small bowel from large bowel obstruction. The underlying cause of ileus was yielded by ultrasound in 45% of the cases. On the basis of our experience ultrasound is proven to be of significant importance in the diagnosis and differentiation of ileus.     

Computer-aided diagnosis of the character of bowel obstruction.

A computer programme for the differential diagnosis of bowel obstruction was created and put into clinical practice to accelerate and simplify the diagnostic process. The training material was 503 cases of bowel obstruction admitted to the Surgical Clinic of Kaunas Medical University during 1990-1996. Based on 36 statistically significant anamnestical, clinical, laboratory investigations and plain abdominal X-ray findings, the computer programme was built up using a Bayesian formula. Retrospectively, the prognostic diagnosis was compared with the final clinical diagnosis based on instrumental or operative findings. Then, in a control group of 136 patients, the prospective prognostic diagnosis was obtained. The accuracy of the prognostic diagnosis in the control group of patients with complete small bowel obstruction amounted to 88.7% and for the patients with complete large bowel ileus 95.8%. Prognostic accuracy for partial small bowel obstruction was the most precise (96.1%) and for partial large bowel ileus (87.5%). The overall diagnostic accuracy of the computer algorithm was 92.6%. All cases were classified. This computer algorithmic programme for the differential diagnosis of the character of mechanical bowel obstruction has markedly shortened and facilitated the process of diagnosis of ileus.     

Modern diagnostic strategy in ileus

During the last 4 years (11/93-11/97) 330 patients with acute bowel obstruction were treated and analysed retrospectively. 80% of the obstructions (n = 265) were in the small bowel and 20% (n = 65) in the large bowel localized. Adhesions were the main cause in 65.7% (n = 174) of all small bowel obstructions, and one third (35.1%, n = 61) of these patients were treated conservatively. In the large bowel, however, 37% were caused by obstructing colon carcinoma mainly localized in the rectosigmoid region. Mechanical bowel obstruction remains to be one of the most common emergencies in general surgery. A successful treatment is based on a rapid and correct diagnosis followed by an immediate surgical intervention if indicated. There are no reliable clinical, laboratory or radiological signs of bowel strangulation available. Preoperative diagnostic examinations should confirm bowel obstruction, determine its localization and origin and exclude other pathologies. Furthermore, it should help in selecting a patient subgroup with small bowel obstruction due to adhesions, which might be treated conservatively. Preoperative diagnostic procedures include case history, clinical examination, basic laboratory tests and a plain abdominal x-ray. In patients with suspected small bowel obstruction due to adhesions without any signs of strangulation a contrast medium follow-through study may be indicated. If the contrast medium fails to pass into the colon within 5 hours, a surgical exploration is recommended. In large bowel obstruction a contrast medium enema, a computed tomography or a colonoscopy are valuable diagnostic tools.     

Intestinal obstruction after lung transplantation in children with cystic fibrosis.

BACKGROUND/PURPOSE: Distal intestinal obstruction syndrome (DIOS) occurs in 15% of patients with cystic fibrosis (CF). The authors reviewed their experience to determine the incidence, risk factors, and natural history of adhesive intestinal obstruction and DIOS after lung transplantation. METHODS: Eighty-three bilateral transplants were performed in 70 CF patients between January 1990 and September 1998. All were on pancreatic enzymes preoperatively, and none had preoperative bowel preparation. Fifty-six patients (80%) had prior gastrostomy (n = 54) or jejunostomy (n = 2). Eighteen patients (25.7%) had a previous laparotomy for meconium ileus (n = 8), fundoplication (n = 4), liver transplant (n = 1), jejunal atresia (n = 1), Janeway gastrostomy takedown (n = 1), pyloromyotomy (n = 1), free air (n = 1), or appendectomy (n = 1). RESULTS: After lung transplantation, 7 patients (10%) required laparotomy for bowel obstruction (6 during the same hospitalization, and 1 during a subsequent hospitalization). The causes of obstruction were adhesions only (n = 1), DIOS only (n = 2), and a combination of DIOS and adhesions (n = 4). Adhesiolysis was performed in the 5 patients with adhesions, and a small bowel resection was also performed in 1 patient. DIOS was treated by milking secretions distally without an enterotomy (n = 3) with an enterotomy and primary closure (n = 1) or with an end ileostomy and mucus fistula (n = 2). Five had recurrent DIOS early postoperatively. One resolved with intestinal lavage, 2 were treated successfully with hypaque disimpaction, and 2 underwent reoperation; 1 required an ileostomy. The most important risk factor for posttransplant obstruction was a previous major abdominal operation. Obstruction occurred in 7 of 18 (39%) who had undergone a prior laparotomy versus 0 of 52 who had not (P < .001, chi2). CONCLUSIONS: (1) The incidence of intestinal obstruction is high after lung transplantation in children with CF. (2) Previous laparotomy is a significant risk factor. (3) Recurrent obstruction after surgery for this condition is common. (4) Preventive measures such as pretransplant bowel preparation and early postoperative bowel lavage may be beneficial in these patients.     

肠粘连束带腹内疝的CT诊断

目的探讨肠粘连束带腹内疝的CT表现特点,提高术前早期诊断水平。 方法回顾性分析2001年1月至2017年3月,贵州医科大学附属医院经手术、病理证实为肠粘连束带腹内疝21例患者的临床与CT检查资料,同时有3例行多期增强CT,15例行腹部立位平片检查。在飞利浦影像工作站2位腹部放射高级职称医师双盲法评价图像。 结果术前21例患者均有程度不等的腹胀腹痛等肠梗阻症状,术前CT诊断小肠梗阻21例,提示肠粘连束带腹内疝3例,肠管绞窄5例,术前诊断符合率14.29%,漏诊率为85.71%。所有患者均手术证实小肠梗阻,肠管绞窄9例,11例合并肠扭转,1例合并腹茧症。主要影像表现包括：局部明显粘连伴束带形成21例（100%）,局限性肠梗阻21例（100%）,肠管异位21例（100%）,无疝囊（100%）,占位征象/周围脏器移位21例（100%）,鸟嘴征13例（61.90%）,缆绳征/漩涡征17例（80.95%）,肠壁增厚伴肠周明显渗出15例（71.43%）。肠粘连束带腹内疝的CT表现特征与手术结果存在相关性。 结论肠粘连束带腹内疝CT表现具有一定特点,提高认识并熟知其影像征象对早期诊断至关重要。     

Evaluation of findings during re-exploration for obstructive ileus after radical cystectomy and ileal-loop urinary diversion: insight into potential technical improvements

OBJECTIVE: To retrospectively evaluate the findings during re-exploration for obstructive ileus after radical cystectomy (RC) and ileal conduit diversion. PATIENTS AND METHODS: During a 12-year period, 434 patients who had RC and ileal conduit diversion were retrospectively evaluated for the diagnosis of early (相似文献   

生长抑素联合肠梗阻导管治疗粘连性肠梗阻

目的 探讨生长抑素联合肠梗阻导管在粘连性肠梗阻非手术治疗中的应用价值.方法 将91例粘连性肠梗阻患者按入院顺序随机分为A组(生长抑素+肠梗阻导管组),B组(生长抑素+鼻胃管减压组),C组(肠梗阻导管组)和D组(鼻胃管组).常规治疗包括禁食、纠正水电解质和酸碱平衡紊乱,全胃肠外营养以及应用抗生素.A组在常规治疗基础上应用生长抑素类似物(善宁)0.6 mg加入0.9％氯化钠溶液500 ml持续静脉滴注,同时联合置入肠梗阻导管取代普通鼻胃管行肠内减压.观察和比较4组治疗前后临床症状及体征改善情况、胃肠减压量、自主排气、排便时间和中转手术率.数据分别采用方差分析和x2检验进行分析.结果 各组平均腹痛和腹胀的缓解时间分别为3.6±1.5,5.3±1.8,5.8±1.7和8.4±2.2d (F=28.715,P=0.000);恢复排气、排便时间分别为4.5±1.9,5.7±1.4,6.0±1.1和7.8±1.7 d(F=23.857,P=0.000);A组临床症状明显改善.平均胃肠减压量分别为A组:632±102 ml/d;B组:410±86 ml/d,C组:1020±148 ml/d和D组590±97 ml/d.在C组,患者的胃肠减压量明显增加(F值分别为17.367,16.347,P=0.000),而A组则明显减少(F值分别为11.687,10.399,P=0.000).4组中转手术率分别为0(0/22),10％ (2/19),9％( 3/23)和22％ (6/27),A组中转手术率明显低于D组(x2=5.571,P=0.018).结论在常规治疗的基础上,应用生长抑素静脉持续泵入联合肠梗阻导管治疗,可加速改善粘连性肠梗阻患者的临床症状,并且提高保守治疗的成功率.     

Invagination caused by a malignant jejunal polyp--lessons from a diagnostic error

Authors reviewed the records of a patient with a 6 year long history of severing abdominal complaints, correct diagnosis came only in the state of acute abdomen for ileus. He underwent numerous radiological exams and gastroscopies in the course of repeated check-ups in other institute. Due to these results his complaints were managed as gastro esophageal reflux. After years of ineffective therapy his parents and physician suggested him to apply for psychiatric treatment. Finally, for the symptoms and radiological results of mechanical upper small bowel obstruction he underwent urgent laparotomy. Approximately a 40 cm long jejunal invagination was found caused by a large jejunal polyp. Segmental small bowel resection was carried out. Histologic examination of the resected specimen proved Grade I. adenocarcinoma. One year after an uneventful postoperative period the patient is free of complaints and symptoms. The differential diagnosis between upper small bowel obstruction and severe vomiting of esophago-gastro-duodenal origin is relatively difficult. For this we recommend utilizing all the recent diagnostic methods in case of hesitancy or ineffective therapy.     

腹腔镜下根治性膀胱切除+尿流改道术后肠梗阻的防治策略

目的:探讨腹腔镜根治性膀胱切除术后肠梗阻的诊治措施及预防策略。方法:回顾分析5年来腹腔镜下根治性膀胱切除术及开放手术患者的临床资料。结果:27例发生肠梗阻,23例经保守治疗后好转,4例再次手术。腹腔镜与开放手术后肠梗阻的胃肠功能恢复时间、保守治疗的效果差异无统计学意义。结论:根治性膀胱切除术后肠梗阻一般均表现为小肠梗阻,发生术后肠梗阻的10项防治策略为:(1)正确诊治术后早期炎性肠梗阻;(2)腹膜化;(3)加强围手术期营养支持,控制血糖;(4)减少腹腔引流管的放置,避免气腹压过高;(5)关注小肠坠入盆腔粘连成团的问题;(6)术后早期活动;(7)合理选择尿路改道术式;(8)减少尿漏,提高手术技巧;(9)胃肠减压,防治腹腔间隔室综合征;(10)正确使用相关药物,控制感染。     

Congenital and acquired mesocolic hernias presenting with small bowel obstruction in childhood and adolescence

Objective

The objective was to present a case series of pediatric patients presenting with small bowel obstruction secondary to both congenital and acquired internal mesocolic hernias, and the use of imaging technology in the management of this condition.

Methods

A retrospective review of patients treated at the Yale-New Haven Children's Hospital for small bowel obstruction from 1998 to 2008 (n = 6) who presented with acute small bowel obstruction secondary to internal mesocolic hernias was performed.

Results

We present 6 patients with small bowel obstruction caused by congenital (n = 4) and acquired (n = 2) mesocolic hernias after previous surgery. The median age at presentation was 13 years. Small bowel obstruction with a mesocolic hernia was identified by preoperative abdominal computerized tomography in 3 patients (50%) and at operation in the others. The mean length of stay was 6 days, with no recurrent episodes in the follow-up period.

Conclusion

Small bowel obstruction secondary to mesocolic hernias, although rare, may be considered in the differential diagnosis of patients with history of malrotation or abdominal wall defects owing to their association with congenital mesenteric anomalies. This condition requires special attention from the clinician because of its catastrophic consequences. Imaging studies are an important asset because of the difficulty in making an accurate clinical diagnosis and the rarity of internal hernias.     

Subtotal colectomy in the course of gallstone-ileus surgery

A big gallstone penetrating through a bilio-digestive fistula into the bowel can make a complete obstruction of it in the majority of the cases requiring an urgent operation. It is a rare situation that a fistula like this leads into the colon and the stone makes a large bowel obstruction. A 72-year-old male patient was admitted to our department with the symptoms of colon obstruction. After the examinations he underwent an explorative laparotomy. During the course of the operation an obstruction was found in the proximal third of the descending colon. A subtotal colectomy was carried out. At the opening of the resected colon a big gallstone was found as the cause of the obstruction, which simulated a tumorous obstruction. We present through this case the possibilities and results of the diagnosis and treatment of gallstone ileus. We conclude that in the prevention of gallstone ileus, the early operative treatment of detected gallstone is essential.     

The role of computed tomography with contrast and small bowel follow-through in management of small bowel obstruction.

BACKGROUND: In a significant percentage of patients, radiologic evaluation other than plain abdominal films are required to confirm or exclude the presence of small bowel obstruction. METHODS: Over a 1-year period, 55 patients had both computed tomography and small bowel follow-through studies. Patients were classified as having (1) paralytic ileus, (2) low-grade obstruction, (3) high-grade obstruction, or (4) complete mechanical obstruction. The gold standard for diagnosis was celiotomy in 42 patients and clinical follow-up in 13 patients. RESULTS: Thirty-six out of 42 patients had proven intestinal obstruction at the time of celiotomy. Computed tomography identified 32 out of the 36 high-grade and complete mechanical obstructions. Computed tomography was superior to small bowel follow-through in identifying masses, malignancies, and features of strangulation. Small bowel follow-through correctly identified "insignificant obstructions" when contrast reached the cecum within 4 hours in 18 of 19 patients. CONCLUSIONS: In patients with equivocal findings of small bowel obstruction, computed tomography should be used initially and then small bowel follow-through if computed tomography is not diagnostic. Computed tomography was superior in this study for detecting the cause of the intestinal obstruction and presence of strangulation.     

Small bowel obstruction by a congenital band in 16 adults

During embryogenesis, abnormal adhesion of the peritoneal folds induces a congenital band which can cause small bowel obstruction. PATIENTS AND METHODS: From 1987 to 2001, 16 adult patients underwent surgery for small bowel obstruction due to a congenital band. There were 8 men and 8 women with a mean age of 59 years (range 23-90). None presented previous abdominal surgery. RESULTS: Six patients presented acute abdominal pain the month before hospitalization. Among the 16 patients, 9 were operated at admission, and 7 after initial surveillance. Suspected diagnosis before operation was small bowel obstruction in 8 cases (with a diagnosis of congenital band in 3); perforated duodenal ulcer (n = 2); appendicitis (n = 2); mesenteric infarction (n = 1); diverticultis (n = 1); cholecystitis (n = 1); and strangulated hernia (n = 1). During operation performed through laparotomy or laparoscopy, a congenital band was noted in 100% of the cases, associated with intestinal necrosis in 5. One patient died postoperatively. CONCLUSION: Because small bowel obstruction by congenital band is a rare condition, it represents a frequent problem of diagnosis. In this situation, the possibility of intestinal necrosis expose the patient to a possible fatal outcome.     

Gallstone ileus as a complication of acute cholecystitis. Laparoscopic diagnosis and treatment

Gallstone ileus accounts for 1-4% of all cases of intestinal obstruction, with its incidence rising with age of patients. There is often a long delay between onset of symptoms (usually abdominal pain, vomiting, and bowel distension) and proper treatment, with a simple enterolithotomy as the one of choice. We report a case of an atypical gallstone ileus presented as a complication of acute cholecystitis, treated with a laparoscopic guided enterolithotomy. A 67-year-old woman on the 5th p.o. day after a laparoscopic procedure for an empyematous cholecystitis (no sign of fistula or duodenal perforation and a "negative" intraoperative cholangiography) presented continuous vomiting as the only symptoms of a subileus (radiographic diagnostic images negative for intestinal obstruction or intraluminal gallstone or duodenal fistula). A laparoscopic diagnostic approach revealed a gallstone in the distal jejunum. Through a 5 cm midline incision the intestine, including the gallstone, was brought out extracorporally and the stone was removed by a simple enterolithotomy. The postoperative course was uneventful and the patient had no complaint at a 1-year follow-up. We consider the laparoscopic approach, in patients with "abdominal emergencies," feasible and safe in experienced hands. It provides diagnostic accuracy as well as therapeutic capabilities, as in the case of gallstone ileus we have reported.     

Laparoscopic management of a primary small bowel volvulus: a case report

Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.     

Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain.

In an effort to develop referral criteria for the ordering of abdominal radiographs for patients presenting with abdominal symptoms, we prospectively studied the relation between clinical data and radiographic abnormalities. Of 1780 examinations, 179 (10.0%) showed some radiographic abnormality. If abdominal radiographs would have been limited to those patients who had moderate or severe abdominal tenderness, or to patients with a high clinical suspicion of bowel obstruction, renal or ureteral calculi, trauma, ischemia, or gallbladder disease, regardless of the degree of tenderness, 956 (53.7%) examinations would not have been done. All radiographic abnormalities reflecting a serious pathologic process would have been identified. Only 33 (3.5%) abnormalities of limited significance, almost all localized or generalized ileus, would have been undetected. The adoption of these referral criteria would result in minimal loss of clinically useful information, large financial savings, and a reduction in radiation exposure.     

Bilious vomiting in the newborn: How often is it pathologic?

Background/Purpose: Intestinal obstruction is one of the most common reasons for admission to a neonatal surgical unit and frequently is manifest by bilious vomiting. Not all cases of neonatal bilious vomiting are caused by intestinal obstruction. This study aimed to investigate the outcome of neonates with bilious vomiting. Methods: A prospective audit was undertaken of all neonates with a history of bilious vomiting referred to a regional pediatric surgical unit during a 2-year period (1998 to 2000). Infants with bilious nasogastric aspirates but no vomiting were not included. Demographic details, symptomatology, investigations, and final diagnoses were recorded. Subsequent clinical progress was ascertained by out-patient review or telephone interview. Results: Sixty-three consecutive neonates (35 boys, 28 girls) were identified with a median gestational age of 40 (range 31 to 42) weeks and median birth weight of 3.5 kg (range 1.67 to 4.64). Median age at presentation was 26 hours (range, 9 hr to 28 days). A surgical cause of bilious vomiting was identified in 24 (38%): Hirschsprung's disease (n = 9), small bowel atresia (n = 5), intestinal malrotation (n = 4), meconium ileus (n = 3), meconium plug (n = 1), colonic atresia (n = 1), and milk inspissation (n = 1). Nineteen of these had both abdominal signs and an abnormal plain abdominal radiograph, and 4 had an abnormal abdominal radiograph only. In one infant with intestinal malrotation, clinical examination and plain radiography were unremarkable. After definitive surgery, all 24 infants were well at a median age of 14 (7 to 28) months. No surgical cause for bilious vomiting was found in 39 (62%) neonates whose symptoms resolved with conservative management. Conclusions: These data emphasize the maxim that bilious vomiting in the newborn should be attributed to intestinal obstruction until proved otherwise. However, in this prospective audit, bilious vomiting was not caused by intestinal obstruction in 62% of cases, and most of these infants suffered no further sequelae. J Pediatr Surg 37:909-911.     

Gallstone ileus of the sigmoid colon: a rare complication of cholelithiasis

The authors report a case of gallstone ileus of the sigmoid colon in an 80-year-old woman admitted to the hospital with symptoms and signs of large bowel obstruction and asymptomatic cholelithiasis. Radiological investigation (abdominal X-ray and CT scan) showed a large gallstone impacted in the sigmoid colon. At first, the patient was managed conservatively, but the recurrence of the intestinal obstruction required open cholecystectomy, suturing of the colonic fistula and sigmoidectomy.     

肠内全程导管减压法用于术后早期炎性肠梗阻治疗的研究

目的评价经鼻置入导管行肠内全程减压在术后早期炎症性肠梗阻保守治疗中的作用。方法回顾性分析北京大学第三医院2005年3—8月收治的8例腹部手术后早期炎症性肠梗阻的病人，使用鼻胃管减压等常规保守治疗无效后，经鼻置入导管行肠内全程减压，并进行胃肠减压治疗，观察其治疗效果。结果与鼻胃管相比，使用肠内全程导管减压后，病人的胃肠减压量明显增加、腹围和腹腔内压力明显降低；通过3～10d的经鼻置入导管减压等保守治疗后，8例病人的肠梗阻症状均缓解，未再接受手术治疗。结论经鼻肠内全程导管减压用于治疗术后早期肠梗阻安全有效，且可能使病人免于再次急诊手术。     

Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible