Superior mesenteric thrombosis associated with small bowel stricture. Case report

Intestinal stricture from superior mesenteric vein (SMV) thrombosis is a relatively infrequent, though important cause of intestinal obstruction. The symptom of intestinal obstruction in a patient with chronic SMV thrombosis should be considered as the possibility of bowel stricture. We report 2 cases of small bowel stricture that is related to chronic SMV thrombosis which were treated with segmental resection of strictured bowel.     

Preservation of small bowel with the selective use of heparin and second look laparotomy in acute mesenteric ischaemia: A case report

IntroductionAcute mesenteric ischaemia may occur due to mesenteric arterial embolus, thrombosis, non-occlusive mesenteric ischaemia or venous thrombosis resulting in ischaemia of the bowel wall.Presentation of caseA 41 year old woman presented with worsening abdominal pain, decreased appetite, nausea and vomiting. Examination revealed right lower quadrant tenderness. Investigations revealed elevation of her inflammatory markers. At laparotomy two separate segments of ischaemic but potentially viable small bowel were identified secondary to mesenteric venous thrombosis. Bowel salvage was attempted with the use of intravenous unfractionated heparin and this was confirmed following a second look laparotomy.DiscussionDespite a normal platelet count at presentation a diagnosis of JAK-2 positive essential thrombocythaemia was made thus explaining the acquired prothrombotic state underlying the venous thrombosis. The selective use of intravenous unfractionated heparin and second look laparotomy may provide a means for bowel preservation in these cases.ConclusionThis case highlights the potential of bowel salvage can be achieved following an episode of acute mesenteric ischaemia with the use of intravenous unfractionated heparin and selective second look laparotomy and the importance of considering underlying myeloproliferative disease in such cases even in the absence of a thrombocytosis at presentation.     

Recurrent intestinal volvulus in midgut malrotation causing acute bowel obstruction: A case report

Intestinal malrotation occurs when there is a disruption in the normal embryological development of the bowel. The majority of patients present with clinical features in childhood, though rarely a first presentation can take place in adulthood. Recurrent bowel obstruction in patients with previous abdominal operation for midgut malrotation is mostly due to adhesions but very few reported cases have been due to recurrent volvulus. We present the case of a 22-year-old gentleman who had laparotomy in childhood for small bowel volvulus and then presented with acute bowel obstruction. Preoperative computerised tomography scan showed small bowel obstruction and features in keeping with midgut malrotation. Emergency laparotomy findings confirmed midgut malrotation with absent appendix, abnormal location of caecum, ascending colon and small bowel. In addition, there were small bowel volvulus and a segment of terminal ileal stricture. Limited right hemicolectomy was performed with excellent postoperative recovery. This case is presented to illustrate a rare occurrence and raise an awareness of the possibility of dreadful recurrent volvulus even several years following an initial Ladd’s procedure for midgut malrotation. Therefore, one will need to exercise a high index of suspicion and this becomes very crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality.     

Acute Mesenteric Ischaemia—<Emphasis Type="Italic">An Indian Perspective</Emphasis>

In Western countries, acute mesenteric ischaemia is commonly due to arterial occlusion and occurs in patients who are usually in their seventh decade. A venous cause for intestinal gangrene has been reported in only about 10 %. We examined whether this was so in India and compared the clinical features of patients with mesenteric arterial and venous ischaemia and relate these to their ultimate prognosis. We studied retrospectively, the records of all patients admitted or referred to the department with a diagnosis of acute mesenteric ischaemia between January 1997 and October 2012, noting their demographic details and mode of presentation, the results of preoperative imaging and blood investigations, the extent of bowel ischaemia, and the length of bowel that was resected at operation and their outcome. There were 117 patients, 85 males and 32 females whose median age was 53 years. Mesenteric venous thrombosis was seen in 56 patients (48 %) and mesenteric arterial occlusion in 61 (52 %). Forty six patients died (39 %); 15 with venous occlusion (27 %) and 31 with arterial occlusion (51 %). Compared to patients with arterial occlusion, the patients with venous obstruction were younger, had a longer duration of symptoms, were less frequently hypotensive at presentation, had higher platelet counts, had a shorter length of bowel resected, had fewer colonic resections and had a lower mortality. Other predictors of mortality on multivariate analysis were a longer duration of symptoms, lower serum albumin and higher creatinine levels at presentation and a shorter length of residual bowel. In India, acute mesenteric ischaemia in tertiary care centres is due to venous thrombosis in almost half of the patients who are at least a decade younger than those in the West. Significant predictors of mortality include low serum albumin and raised creatinine levels, a shorter residual bowel length and an arterial cause for mesenteric ischaemia.     

Post traumatic acquired multiple mesenteric defects

INTRODUCTIONInternal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.¹ Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2–0.9%.²PRESENTATION OF CASEIn this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.DISCUSSIONIn the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.¹¹ Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries.In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. ¹⁶CONCLUSIONThe diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.     

Ischémie mésentérique étendue associée à la prise excessive de naratriptan et de jus de pamplemousse

We reported the case of a 61-year-old woman, who has been hospitalized in ICU because of an extensive mesenteric ischaemia, involving the small bowel, secondary to a naratriptan overuse. This mesenteric ischaemia was complicated by multiple organ failure and was responsible for extensive small bowel resection and left colectomy. A concomitant abundant absorption of grapefruit juice, a well-known P450 inhibitor, may have enhanced this naratriptan toxicity. This case underscore that an abdominal pain occurring in the context of headache treatment may be related to a mesenteric ischaemia.     

Intestinal infarction. Retrospective clinical study

Acute mesenteric ischaemia is the result of inadequate blood flow to all or part of the small intestine and the right half of the colon. Irrespective of the cause of the ischaemic insult, the end results are similar, namely, a spectrum of bowel injury ranging from completely reversible alterations of bowel function to transmural haemorrhagic necrosis of the intestinal wall. Depending on the degree of ischaemia and the length of bowel involved, a wide variety of clinical presentations are observed. Mesenteric infarction is a pathology which is encountered fairly often in elderly patients where the concomitance of other diseases make its prognosis more severe, especially since the diagnosis is usually late. The pessimism expressed more than 70 years ago concerning this disease is still shared by many physicians today. The authors report on their experience with 37 cases of mesenteric infarction. The median age of the patients was 77 years (range: 66-91). The mortality rate was 67.5% (25 deaths) which is in line with the results in the literature. The median hospital stay was 17 days (range: 10-71). The authors emphasise the difficulty of diagnosing and treating this entity, also in view of the fact that, in most centres, it is impossible to perform emergency selective angiography of the superior mesenteric artery. The need for an early specific diagnosis is stressed, because the therapeutic options may vary widely in relation to the different causes of acute intestinal ischaemia.     

Female urethral stricture disease

Female urethral stricture disease is a rare entity. The most common etiologies are traumatic injury, iatrogenic injury, and inflammatory disease resulting in periurethral fibrosis. Hallmark symptoms are frequency and urgency, and may also be dysuria, hesitancy, slow stream, incontinence, and recurrent urinary tract infections. Female bladder outlet obstruction is a difficult entity to define, and the subset representing stricture disease may also be elusive. The diagnosis of female urethral stricture disease is usually based on symptoms, meatal appearance, and difficult instrumentation of the patient. Other testing, such as urodynamics, voiding urography, or cystoscopy, may be helpful. Treatment options are conservative management with dilatation, endoscopic treatment, or open repair with various tissue flaps or grafts. Considerable controversy surrounds the efficacy of urethral dilatation in women with voiding dysfunction.     

Delayed Presentations of Blunt Mesenteric and Intestinal Trauma in the Wake of Injury

Abstract Objective:  To analyze the presentation and timing of blunt mesenteric and intestinal trauma requiring surgical intervention. Methods:  The Hadassah-Hebrew University trauma registry was scanned for patients who required surgery following blunt mesenteric and/or bowel trauma. Demographic data, mechanism of injury, time to diagnosis and pathology reports were recorded. A literature search was also performed. Results:  The majority of patients were injured in motor vehicle accidents (26/30, 86.7%). Patients were divided into three groups. Seventeen patients diagnosed within 4 h of admission were defined as the immediate group. Indication for surgery was hemodynamic instability and/or peritonitis. The most commonly injured region was the terminal ileum (10/17 patients, 59%). The second group (n = 4) had surgery within 2 weeks of injury (early group). These patients presented initially with hemodynamic instability. The operative findings were consistent with a low-flow state of the terminal ileum and cecum. The third group (n = 9) consisted of patients who were operated later than 2 weeks from the date of injury (late group). These patients presented with prolonged abdominal symptoms, chiefly partial small bowel obstruction. Operative findings were bowel strictures, most commonly of the terminal ileum (7/9 patients, 77.8%). Conclusions:  Acceleration–deceleration abdominal injury affects the terminal ileum more commonly. We propose that the ensuing clinical picture depends on the level of energy transmitted: high-energy trauma leads to extensive mesenteric and bowel tears and is diagnosed immediately. Low-energy trauma may lead to chronic ischemia, fibrosis and stricture-formation. The right colon appears to be more vulnerable to lowflow states following blunt trauma.     

Intestinal ischemia caused by mesenteric veno-occlusive inflammatory disease: description of a clinical case

The Authors report a case of small bowel venous ischaemia due to a peculiar form of vasculitis called Mesenteric Inflammatory Veno-Occlusive Disease. Such disease represents a new anatomopathological entity, with exclusive thrombotic and inflammatory infiltration of the mesenteric veins, with no arterial flogistic involvement. Clinical manifestation of the diseases is that of the venous mesenteric thrombosis in patients in whom the more common forms of systemic vasculitis are not recognizable.     

Enterolith Containing Uric Acid: An Unusual Cause Of Intestinal Obstruction

Enterolith is a rare clinical entity that may be found on imaging or at surgery. We report an unusual case of intestinal obstruction caused by a large uric acid containing enterolith which was formed in the absence of any bowel inflammation, stricture or diverticulum.     

Meckel’s diverticulum with benign stricture: A very rare cause of intestinal obstruction

We report a very rare case of Meckel’s diverticulum with benign stricture presenting as recurrent small bowel obstruction in a malnourished young adult female. Extensive preoperative investigations were unable to diagnose the cause of recurrent obstruction. Segmental small bowel resection with attached diverticulum was performed.     

Adult transmesenteric hernia: report of two cases

Transmesenteric hernia is a rare cause of bowel obstruction in adults. We herein describe two cases that occurred in adult women, ages 27 and 19. Both cases presented with abdominal pain without muscular defense signs. Computed tomography of both cases showed features of small bowel obstruction by an internal hernia. A laparotomy showed mesenteric defects of the mesentery of the ileum in the former case and the mesentery of the transverse colon in the latter case, with a herniating ileum. The involved small bowel was viable in both cases, and the bowel was pulled out of the mesenteric defect without resection. The mesenteric defects were then successfully repaired.     

Congenital Internal Hernia a Rare Cause of Acute Intestinal Obstruction

Internal hernia may either be congenital or acquired. Acquired internal hernias are usually complications of previous abdominal surgery. Congenital internal hernia is a rare entity and it being a cause of small bowel obstruction is still rare. We report a case of congenital internal hernia presenting as acute intestinal obstruction and its surgical management.     

Rectal strictures following abdominal aortic aneurysm surgery

Rectal stricture formation is a rare complication of aortic aneurysm repair. Two case are described here. A combination of hypotension, a compromised internal iliac circulation and poor collateral supply following inferior mesenteric artery ligation can result in acute ischaemic proctitis--an infrequently described clinical entity. Ulceration and necrosis are the sequelae of prolonged ischaemia and fibrous stricture formation may result. One patient responded to dilatation and posterior mid-rectal myotomy; the other failed to respond to conservative measures and eventually had an end colostomy fashioned following intractable symptoms.     

Hepatic perfusion index (HPI) in mesenteric angina and following successful revascularization

This is a case report of a 45 year old man who had previously undergone a small bowel resection for acute mesenteric ischaemia. He subsequently suffered from mesenteric angina due to stenosis of the origin of the superior mesenteric artery and intermittent claudication due to aorto-iliac atheroma. The patient underwent a successful aorto-bifemoral Y graft and small bowel revascularization with a saphenous vein graft between the Y graft and the accessible proximal portion of the superior mesenteric artery. Before vascular reconstruction, the hepatic perfusion indices (HPI) in both the fasted and fed states were elevated; after mesenteric revascularization the HPI values were substantially lowered. The hepatic perfusion index may, by demonstrating functional abnormality, be useful in the diagnosis of mesenteric ischaemia and also in the assessment of treatment. Further evaluation of HPI in patients with suspected mesenteric ischaemia is therefore required.     

Spontaneous adult transmesentric hernia with bowel gangrene

Internal hernia may be either congenital or acquired. Its incidence has been reported to be 1–2%. Internal hernia is a rare cause of small bowel obstruction with a reported incidence of 0.2–0.9%. The herniation may lead to a variable degree of vascular compromise to the herniated bowel. We report a rare case of spontaneous transmesenteric hernia of ileum with associated gangrene of bowel caused by a congenital mesenteric defect in a 35-year-old adult male, and review the relevant literature.     

Post-traumatic Subserosal Small Bowel Herniation Leading to Obstruction in a Child with Acute Spinal Cord Injury

The presentation of small bowel injury from lap belt use varies substantially, ranging from gross hemodynamic instability to insidious physiologic deterioration to simple failure of improvement. Rarely does small bowel injury manifest as an obstruction. This paper describes one such occurrence; in this case, herniation of intact mucosa/submucosa through a serosal tear caused a high-grade small bowel obstruction in a pediatric patient with an acute spinal cord injury and a virgin abdomen.     

A case report of small bowel obstruction from previously undiagnosed lobular breast carcinoma: First in Australian literature

IntroductionThis case report is the first in the Australian literature of a patient, without prior diagnosis, presenting with a bowel obstruction secondary to lobular breast cancer. This highlights a relatively rare cause of bowel obstruction, but also the importance of breast self-examination as a compliment to the current BreastScreen Australia program.Presentation of caseA 67-year-old female presented to the Emergency Department with a 48-h history of sharp, constant epigastric pain, vomiting and constipation. The patient proceeded to emergency laparotomy for presumed large bowel obstruction, which revealed a stricture in the distal terminal ileum causing a distal small bowel obstruction. A right hemicolectomy was performed. Histopathology revealed the terminal ileum stricture to be metastatic lobular breast carcinoma. Clinical examination of the patient’s right breast revealed a lesion suggestive of the primary malignancy despite a normal ultrasound and mammogram in 2014. After failing to progress, a CT scan was performed which revealed progressive small and large bowel distension. A repeat laparotomy was performed revealing dilated large bowel without obstructing pathology and an intact anastomosis. A loop ileostomy was performed. Following a further febrile episode, the patient decided to withdraw care and the patient passed away three weeks into her admission from suspected intra-abdominal sepsis.DiscussionBreast cancer is becoming the third most common cancer amongst Australian women with a significant burden of disease and mortality.ConclusionDespite the rare presentation, this case reminds the medical community and general population of the importance of breast self-examination and the BreastScreen Australia program.     

Incarcerated small bowel within a spontaneous lumbar hernia

Lumbar hernias are rare, resulting from protrusion through the posterior abdominal wall that may be congenital, acquired or spontaneous. They very rarely present with acute bowel obstruction. We present a case of incarcerated small bowel within a spontaneous inferior (Petit’s) lumbar hernia, treated by early open repair with mesh insertion. This case highlights the importance of thorough clinical examination and a high index of suspicion, even in the absence of previous surgery around the anatomical site of the suspected hernia, in order to effect an early repair before the onset of ischaemia in incarcerated contents.