Diverticulosis of the jejunum with intestinal obstruction： A case report

A diagnosis of intestinal diverticulosis is difficult to make pre-operatively because the clinical symptoms are usually non-specific. We report the case of a 70-year-old man who had suffered from three episodes of intestinal obstruction in 1 year. He experienced dull pain and a sensation of fullness over the whole abdomen. The symptoms did not improve after conservative treatment. The presumptive diagnosis was intestinal obstruction, and an exploratory laparotomy found diverticulosis of the proximal jejunum, with an adhesion band formed from the base of one diverticulum. Strangulation of a segment of the jejunum resulted from the internal herniation caused by the band. The band was removed and the proximal jejunum segmentally resected. His postoperative course was uneventful.     

Idiopathic sclerosing encapsulating peritonitis （or abdominal cocoon）： A report of 5 cases

Sclerosing encapsulating peritonitis （SEP） is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic, also known as abdominal cocoon, or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon, and the case files were reviewed retrospectively for the clinical presentation, operative findings and outcome. All the patients presented with acute, subacute and chronic intestinal obstruction. Computed tomography （CT） showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period, one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.     

Combined small bowel and reduced auxiliary liver transplantation：case report

AIM：To present a case of combined small bowel and reduced auxiliary liver transplantation.METHODS:A55-year-old patient with short bowel syndrome and TPN-related liver dysfunction received small bowel transplantation combined with a reduced auxiliary liver graft.A liver was added to restor the patient‘s liver function and to protect the intestinal allograft from rejection.His own liver was not removed.RESULTS:Without donor pretreatment and by conventional immunosuppresive therapy following transplantation,the patient exparienced had only one episode of mild intestinal rejection,which was easily reversed by treatment with Methylprednisolone,No liver rejection occurred.Unfortunately,the patient died of heart and lung failure 30d after transplantation,despite successful graft replacement,Histopathologic examination of specimens after death demonstrated normal structure in both intestinal and liver grafts.CONCLUSION:The auxiliary liver graft might play a role in preventing intestinal allograft rejection.However,the observation periol in this case is short.Further study is needed to determine the risks ,effect on the protecting the small-bowel from rejection,and feasibility of general application of this procedure.     

Fecal microbiota transplantation and prednisone for severe eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare disease of unknown etiology.It is characterized by patchy or diffuse eosinophilic infiltration of the bowel wall to a variable depth and various gastrointestinal manifestations.We describe a case of severe eosinophilic gastroenteritis presenting as frequent bowel obstruction and diarrhea in a 35-year-old man.The patient was misdiagnosed and underwent surgery because of intestinal obstruction when he was first admitted to a local hospital.Then he was misdiagnosed as having Crohn’s disease in another university teaching hospital.Finally,the patient asked for further treatment from our hospital because of the on-going clinical trial for treating refractory Crohn’s disease by fecal microbiota transplantation.Physical examination revealed a slight distended abdomen with diffuse tenderness.Laboratory investigation showed the total number of normal leukocytes with neutrophilia as 90.5%,as well as eosinopenia,monocytopenia and lymphocytopenia.Barium radiography and sigmoidoscopy confirmed inflammatory stenosis of the sigmoid colon.We diagnosed the patient as having eosinophilic gastroenteritis by multi-examinations.The patient was treated by fecal microbiota transplantation combined with oral prednisone,and was free from gastrointestinal symptoms at the time when we reported his disease.This case highlights the importance of awareness of manifestations of a rare disease like eosinophilic gastroenteritis.     

Giant vesical diverticulum： A rare cause of defecation disturbance

Vesical diverticula frequently result from bladder outlet obstructions. However, giant vesical diverticula which cause acute abdomen or intestinal obstruction are very rare. Our review of the English medical literature found 3 cases of bladder diverticula which caused gastrointestinal symptoms. Here, we present a 57-yearold man with a giant diverticulum of the urinary bladder who complained of abdominal pain, nausea and vomiting, constipation, no passage of gas or feces, and abdominal distension for 3 d. A 20 cm x 15 cm diverticulum was observed upon laparotomy. The colonic obstruction was secondary to external compression of the rectum against the sacrum by a distended vesical diverticulum. We performed a diverticulectomy and primary closure. Twelve months postoperatively, the patient had no difficulty with voiding or defecation.     

Successful liver resection in a giant hemangioma with intestinal obstruction after embolization

Hepatic hemangiomas are the most common benign tumor of the liver.Most hepatic hemangiomas remain asymptomatic and require no treatment.Giant hepatic hemangiomas with established complications,diagnostic uncertainty and incapacitating symptoms,however,are generally considered an absolute indication for surgical resection.We present a case of a giant hemangioma with intestinal obstruction following transcatheter arterial embolization,by which the volume of the hemangioma was significantly reduced,and it was completely resected by a left hepatectomy.A 21-yearold Asian man visited our hospital for left upper quadrant pain.Examinations at the first visit revealed a left liver hemangioma occupying the abdominal cavity,with a maximum diameter of 31.5 cm.Embolization of the left hepatic artery was performed and confirmed a decrease in its size.However,the patient was readmitted to our hospital one month after embolization for intestinal obstruction.A left hepatectomy was completed through a herringbone incision,and safely removed a giant hemangioma of 26.5 cm × 19.5 cm × 12.0 cm in size and 3690 g in weight.Pre-operative arterial embolization is effective for reducing tumor size,but a close follow-up to decide the time for hepatectomy is important.     

Eosinophilic gastroenteritis presenting as small bowel obstruction： A case report and review of the literature

Eosinophilic gastroenteritis is a rare disease of unknown etiology. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract. Recently, the authors experienced a case of eosinophilic gastroenteritis presenting as small bowel obstruction. A 51-year old woman was admitted to our hospital complaining of abdominal pain and vomiting. Physical examination revealed a distended abdomen with diffuse tenderness. Complete blood count showed mild leukocytosis without eosinophilia. Computed tomography confirmed a dilatation of the small intestine with ascites. An emergency laparotomy was performed for a diagnosis of peritonitis due to intestinal obstruction. Segmental resection of the ileum and end to end anastomosis were performed. Histologically, there was a dense infiltration of eosinophils throughout the entire thickness of ileal wall and eosinophilic enteritis was diagnosed. The patient recovered well, and was free from gastrointestinal symptoms at the time when we reported her disease.     

Complications arising in simple and polycystic liver cysts

Liver cysts are common,affecting 5%-10% of the population.Most are asymptomatic,however 5% of patients develop symptoms,sometimes due to complications and will require intervention.There is no consensus on their management because complications are so uncommon.The aim of this study was to perform a collected review of how a series of complications were managed at our institutions.Six different patients presenting with rare complications of liver cysts were obtained from Hepatobiliary Units in the United Kingdom and The Netherlands.History and radiological imaging were obtained from case notes and computerised radiology.As a result,1 patient admitted with inferior vena cava obstruction was managed by cyst aspiration and lanreotide;1 patient with common bile duct obstruction was first managed by endoscopic retrograde cholangiopancreatography and stenting,followed by open fenestration;1 patient with ruptured cysts and significant medical co-morbidities was managed by percutaneous drainage;1 patient with portal vein occlusion and varices was managed by open liver resection;1 patient with infected cysts was treated with intravenous antibiotics and is awaiting liver transplantation.The final patient with a simple liver cyst mimicking a hydatid was managed by open liver resection.In conclusion,complications of cystic liver disease are rare,and we have demonstrated in this series that both operative and non-operative strategies have defined roles in management.The mainstays of treatment are either aspiration/sclerotherapy or,alternatively laparoscopic fenestration.Medical management with somatostatin analogues is a potentially new and exciting treatment option but requires further study.     

Chronological changes in the liver after temporary partial portal venous occlusion

AIM:To investigate time-dependent changes caused by temporal portal vein obstruction and subsequent reperfusion in the lobe with or without an occluded portal vein.METHODS:The portal vein(PV)of the anterior lobe of the liver of a male Wistar rat(8 wk-old)was obstructed(70%)for 12,24,36 and 48 h,respectively,and models were sacrificed at 48 h after reperfusion(each group:n=10).The histological changes and the status of liver regeneration were compared between a liver biopsy performed on each lobe after temporary obstruction of the portal vein in the same rat liver,and the liver extracted at the time of sacrifice(48 h after reperfusion).RESULTS:With regard to the obstructed lobe,the liver weight/body weight ratio significantly decreased according to obstruction time.On the other hand,in thenon-obstructed lobe,there were no significant differences within each group.The duration of PV occlusion did not seem to be strong enough to introduce liver weight increase.Stimulation of liver regeneration was brought about in the non-occluded lobe by 12-h occlusion,and was sustained even at 48 h after reperfusion.The obstructed lobe atrophied with the passage of time in the obstructed state.However,the proliferating-cell nuclear antigen labeling index also increased at 48 h after reperfusion,and a repair mechanism was observed.CONCLUSION:Temporary blood flow obstruction of the portal vein may become a significant trigger for liver regeneration,even with an obstruction of 12 h.     

Epithelial markers of colorectal carcinogenesis in ulcerative colitis and primary sclerosing cholangitis

AIM:To evaluate the expression of epithelial markers of colorectal carcinogenesis in patients with long-term ulcerative colitis(UC) and primary sclerosing cholangitis(PSC) before and after transplantation.METHODS:Eight patients with UC and PSC prior to liver transplantation(PSC-UC),22 patients with UC after liver transplantation for PSC(OLT),9 patients with active ulcerative colitis without PSC(UCA),7 patients withUC in remission(UCR) and 10 controls(N) underwent colonoscopy with multiple biopsies.Specimens were analysed histologically and semi-quantitatively immunohistochemically for p53,Bcl-2 and cyclooxygenase-2(COX-2) markers.Statistical analysis was performed by Kruskal-Wallis and Fisher’s exact tests.RESULTS:PSC-UC had a statistically significantly higher expression of p53 in the nondysplastic mucosa as compared to OLT,UCA,UCR and N(P < 0.05).We also found a statistically significant positive correlation between the incidence of PSC and the expression of p53(P < 0.001).UCA had a higher p53 expression as compared to UCR.OLT had a significantly lower expression of p53 as compared with PSC-UC(P < 0.001).Bcl-2 had a significant higher bcl-2 expression as compared with controls.No difference in COX-2 expression between PSC-UC,UCR and UCA was found.UCA had higher COX-2 expression as compared to UCR.We also found a statistically significant positive correlation between the expression of COX-2 and p53.Patients after liver transplantation for PSC had a statistically significantly lower expression of the p53 compared with PSCUC(P < 0.001).PSC-UC had the same inflammatory endoscopic activity as OLT and UCR when evaluated with the Mayo score.CONCLUSION:Our study shows that the nondysplatic mucosa of UC patients with PSC is characterised by a higher expression of the tumour suppressor gene p53,suggesting a higher susceptibility of cancer.This p53 overexpression correlates with the presence of PSC whilst it is not present in patients with UC after liver transplantation for PSC.     

Peritoneovenous shunting for refractory ascites results in worsening of nephrotic syndrome

Peritoneovenous shunt (PVS) is accepted as a treatment for refractory ascites due to liver cirrhosis. Infection is a well‐known complication of shunting. However, the effects of PVS in terms of complications for renal disease are unclear. We encountered a case involving a 52‐year‐old man with alcoholic liver cirrhosis and complications of nephrotic syndrome that were worsened by PVS. He received PVS for refractory ascites due to alcoholic liver cirrhosis before coming to our hospital for evaluation for liver transplantation. Nephrotic syndrome was then identified due to cirrhosis‐related membranoproliferative glomerulonephritis (MPGN). Prednisolone was administrated at 60 mg/day for MPGN. On day 5, he showed grade IV hepatic encephalopathy (West Haven criteria). Tapering prednisolone and intestinal cleansing with lactulose treatment improved hepatic encephalopathy, but hyperammonemia persisted and the PVS was removed. After shunt removal, urinary protein levels decreased from 4–6 g/day to 0.3–0.5 g/day and ammonia levels decreased. PVS may increase the excretion of urinary protein and increase ammonia levels in patients with complications of glomerulonephritis.     

Role of conservative management in tubercular abdominal cocoon: a case series

Background

Sclerosing encapsulating peritonitis (Abdominal cocoon) is an uncommon cause of intestinal obstruction and tuberculosis is an important etiology. Appropriate management of this entity is still uncertain.

Methods

We did a retrospective analysis of patients with abdominal cocoon who were seen over a two year period at a tertiary care center in North India. We included patients with tubercular abdominal cocoon (TAC) who were managed primarily with antitubercular therapy in the present report. The diagnosis of TAC was made using combination of criteria (radiological or surgical findings of cocoon with evidence of tuberculosis in form of microbiological, histological or biochemical evidence). The clinical presentation, outcome and need for surgery for these patients were retrieved from the records of these cases maintained in a database.

Results

Of 18 patients with abdominal cocoon, 15 patients had underlying tuberculosis. The median age was 28 years (interquartile range 24) and 12 (80%) were males. Three patients had confirmed tuberculosis on basis of microbiological evidence. All had abdominal pain for 1–9 months, and 11 had intestinal obstruction. Twelve patients had positive Mantoux test, none had HIV. Pulmonary tuberculosis was noted in four patients, pleural in five, splenic and intestinal in two each, hepatic and mediastinal lymph-nodal in one each. Thirteen patients were started on usual 4-drug anti-tubercular therapy (ATT) while two cirrhotics needed modified ATT. Three patients were on steroids with ATT and all three improved. One patient was lost to follow up. Of the rest 14 patients, 2 underwent surgery, 1 at initial presentation while another after 4 months of ATT. Overall five patients developed intestinal obstruction while on ATT, one needed surgery and one died of liver failure while others improved with conservative means.

Conclusion

TAC can be managed conservatively in a subset of patients.

     

原发性腹茧症合并隐睾术前误诊4例

目的:提高腹茧症的诊治水平.方法:我院2006-01/12收治的原发性腹茧症患者4例临床资料,以急性肠梗阻入院,查体发现均合并单侧隐睾,全部病例行剖腹探查.结果:术中证实腹茧症诊断,手术方案采取全部或部分包膜切除、肠黏连松解、肠排列术等,均痊愈出院.结论:腹茧症临床表现无特异性,术前诊断困难,对合并隐睾的肠梗阻应考虑到腹茧症的可能,手术治疗是腹茧症有效的治疗方法.     

Rare cause of jaundice in a post liver transplant patient

A hepatitis B virus carrier suffering from acute flare of chronic hepatitis B infection underwent deceased‐donor liver transplantation. He was put on the immunosuppressive agent tacrolimus. On routine follow‐up, he was found to have abnormal liver function. Computed tomography scan of the abdomen did not show any dilatation of the biliary system. Liver biopsy showed scattered microabscesses, and a microgranuloma was detected. Endoscopic retrograde cholangiography was performed and a biliary anastomotic stricture (BAS) was noted. In addition, the Chinese liver fluke, Clonorchis sinensis, was discovered. Balloon dilatation and stenting were performed. The patient was given a course of praziquantel. His liver function improved and normalized. We present the case of a liver transplant recipient with cholangitis caused by C. sinensis infestation and infection and biliary obstruction resulting from BAS.     

Small bowel obstruction due to an unconjugated ursodeoxycholic acid enterolith following living donor liver transplantation: Report of a case

We report an unusual case of small bowel obstruction due to an ursodeoxycholic acid (UDCA) enterolith that occurred 7 years after liver transplantation. A 70‐year‐old man had undergone multiple operations, including a living donor liver transplantation (LDLT) and hepaticojejunostomy. Four years after the LDLT, cholestasis developed, for which oral UDCA was administrated. Seven years after the LDLT, he was admitted to our hospital because of pneumonia; intestinal obstruction occurred following its resolution. A radiographic contrast study and computed tomographic scan indicated a movable mass as the cause of the ileus, suggesting a giant stone. We were unable to observe or remove the stone by double balloon enteroscopy owing to the presence of severe adhesion; thus, we surgically removed the mass. The patient's postoperative course was uneventful. He was discharged 20 days after the operation. An infrared spectrophotometric analysis revealed that the stone was a true enterolith, primarily composed of unconjugated UDCA. An ileus caused by a true enterolith is a rare clinical complication of LDLT. Nevertheless, it must be considered in the differential diagnosis of intestinal obstructions in liver transplant recipients with Roux‐en‐Y hepaticojejunostomies and/or bowel stasis.     

Sclerosing encapsulating peritonitis: differential diagnosis to peritoneal encapsulation and abdominal cocoon--a case report.

A 59 year old man presented with symptoms of partial bowel obstruction. Small bowel x-ray studies did not allow to identify the nature of the intestinal process in the upper ileum. At laparotomy small bowel encapsulation with a whitish membrane was encountered. Despite partial removal of this membrane small bowel obstruction persisted and two weeks postoperatively the patient died of peritonitis and cardiac insufficiency. Autopsy findings revealed massive fibrous adhesions in the abdomen with granulomatous inflammation. The presence of foreign body giant cells and bifringent crystals were characteristic for talcum powder. The latter suggested a causal role of an appendectomy 45 years earlier. The diagnosis of sclerosing encapsulating peritonitis as established in our patient needs to be separated from peritoneal encapsulation, a congenital malformation, and abdominal cocoon, which contains histological elements of inflammation. This case report should draw attention to these entities in the differential diagnosis and surgical management of small bowel obstruction.     

Idiopathic abdominal cocoon syndrome with unilateral abdominal cryptorchidism and greater omentum hypoplasia in a young case of small bowel obstruction

Abdominal cocoon syndrome (ACS) is a rare cause of intestinal obstruction due to total or partial encapsulation of the small intestine by a fibrocollagenous membrane. Idiopathic ACS with abdominal cryptorchidism and greater omentum hypoplasia is even rarer clinically. We successfully treated a 26-year-old male case of small bowel obstruction with acute peritonitis. He was finally diagnosed with idiopathic ACS with unilateral abdominal cryptorchidism and greater omentum hypoplasia during exploratory laparotomy. He then underwent enterolysis, cryptorchidectomy, and appendectomy. He recovered gradually from the operations and early postoperative inflammatory ileus. There has been no recurrence of intestinal obstruction since the operation, and he is still in follow-up. We analyzed his clinical data and retrospectively reviewed the literature, and our findings may be helpful for the clinical diagnosis and treatment on ACS.     

Abdominal cocoon syndrome: Rare cause of intestinal obstruction—Case report and systematic review of literature

Background:Abdominal cocoon or sclerosing encapsulating peritonitis is an uncommon condition in which the small bowel is completely or partially encased by a thick fibrotic membrane. Our study presents a case of sclerosing encapsulating peritonitis and conducts a literature review.Methods:A bibliographic research was conducted. Our research comprised 97 articles. Gender, age, symptoms, diagnostic procedures, and treatment were all included in the database of patient characteristics.Case presentation:A 51-year-old man complaining of a 2-day history of minor diffuse abdominal pain, loss of appetite, and constipation was presented in emergency department. Physical examination was indicative of intestinal obstruction. Laboratory tests were normal. Diffuse intraperitoneal fluid and dilated small intestinal loops were discovered on computed tomography (CT). An exploratory laparotomy was recommended, in which the sac membrane was removed and adhesiolysis was performed. He was discharged on the tenth postoperative day.Results:There were 240 cases of abdominal cocoon syndrome in total. In terms of gender, 151 of 240 (62.9%) were male and 89 of 240 (37%) were female. Ages between 20 and 40 are most affected. Symptoms include abdominal pain and obstruction signs. For the diagnosis of abdominal cocoon syndrome, CT may be the gold standard imaging method. The surgical operation was the treatment of choice in the vast majority of cases (96.7%). Only 69 of 239 patients (28.9%) were detected prior to surgery, and CT was applied in these cases.Conclusion:Abdominal cocoon is a rare condition marked by recurrent episodes of intestinal obstruction. Surgical therapy is the most effective treatment option.     

Liver cirrhosis with encapsulating peritoneal sclerosis after 4 years of peritoneal dialysis: A case report

Rationale:Encapsulating peritoneal sclerosis (EPS), or abdominal cocoon, is a rare but fatal syndrome characterized by intestinal obstruction owing to adhesions in a diffusely thickened peritoneum. Long-term peritoneal dialysis (PD) for more than 5 years is commonly associated with EPS, while liver cirrhosis also carries a risk of EPS. However, there have been only a few reports that describe a case of EPS complicated with both cirrhosis and PD. We herein describe a case of advanced liver cirrhosis with end-stage renal disease (ESRD) who developed EPS after 4 years of PD and who was successfully recovered by surgery.Patient concerns:A 58-year-old man with alcoholic liver cirrhosis suffered abdominal pain. The patient had a 4-year history of continuous cycling PD to manage ESRD as well as cirrhotic complications of refractory ascites and hypotension. Laboratory test results showed increased levels of inflammation, and contrast-enhanced computed tomography scan showed dilated loops of small bowel proximal to the site of intestinal obstruction. The patient was suspected to have developed intestinal obstruction owing to EPS. The patient discontinued continuous cycling peritoneal dialysis and switched to hemodiafiltration.Diagnoses:Laparoscopy revealed a whitish membranous material wrapped around the bowel, especially at the terminal ileum with a narrowed portion, consistent with EPS.Interventions:Repeated decortication of fibrous peritoneal membranes successfully released the intestinal obstruction.Outcomes:The postoperative course went well and abdominal pain remained in remission. Because abdominal distension owing to ascites got intolerable in a few days after surgery, a PD catheter was re-inserted and ascitic fluid drainage was resumed with peritoneal lavage. The patient continued hemodiafiltration using vasopressor agents.Lessons:The Cirrhotic patient with ESRD undergoing PD could develop EPS after a short duration of PD.