Intestinal obstruction

Intestinal obstruction is a common surgical emergency, accounting for up to 20% of admissions with acute abdominal pain. Of these, 80% will have small bowel obstruction, the most common cause being adhesions. Colorectal cancer is the most common cause of large bowel obstruction. The cardinal features of obstruction are abdominal pain, vomiting, distension and absolute constipation. Initial management comprises adequate fluid resuscitation, decompression with a nasogastric tube and early identification of strangulation (signs of which may include tachycardia, tenderness, fever and leucocytosis) requiring operative intervention. Appropriate use of contrast imaging can differentiate between patients that are likely to settle conservatively and those that will require surgery.     

Intestinal obstruction

Intestinal obstruction is a common surgical emergency, accounting for up to 20% of admissions with acute abdominal pain. Of these, 80% will have small bowel obstruction, the most common cause being adhesions. Colorectal cancer is the most common cause of large bowel obstruction. The cardinal features of obstruction are abdominal pain, vomiting, distension and absolute constipation. Initial management comprises adequate fluid resuscitation, decompression with a nasogastric tube and early identification of strangulation (signs of which may include tachycardia, tenderness, fever and leucocytosis) requiring operative intervention. Appropriate use of contrast imaging can differentiate between patients that are likely to settle conservatively and those that will require surgery.     

Intestinal obstruction

Intestinal obstruction is a common surgical emergency, accounting for up to 20% of admissions with acute abdominal pain. Of these, 80% will have small bowel obstruction, the common cause being adhesions. Colorectal cancer is the most common cause of large bowel obstruction. The cardinal features of obstruction are abdominal pain, vomiting, distension and absolute constipation. Initial management comprises adequate fluid resuscitation, decompression with a nasogastric tube and early identification of strangulation (tachycardia, tenderness, fever and leukocytosis) requiring operative intervention. Appropriate use of contrast imaging can differentiate between patients that are likely to settle conservatively and those that will require surgery.     

Intestinal obstruction

Intestinal obstruction is a common surgical emergency. In the developed world approximately 20% of patients with acute abdominal pain admitted to surgical units have intestinal obstruction and 80% of these will have small bowel obstruction. In the western world, adhesional obstruction is by far the most common cause of small bowel obstruction, reflecting the increasing number of abdominal surgical procedures being performed. Malignancy is the leading cause of obstruction of the large intestine. The cardinal clinical features are vomiting, abdominal pain, distension and gross constipation which differ in predominance depending on the site of the obstruction. Management of bowel obstruction requires prompt identification, meticulous attention to fluid and electrolyte balance and timely surgical intervention.     

Laparoscopic approach to acute small bowel obstruction: Review of 1061 cases

Background Acute small bowel obstruction has previously been considered a relative contraindication for laparoscopic management. As experience with laparoscopy grows, more surgeons are attempting laparoscopic management for this indication. The purpose of this study is to define the outcome of laparoscopy for acute small bowel obstruction through an analysis of published cases. Methods A literature search of the Medline database was performed using the key words laparoscopy and bowel obstruction. Further articles were identified from the reference lists of retrieved literature. Only English language studies were reviewed. We excluded studies that included patients with chronic abdominal pain, chronic recurrent small bowel obstruction, or gastric or colonic obstruction, when the data specific to acute small bowel obstruction could not be extracted. Data was analyzed based on an intention to treat. Results Nineteen studies from between 1994 and 2005 were identified. Laparoscopy was attempted in 1061 patients with acute small bowel obstruction. The most common etiologies of obstruction included adhesions (83.2%), abdominal wall hernia (3.1%), malignancy (2.9%), internal hernia (1.9%), and bezoars (0.8%). Laparoscopic treatment was possible in 705 cases with a conversion rate to open surgery of 33.5%. Causes of conversion were dense adhesions (27.7%), the need for bowel resection (23.1%), unidentified etiology (13.0%), iatrogenic injury (10.2%), malignancy (7.4%), inadequate visualization (4.2%), hernia (3.2%), and other causes (11.1%). Morbidity was 15.5% (152/981) and mortality was 1.5% (16/1046). There were 45 reported recognized intraoperative enterotomies (6.5%), but less than half resulted in conversion. There were, however, nine missed perforations, including one trocar injury, often resulting in significant morbidity. Early recurrence (defined as recurrence within 30 days of surgery) occurred in 2.1% (22/1046). Conclusion Laparoscopy is an effective procedure for the treatment of acute small bowel obstruction with acceptable risk of morbidity and early recurrence.     

Acute pelvic inflammatory disease as a rare cause of acute small bowel obstruction

Introduction: Small bowel obstruction (SBO) is a common presentation to emergency abdominal surgery. The most frequent causes of SBO are congenital, postoperative adhesions, abdominal wall hernia, internal hernia and malignancy.

Patients: A 27-year-old woman was hospitalized because of acute abdominal pain, blockage of gases and stools associated with vomiting. Abdominal computed tomography showed an acute small bowel obstruction without any obvious etiology. In view of important abdominal pain and the lack of clear diagnosis, an explorative laparoscopy was performed. Diagnostic of pelvic inflammatory disease was established and was comforted by positive PCR for Chlamydia Trachomatis.

Results: Acute small bowel obstruction resulting from acute pelvic inflammatory disease, emerging early after infection, without any clinical or X-ray obvious signs was not described in the literature yet. This infrequent acute SBO etiology but must be searched especially when there is no other evident cause of obstruction in female patients. Early laparoscopy is mostly advised when there are some worrying clinical or CT scan signs.     

Preoperative evaluation by magnetic resonance imaging in patients with bowel obstruction

BACKGROUND: Bowel obstruction is a problematic condition because the main clinical issue is to determine whether emergency laparotomy or observation with a long tube is required. The recent development of imaging diagnostic modalities such as magnetic resonance imaging (MRI) is thought to be promising to support therapeutic decisions in patients with bowel obstruction. METHODS: Twenty-seven patients with bowel obstruction who underwent laparotomy were evaluated by plain x-ray film, computed tomography (CT) scan, and MRI preoperatively with regard to the presence or absence of bowel obstruction, and the site and cause of bowel obstruction. Diagnostic accuracies were compared among these radiological modalities. RESULTS: The presence of bowel obstruction was detected in 22 (81.5%) of 27 patients by plain abdominal x-ray film, in 24 (92.3%) of 26 patients by CT scan, and in 25 (92.6%) of 27 patients by MRI. The sites of obstruction were consistent with surgical findings in 25 (92.6%) of 27 patients by MRI, and in 15 (57.7%) of 26 patients by CT scan. The causes of bowel obstruction were accurately diagnosed by MRI in 25 (92.6%) of 27 patients, and in 23 (88.5%) of 26 patients by CT scan. CONCLUSIONS: MRI could identify the presence and the site and cause of bowel obstruction in most of the cases. MRI is assumed to be superior to CT scan in the preoperative diagnosis of bowel obstruction.     

Intussusception

Intussusception is the invagination of a segment of bowel into the distal adjacent bowel. Mostly it involves the distal ileum and proximal colon and no lead point can be identified. It is the most common cause of bowel obstruction in infants and young children. It typically presents in infants between 2 months and 2 years of age with episodic severe colicky abdominal pain, vomiting that progresses to being bilious, abdominal distension, and bleeding per rectum which is classically described as ‘redcurrant jelly’ stool. If not diagnosed and treated promptly the pathology will progress to bowel necrosis, sepsis and death.     

Intussusception

Intussusception is the most common cause of intestinal obstruction in infancy and early childhood. It occurs when one segment of bowel (the intussusceptum) invaginates into an adjacent distal segment of bowel (the intussuscepien). The classical presentation is with intermittent abdominal pain, vomiting and redcurrant jelly like stool. Diagnosis can be accurately confirmed with an ultrasound scan. Initial management is with fluid resuscitation and antibiotics. Following adequate resuscitation, treatment is usually with a non-operative air enema reduction under fluoroscopic guidance. If this fails to completely reduce the intussusception, the air enema may be repeated in patients that are clinically stable. The main risks associated with an air enema are bowel perforation, failed reduction and recurrence. Surgical intervention is indicated in patients presenting with perforation, those that are clinically unstable or where multiple air enemas have failed to reduce the intussusception. Surgery can be performed open or laparoscopic and involves attempted manual reduction of the intussusception and may require bowel resection and anastomosis.     

Intussusception

Intussusception is the most common cause of intestinal obstruction in infancy and early childhood. It occurs when one segment of bowel (the intussusceptum) invaginates into an adjacent distal segment of bowel (the intussuscepien). The classic presentation is with intermittent abdominal pain, vomiting and redcurrant jelly-like stool. Diagnosis can be accurately confirmed with an ultrasound scan. Initial management is with fluid resuscitation and antibiotics. Following adequate resuscitation, treatment is usually with a non-operative air enema reduction under fluoroscopic guidance. If this fails to completely reduce the intussusception, the air enema may be repeated in patients that are clinically stable. The main risks associated with an air enema are bowel perforation, failed reduction and recurrence. Surgical intervention is indicated in patients presenting with perforation, those that are clinically unstable or where multiple air enemas have failed to reduce the intussusception. Surgery can be performed open or laparoscopic and involves attempted manual reduction of the intussusception and may require bowel resection and anastomosis.     

A case report of small bowel obstruction secondary to congenital peritoneal band in adult

IntroductionSmall bowel obstruction (SBO) is common in adult surgical procedures, mainly due to postoperative adhesions. Acute SBO in adults without history of abdominal surgery, trauma or clinical hernia is less common and has various etiologies. Congenital band is an extremely rare cause.Presentation of caseA 56-year-old man was admitted to our hospital with a two-day history of abdominal pain and bilious vomiting. He had no history of abdominal surgery or any other medical problems. A contrast-enhanced CT of the abdomen showed a distention of small bowel loops with transition point in the right hypochondrium. Distended loops of small bowel were located in the left side of the abdomen, whereas collapsed loops was located in the right side. The normal bowel wall enhancement was preserved. After initial treatment with intravenous fluid and nasogastric suction, he was operated. At laparoscopy a band obstructing the ileum was clearly observed. This anomalous band extending from gallbladder to transverse mesocolon caused a small window leading to internal herniation of the small bowel and obstruction. The band was coagulated and divided. Postoperative outcome was uneventful and the patient was discharged on the second postoperative day. There was no recurrence of symptoms on subsequent follow-up.DiscussionCongenital peritoneal bands are not frequently encountered in surgical practice and these bands are often difficult to classify and define. Diagnosis of acute intestinal obstruction due to CPB must be included in the differential diagnosis in any patient with no history of abdominal surgery, trauma, clinical hernia, inflammatory bowel disease or peritoneal tuberculosis.ConclusionDespite technological advances in radiology preoperative diagnosis remains difficult, however the diagnosis of SBO due to CPB must be considered in any patient with no history of abdominal surgery, Trauma or clinical hernia consulting for occlusive syndrome. The laparoscopic approach should be intended initially for its feasibility and benefits.     

Appendiceal tie syndrome:A very rare complication of a common disease

Acute appendicitis is the most common surgical emergency that we encounter. Adynamic Intestinal obstruction due to appendicitis or its complication may be seen time and often. Mechanical obstruction because of appendicitis is uncommon and even rarer for a closed loop obstruction to occur. Although it was described as early as 1901, very few cases have been reported. We report the case of a 20 years male who presented with generalized colicky pain abdomen, abdominal distension, vomiting and obstipation for three to four days. Vital signs were stable. His abdomen was distended and peritonitic, especially in the right iliac fossa. Rest of the physical examination was unremarkable. Blood tests were normal except for leucocytosis with neutrophilia. An abdominal X-ray finding was indicating a small bowel obstruction. A midline laparotomy was performed. On intraoperative examination, distended loops of small bowel from the jejunum to the distal ileum was observed, and a constricting ring around the terminal ileum created by a phlegmonous appendicitis with its tip adherent to the root of mesentery was found, obstructing an edematous loop of small bowel without signs of ischemia. As the bowel was viable simple appendectomy was done. Postoperatively, he had an uneventful recovery and was discharged after 3 d.     

腹部手术后早期炎性肠梗阻的处理

目的腹部手术后早期发生的肠梗阻原因较复杂,处理亦较困难,尤其是炎性肠梗阻,既有麻痹性因素,亦有机械性因素,使外科医师的医疗决策难以取舍,如是否需要手术、手术的时机、以及手术可能造成的并发症等均值得探讨。我科自1987年至1996年12月共收治了重型术后炎性肠梗阻48例,40例(83.3%)经非手术治疗痊愈;7例(14.6%)于症状消退后择期手术治疗并存症后治愈,1例2.1%死亡,临床非手术治疗时间为9～58天,平均27.6±10天,取得较满意的结果,为这种类型的肠梗阻治疗提供了一些经验。     

Intussusception secondary to endometriosis of the cecum

INTRODUCTION

Intussusception in adults is a rare cause of bowel obstruction. Endometriosis of the bowel is also a rare entity that can be the cause of bowel obstruction. Here, we report a rare case of intussusception secondary to endometriosis of the cecum.

PRESENTATION OF CASE

A 40-year-old woman presented to the hospital with a one-week history of intermittent epigastric pain. On physical examination, there was a soft, round non-tender palpable mass in the right flank and abdominal computed tomography scan revealed an intussusception. We made the diagnosis of ileo-colic intussusception and performed ileocecal resection. The surgical specimen revealed a round submucosal cystic mass in the cecum and the histology showed endometriosis of the cecum.

DISCUSSION

Intussusception in adults is a rare entity present in just 1% of all patients with bowel obstruction, and 5% of all intussusceptions. In general, intussusception in adults has a pathologic lesion as the lead point and the lesion is a malignancy in 20–50% of the cases. Thus, the treatment of an intussusception in adults should be operative. Endometriosis of the bowel is a rare cause of intussusception. Small endometriosis lesions of the bowel are unlikely to cause symptoms; however, in patients presenting with bowel obstruction, urgent treatment is indicated.

CONCLUSION

Intussusception in an adult is a rare cause of bowel obstruction and intussusception caused by endometriosis is also rare. Although rare, the diagnosis of endometriosis as a cause of intussusception must be considered as part of the differential diagnosis.     

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.     

Small Bowel Obstruction during Pregnancy

The authors report the case of a 28-year old pregnant woman with abdominal pain and contractions at 37 weeks of gestation. After labour and delivery, abdominal pain persisted and laparoscopy was performed. A bowel obstruction was diagnosed and surgically corrected. The authors discuss the clinical and therapeutic consequences of bowel obstruction during pregnancy.     

Delayed Small Bowel Obstruction after Blunt Abdominal Trauma. A Case Report

We present a case of small bowel stricture and obstruction with delayed and subtle presentation 3 months after a car accident. Such a presentation is a rare clinical entity.

The most likely cause, supported by most authors, implicates an injury to the mesentery. Post-traumatic ischaemic bowel stenosis may result from even small tears and contusions. These lesions may cause partial thickness ischaemia of the bowel wall, with mucosal ulceration and submucosal inflammation and fibrosis, or may cause full-thickness ischaemia with fibrosis of all layers. Mesenteric tears or intramural haematomas have been found on close inspection of the specimens. Our case supports the mesenteric injury theory since there is the initial CT-scan proof of retroperitoneal and consequently, mesenteric haematomas.

Regardless of the pathophysiology of this clinical entity, it is very important that the condition of post-traumatic small bowel stricture should be suspected when a patient experiences bowel obstruction weeks, or even years, after sustaining abdominal injury, especially in connection with a seat-belt injury.     

Small bowel obstruction in the virgin abdomen: time to challenge surgical dogma with evidence

Background

Although adhesions account for more than 70% of small bowel obstruction (SBO), they are thought to be less likely aetiologies in patients without previous abdominal surgery. Expedient surgery has historically been advocated as prudent management in these patients. Emerging evidence appears to challenge such a dogmatic approach.

Methods

A retrospective analysis was performed in all SBO patients with a virgin abdomen admitted between January 2012 and August 2014. Patients with obstruction secondary to abdominal wall hernias were excluded. Patient demographics, clinical presentation, management strategy and pathology involved were reviewed.

Results

A total of 72 patients were included in the study. The majority of patients were males (66.7%), with a median age of 58 years (range: 23–101). Abdominal pain (97%) and vomiting (86%) were the most common presentations while abdominal distention (60%) and constipation (25%) were reported less frequently. Adhesions accounted for the underlying cause in 44 (62%) patients. Other aetiologies included gallstone ileus (n = 5), phytobezoar (n = 5), intussusception (n = 4), internal herniation (n = 4), newly diagnosed small bowel tumour (n = 3), mesenteric volvulus (n = 3), stricture (n = 3) and Meckel's diverticulum (n = 1). Twenty‐nine (40%) patients were successfully managed conservatively while the remaining 43 (60%) underwent surgery. The intraoperative findings were in concordance with the preoperative computed tomography scan in 76% of cases.

Conclusion

Adhesions remain prevalent despite the absence of previous abdominal surgery. Non‐operative management is feasible for SBO in a virgin abdomen. Computed tomography scan can be a useful adjunct in discerning patients who may be treated non‐operatively by elucidating the underlying cause of obstruction.     

Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction

Background: Small bowel obstruction (SBO) is a leading cause of admission to surgical emergency units. Strangulation is associated with a 10-fold increase in mortality. The aim of the present study was to identify the most frequent causes of strangulation in patients presenting with small bowel obstruction. Methods: A prospective study was conducted of all patients presenting with SBO in one teaching hospital between 2003 and 2004. Results: One hundred and sixty-one patients with symptoms and signs of small bowel obstruction were admitted. Eighty-three were confirmed with contrast studies. The male:female ratio was 1:1.6. The aetiology of obstruction was adhesions in 97 patients (60.2%), hernia in 29 (18%), malignancy in 17 (10.6%) and miscellaneous causes in 18 (11.2%). Operative procedures were performed on 74 patients (46%), 31 of them (42%) with adhesions, 25 (34%) with hernias and 18 (24%) due to other causes. Strangulated bowel occurred in 15 patients (9.3%); 12 had hernias whilst three had adhesions (P < 0.0001). Of the strangulated hernias, ten were femoral, one was inguinal and one was paraumbilical. There were seven deaths; three occurred in patients declared unfit for surgery, while four occurred post-operatively—two had strangulated bowel, the other two had advanced cancer. Conclusion: Whilst adhesions are the most common cause of small bowel obstruction, hernias remain the most frequent cause of strangulation in patients presenting with this condition.     

Internal hernia traversing the lesser sac

Congenital internal hernias are a rare cause of small bowel obstruction in adults and often present with complications. A high index of suspicion, occasionally aided by appropriate radiological imaging, may lead to early surgical intervention and reduce morbidity and mortality. A 25‐year‐old man presented with colicky abdominal pain and minimal signs on abdominal examination. Computed tomography showed features of a small bowel obstruction and prompted surgery. This revealed an internal hernia traversing the lesser sac through defects in both the gastrocolic ligament and lesser omentum. A gangrenous segment of small bowel incarcerated in the lesser omentum was resected and the patient made a full recovery. The published reports relating to lesser sac hernias are reviewed and features that may lead to early diagnosis identified.