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.     

Congenital mesenteric defect: Description of a rare cause of distal intestinal obstruction in a neonate

INTRODUCTIONInternal hernias are a rare cause of bowel obstruction in the neonate and present with bilious vomiting. Newborns may be at risk of loss of significant length of bowel if this rare condition is not considered in the differential diagnosis of bilious emesis.PRESENTATION OF CASEWe report a case of a twin with an internal hernia through a defect in the ileal mesentery who presented with neonatal bowel obstruction. The patient had a microcolon on the contrast enema suggesting that the likely etiology was an intra-uterine event most likely a vascular accident that prevented satisfactory meconium passage into the colon.discussionAn internal hernia is rarely considered in the differential diagnosis of distal bowel obstruction in a neonate with a microcolon. Congenital trans-mesenteric hernias constitute only 5–10% of internal hernias. True diagnosis of trans-mesenteric hernias is difficult due to lack of specific radiology or laboratory findings to confirm the suspicion.conclusionWhen clinical and radiological findings are not classical, rare possibilities such as an internal hernia must be considered in the differential diagnosis, to avoid catastrophic bowel loss.     

Laparoscopic management of a small bowel obstruction of unknown cause

With the expanding indications for minimally invasive surgery, the management of small bowel obstruction is evolving. The laparoscope shortens hospital stay, hastens recovery, and reduces morbidity, such as wound infection and incisional hernia associated with open surgery. However, many surgeons are reluctant to attempt laparoscopy in patients with significantly distended small bowel and a history of multiple previous abdominal operations. We present the management of a patient with a virgin abdomen who presented with a small bowel obstruction most likely secondary to Fitz-Hugh-Curtis syndrome who was successfully managed with laparoscopic lysis of adhesions.     

Phytobezoar in Meckel's diverticulum: A rare cause of small bowel obstruction

IntroductionMeckel's diverticulum (MD) is the prevailing anomaly of the gastrointestinal tract, found in about 2% of the population; it rarely gives rise to symptoms and its discovery is usually accidental. Phytobezoar is a concretion of poorly digested fruit and vegetable fibres that is found in the alimentary tract and rarely can be the cause of small intestinal obstruction. Herein we report a rare case of intestinal obstruction due to phytobezoar formation into a MD.Presentation of caseA 50 year-old patient, was admitted to author's institution with an history of abdominal pain, nausea and multiples episodes of vomiting. Plain X-ray showed dilated small-bowel loops. Computed tomography (CT) revealed jejunal loops with air-fluid levels. The patient underwent explorative laparotomy where we found a giant Meckel's diverticulum, filled by a phytobezoar that caused small bowel compression. We performed a segmental ileal, resection, containing the MD. The histological exam confirmed Meckel's diverticulum.DiscussionBowel obstruction due to a phytobezoar in a Meckel's diverticulum is rare: only 7 cases have been reported in literature. MD complications are rare and phytobezoar is one of them with only few cases described in literature.ConclusionThe conventional x rays studies were inconclusive whereas abdominal contrast enhanced CT led to a definitive diagnosis. Explorative laparotomy or laparoscopy is mandatory in these cases.     

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.     

Giant Meckel’s diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum(MD) results from incomplete involution of the proximal portion of the vitelline(also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anom-aly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagno-sis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD(≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was suc-cessfully managed by surgical resection and anasto-mosis created with endoscopic stapler device(80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopatho-logic examination indicated Meckel's diverticulitis with-out gastric or pancreatic metaplasia.     

Intestinal chondrolipoma: uncommon cause of bowel obstruction

A case of intestinal obstruction caused by jejunal chondrolipoma in an 11-year-old boy is presented. To the best of our knowledge, this seems to be the first report of chondrolipoma arising from the small bowel in English language literatures.     

恶性肠梗阻的处理与治疗

恶性肠梗阻常见于肠管肿瘤或妇科肿瘤患者.手术治疗对于大部分患者是首选,但对于预后极差的患者并不适用.鼻胃管减压仅用于短期治疗,自膨胀金属支架适用于胃出口梗阻及近端小肠梗阻.     

Congenital nasal pyriform aperture stenosis: a rare cause of neonatal nasal obstruction

Congenital nasal pyriform aperture stenosis has been described as an unusual cause of neonatal nasal obstruction. Clinical suspicion is based on respiratory distress, cyclic cyanosis, apneas, and feeding difficulties. A bony overgrowth of the maxillary nasal processes is thought to be responsible for this deformity. This anomaly has been reported as an isolated feature or can be associated with craniofacial or central nervous system anomalies. Surgery is indicated in cases of severe respiratory distress, feeding difficulties, and when conservative methods fail.     

Meconium obstruction in extremely low-birth-weight neonates: guidelines for diagnosis and management

Background

Guidelines for diagnosis and therapy of meconium obstruction in extremely low birth weight neonates are still not well established.

Methods

All low-birth-weight infants presenting with meconium obstruction over a 5-year period were reviewed retrospectively. Patients with meconium plug syndrome or cystic fibrosis were excluded.

Results

Seven patients were identified. Average birth weight and gestational age were 874 g and 27.7 weeks, respectively. All were products of high-risk pregnancies, and 6 (86%) were delivered by cesarian section. All patients presented with distended abdomens without peritonitis. Abdominal films showed multiple distended intestinal loops without air-fluid levels in all cases. Three patients (43%) had contrast enemas, all showing microcolon. Nonoperative therapy, consisting of rectal irrigations and N-acetylcysteine per orogastric tube, succeeded in 3 patients who were obstructed for less than 10 days and failed in 1 patient obstructed for 12 days. Four patients, all obstructed for more than 10 days, underwent enterotomy and lavage (2), bowel resection and ileostomy (1), and initial peritoneal drainage for perforation followed by bowel resection (1). All patients survived with intact bowel function.

Conclusions

Extremely low-birth-weight infants with meconium obstruction can be diagnosed based on their typical clinical and plain radiographic characteristics, without need for a contrast enema. Nonoperative treatment is successful early in the course of the obstruction. In the absence of an intestinal complication, simple enterotomy and meconium evacuation effectively treats long-standing obstruction.     

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.     

Computed tomography in the assessment of suspected large bowel obstruction

BACKGROUND: The aim of this study was to assess the efficacy of computed tomography (CT) scanning in the diagnosis of acute large bowel obstruction. METHODS: Forty-four patients (22 men; 22 women, ages 39-94 years, mean 71 years) with clinical features and abdominal radiographic findings suggesting acute large bowel obstruction (LBO) or pseudo-obstruction were examined with CT. Supine scans were obtained with i.v. contrast medium (unless contraindicated), but (in the majority) without oral contrast. Additional prone and/or decubitus scans were obtained in 33 patients when clarification of a possible transition point on the supine scan was required. CT diagnosis of LBO was made by finding a transition point +/- mass. Final diagnosis was confirmed by surgery, further imaging and/or clinical course. RESULTS: Twenty-two patients had proven mechanical acute LBO of whom 18 had an obstructing carcinoma; 22 patients had no mechanical obstruction. Sensitivity, specificity, Positive Predictive Value, Negative Predictive Value of CT for diagnosis of mechanical LBO were each 91%. Positive and negative likelihood ratios were 10.1 and 0.1, respectively. There were two false-negative CT scans, although one of these was reported as showing segmental mural thickening. A mass was identified on 14 of 17 patients with true-positive CT, subsequently found to have carcinoma. CONCLUSION: Computed tomography with additional selective prone and/or decubitus scanning is highly effective in the diagnosis of mechanical LBO. It is suggested that it replace contrast enema as the initial imaging method.     

Prospective evaluation of oral gastrografin in postoperative small bowel obstruction

BACKGROUND: Orally administered gastrografin has been used for early resolution of postoperative small bowel obstruction (POSBO) and to reduce the need for surgery in various studies. However the studies have reported conflicting results as patients with complete obstruction and equivocal diagnosis of bowel strangulation were also included. PATIENTS AND METHODS: We carried out a prospective study to evaluate the efficacy of gastrografin in patients with partial adhesive small bowel obstruction. Patients with suspected strangulation, complete obstruction, obstructed hernia, bowel malignancy, and radiation enteritis were excluded. Sixty-two patients with partial adhesive small bowel obstruction were given an initial trial of conservative management of 48 h. Thirty-eight patients improved within 48 h and the other 24 were given 100 ml of undiluted gastrografin through the nasogastric tube. In 22 patients the contrast reached the colon within 24 h. In the remaining two patients the contrast failed to reach the colon and these underwent surgery. RESULTS: The use of gastrografin avoided surgical intervention in 91.3% (22 of 24) patients who failed conservative management of POSBO. Gastrografin also decreased the overall requirement for surgical management of POSBO from the reported rate of 25 to 30% to 3.2% (2 of 62). CONCLUSION: Use of gastrografin in patients with partial POSBO helps in resolution of symptoms and avoids the need for surgical management in the majority of patients.     

Small bowel obstruction caused by a medication bezoar: Report of a case

We report herein the rare case of a 26-year-old woman who developed a small-bowel obstruction caused by a medication bezoar or enterolith, following the long-term ingestion of magnesium oxide cathartics for constipation. Medication bezoars resulting from laxatives or cathartics have rarely been reported and we were only able to find two other such cases in the literature.     

小肠梗阻的临床诊治进展

既往由于缺乏有效的检查手段,以及对小肠梗阻疾病认识局限,小肠梗阻的临床诊疗比较困难,以致延误了该类疾病的诊治。近年来随着各种影像学技术的飞速发展和对小肠粘连性梗阻的深入研究,使小肠梗阻疾病的诊疗水平有了很大的提高。本文就小肠梗阻的诊治现状做一回顾。     

Randomized controlled trial of Gastrografin in adhesive small bowel obstruction

BACKGROUND: Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO). METHODS: Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications. RESULTS: Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03). CONCLUSIONS: Gastrografin accelerates resolution of ASBO by a specific therapeutic effect.     

Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience.

OBJECTIVE: The aim of this study is to evaluate laparoscopy as another tool for management of cases of adhesive acute small bowel obstruction. METHODS: Fourteen patients suffering from suspected adhesive small bowel obstruction were explored laparoscopically over a period of 24 months. The Veress needle was inserted either in a virgin part of the abdomen away from previous scars or under direct vision using an open technique. Careful inspection of the entire abdomen was done, and the small bowel was "run" in a retrograde fashion starting at the cecum. The point of obstruction was localized and adhesiolysis was performed, thus resolving the problem. RESULTS: Laparoscopic exploration was able to determine the site and cause of obstruction precisely in all 14 cases, with resolution of the problem laparoscopically in 12 patients (85.7%). Two cases were converted to open surgery (14.3%). There were no mortalities and low morbidity (7.1%). The mean hospital stay was 3.7 days. CONCLUSION: Laparoscopic surgery can be an advantageous alternative to open surgery in acute small bowel obstruction, thus providing a new technique for its diagnosis and treatment with all the advantages of minimally invasive surgery.