Distal intestinal obstruction syndrome in cystic fibrosis treated by oral intestinal lavage, and a case of recurrent obstruction despite normal pancreatic function.

An oral intestinal lavage solution has been successfully used in the treatment of six patients with chronic distal intestinal obstruction syndrome (previously referred to as meconium ileus equivalent) complicating cystic fibrosis and a further case of recurrent small bowel obstruction. The patient with recurrent obstruction is unusual in having no evidence of pancreatic maldigestion, which previously has been considered a prerequisite for the syndrome.     

Management of a small bowel transplant with complicated central venous access in a patient with asymptomatic superior and inferior vena cava obstruction

During the past few years, small bowel transplantation (SBT) has become a realistic alternative for patients with irreversible intestinal failure who have or will develop severe complications from total parenteral nutrition (TPN). Transplantation can be associated with large fluid shifts and massive blood loss necessitating rapid infusions of large quantities of crystalloid and/or blood products. Invasive monitoring and large-bore venous access are necessary in order to manage these patients intraoperatively. Because patients with irreversible intestinal failure are often managed with total parenteral nutrition via a central venous catheter, thrombotic intraluminal obstruction of major vessels may develop over time. Additionally, this may lead to superior vena cava (SVC) syndrome as well as challenging problems with vascular access. We present a 34-year-old woman with a past medical history for long-standing Crohn's disease with multiple small bowel resections and short gut syndrome who presented for an SBT. The patient had a long history of TPN use, complicated by SVC syndrome and inferior vena cava (IVC) obstruction. She was presently asymptomatic from her SVC obstruction. Central venous access was obtained by an interventional radiologist. A 7-French double-lumen Hickman minicatheter was placed in the left femoral vein with the tip of the catheter positioned just distal to the IVC narrowing. A left radial 20-gauge arterial line was placed for hemodynamic monitoring and frequent blood sampling. The patient's left and right dorsal-saphenous veins were cannulated with 16-guage catheters and adequate flow was observed. Lower extremity pressure was measured via the Hickman catheter in the left femoral vein. A multiplane transesophageal echo was used to assess ventricular volume. The options and intraoperative management of such patients are discussed.     

Distal gastric volvulus as a cause of acute occlusion in paraesophageal hernia. Considerations on a clinical case

A case of distal volvulus of the stomach as a cause of acute intestinal obstruction in a paraesophageal hernia is presented. The patient, an old woman aged 82, had been suffering from abdominal pain and vomiting for about 48 hours. She successfully underwent emergency operation for the reduction of hernia and plasty of the hiatus anterior the esophagus. On the basis of personal experience and review of literature data, stress is laid on the high incidence of paraesophageal hernia complications and the importance of early diagnosis and surgical repair is underlined.     

Venous cannulation for extracorporeal circulation after total cavopulmonary connection with extracardiac conduit

We report two cases of venous cannulation after a total cavopulmonary connection (TCPC) with extracardiac conduit. Venous cannulation was performed via side graft sutured to the extracardiac conduit in an end-to-side fashion. The first case was a 3-year-old girl, who suffered from an atypical inferior vena cava obstruction after TCPC. The obstruction region was distal to the anastomosis site of extracardiac conduit and inferior vena cava. She underwent a surgical release of obstruction under cardiopulmonary bypass without circulatory arrest. The second case was a 2-year-old girl, who needed an extracorporeal membrane oxygenation support after TCPC due to severe low cardiac output syndrome. She was decannulated successfully after thirty-nine-hour support.     

Bouveret's syndrome: successful endoscopic treatment of gastric outlet obstruction caused by an impacted gallstone

Bouveret's syndrome is defined as gastric outlet obstruction caused by duodenal impaction of a large gallstone which passes into the duodenal bulb through a cholecystogastric or cholecystoduodenal fistula. This is a report of a 62 years old female who presented with complaint of persistent vomiting and upper abdominal pain for the last 5 days. Ultrasound abdomen was suggestive of pneumobilia. CT scan of upper abdomen showed cholecystoduodenal fistula and complete obstruction of third part of duodenum by a large stone, which was reported as Bouveret's syndrome. She underwent emergency gastroscopy. The stone was retrieved by Dormia basket, crushed with lithotripter and extracted endoscopically.Complete intestinal obstruction was relieved endoscopically.     

Balloon catheter dilatation of focal intestinal strictures following necrotizing enterocolitis

Dilatation with a balloon catheter was successfully employed for 9 focal intestinal strictures which occurred in 5 infants following necrotizing enterocolitis. Eight of the 9 strictures were located in defunctionalized colon distal to an enterostomy; no infant had clinical intestinal obstruction. Because the dilatation achieved distal patency, subsequent closure of the enterostomy was accomplished without a formal laparotomy. The balloon dilatation technique may be valuable in the management of focal strictures that are not causing clinical intestinal obstruction.     

The association of absent suspensory ligaments of the liver and Marfan syndrome.

Gastrointestinal manifestations of collagen diseases are very rare. The authors report on a patient who has features of Marfan syndrome with mobile liver caused by the absence of its suspensory ligaments. This patient presented with an acute intestinal obstruction secondary to a congenital band across the distal transverse colon. Recurrent intestinal obstruction after resection of the band necessitated the performance of partial colectomy with ileotransverse anastomosis. The patient's phenotypic features are suggestive but not diagnostic of Marfan syndrome. Nevertheless, isolated skeletal manifestations of Marfan syndrome with documented FBN1 gene mutation have been reported, suggesting the existence of milder forms of the syndrome not exhibiting the classic diagnostic criteria. The authors postulate that the absence of suspensory ligaments of the liver in this patient could be attributed to the defective connective tissue of Marfan syndrome.     

Laparoscopic pancreas-preserving distal duodenectomy for duodenal stricture related to nonsteroidal antiinflammatory drugs (NSAIDs)

BACKGROUND: Chronic ingestion of nonsteroidal antiinflammatory drugs (NSAIDs) has rarely been associated with the development of intestinal diaphragm-like strictures. We have explored the role of laparoscopic surgery for the management of NSAID-related long distal duodenal strictures. METHOD: A 49-year-old woman had been on NSAID therapy (ibuprofen) for backache more than 2 years. She showed symptoms of gastric outlet obstruction and gastrointestinal blood loss, and investigations showed a long stricture in the third and fourth parts of the duodenum. She underwent a laparoscopic pancreas-preserving distal duodenectomy with duodenojejunal anastomosis. RESULT: Relaparoscopy on postoperative day 1 for bleeding showed no active source of bleeding. The patient's subsequent recovery was uneventful, and she was discharged on postoperative day 4. Further symptomatic strictures developed 2 months later at the previously ulcerated pylorus and distal duodenal bulb and were managed by a laparoscopic Roux-en-Y gastrojejunostomy. The patient was discharged on postoperative day 3, but represented 2 months later with symptomatic stenosis at the gastrojejunostomy which was managed by a laparoscopic revision gastrojejunostomy. Discharged on the postoperative day 2, she had regained weight and remained symptom free at follow-up assessment 3 months later. CONCLUSION: Laparoscopic pancreas-preserving distal duodenectomy for the management of benign duodenal strictures is feasible and safe. Moreover, we have demonstrated the beneficial role of relaparoscopy for the management of postoperative complications and for revision surgical procedures.     

The Ogilvie syndrome

The authors observed 3 patients with the Ogilvie syndrome. The Ogilvie syndrome is a peculiar form of acute intestinal obstruction characterized by acute dilatation of the colon without obstruction of its distal portions and often developing against the background of other grave diseases. For a timely diagnosed pathology the conservative treatment including a colonoscopic decompression of the colon and epidural anesthesia++ proved to be effective. In cases of ineffective conservative measures a cecostomy was put, resection of the injured portion was used for necrosis and perforation of the over-stretched++ gut.     

Laparoscopic placement of the Chait cecostomy device via appendicostomy

The authors describe their experience with a series of 11 patients in whom they have carried out Chait cecostomy catheter insertion into a laparoscopically formed appendicostomy. This technique has several advantages compared with percutaneous insertion and we now insert the device at the primary procedure. The authors have had one minor complication in their 11 patients, with mean follow-up of 8 months. This technique is recommended for the management of refractory constipation, for etiologies including spina bifida, anorectal malformation, distal intestinal obstruction syndrome, and slow-colonic transit.     

Anisakiasis of the colon presenting as bowel obstruction

Anisakiasis is a disease caused by human infection by the Anisakis larvae, a marine nematode found in raw or undercooked fish. With the increased popularity of eating sushi and raw fish (sashimi) in the United States infection with anisakis is expected to rise. We present the first reported case in the United States of intestinal anisakiasis presenting as a bowel obstruction. A 25-year-old healthy woman with no prior history of surgery presented to the emergency room with bowel obstruction by history and CT. CT also showed a mass in the right lower quadrant. She had eaten seviche, a raw fish appetizer, 2 days earlier and sashimi 3 weeks before admission. She was taken to the operating room for an exploratory laparotomy and was found to have an obstruction, the 2-cm mass in the mesentery, and diffuse mesenteric adenopathy. She had an ileocolectomy. Pathology showed a degenerating fish worm, anisakiasis. She also had a serologic test for immunoglobulin E specific to anisakiasis and it was highly positive. Human infections, as mentioned before, are principally the result of ingestion of the Anisakis larvae. These larvae are usually found in herring, mackerel, salmon, cod, halibut, rockfish, sardine, and squid. Most human infections have been reported from Japan and The Netherlands and involve the stomach. Invasion of the gastric or intestinal wall one to 5 days after eating raw fish may be characterized by the abrupt onset of abdominal pain, nausea and/or vomiting, diarrhea, or an ileus. For transient anisakiasis, supportive measures and reassurance are all that is needed. If the larvae have invaded the intestine or the stomach wall diagnosis and cure occur with endoscopic or surgical removal if evidence of obstruction or perforation is found. The incidence of anisakiasis in the United States is unknown but will likely continue to increase with the popularity of eating sashimi. This case is meant to demonstrate another possible cause for bowel obstruction in the patient who has just eaten raw or undercooked fish.     

Intraluminal Duodenal Obstruction by a Gastric Band Following Erosion

Background: Duodenal obstruction occurred 4 years following gastric banding for morbid obesity, which had had a good result. Method: A 56-year-old female with a history of gastric banding presented with duodenal obstruction. Result: Physical and radiological examination was able to give the diagnosis. At surgery, the gastric band in the distal duodenum was removed. She was discharged on postoperative day 4, with no complication. At 6 months following discharge, her nausea and vomiting have not recurred. Conclusion: Following gastric banding, band erosion through the gastric wall and internalization into the lumen can cause small bowel obstruction.     

CARPAL TUNNEL SYNDROME AFTER EPIPHYSIOLYSIS OF THE DISTAL RADIUS IN A 5-YEAR-OLD CHILD: Case report

Carpal tunnel syndrome after fracture of the distal radius is a well known complication in adults, but in small children carpal tunnel syndrome is extremely rare. A case of carpal tunnel syndrome in a 5-year-old girl is presented. She had a distal epiphysiolysis of the radius, which was treated conservatively. Eight weeks after removal of the plaster of Paris she had clinical signs of carpal tunnel syndrome after excercise but without new injuries. Conservative treatment with a dorsal splint was effective, and all her symptoms disappeared. So conservative treatment seems worth considering before operation in similar cases.     

Soft tissue inflammation: presenting feature of Crohn's disease in a cystic fibrosis adolescent.

We report Crohn's disease in an adolescent with cystic fibrosis (CF). The patient suffered from recurrent abdominal symptoms, which were attributed to distal intestinal obstruction syndrome (DIOS) until a soft tissue inflammation at the right lumbar region and iliac crest revealed an enterosubcutaneous fistula. The diagnosis of Crohn's disease was confirmed on the basis of radiological, endoscopic and histological findings.     

Carpal tunnel syndrome after epiphysiolysis of the distal radius in a 5-year-old child. Case report.

Carpal tunnel syndrome after fracture of the distal radius is a well known complication in adults, but in small children carpal tunnel syndrome is extremely rare. A case of carpal tunnel syndrome in a 5-year-old girl is presented. She had a distal epiphysiolysis of the radius, which was treated conservatively. Eight weeks after removal of the plaster of Paris she had clinical signs of carpal tunnel syndrome after exercise but without new injuries. Conservative treatment with a dorsal splint was effective, and all her symptoms disappeared. So conservative treatment seems worth considering before operation in similar cases.     

肠梗阻的常见病因分类与治疗策略

肠梗阻的常见病因分类较多,按肠梗阻的病因可分为机械性和非机械性两大类;按肠壁血运有无障碍可分为单纯性肠梗阻和绞窄性肠梗阻;按梗阻程度可分为完全性和不完全性或部分性肠梗阻;按梗阻部位可分为高位小肠梗阻,低位小肠梗阻和结肠梗阻等。在治疗策略上大约60%～70%患者可经非手术治愈。需手术的病例,针对不同病因,采用不同的术式治疗。     

Myosin B ATPase activity of the intestinal smooth muscle in intestinal obstruction

Intestinal smooth myosin B was prepared from muscle layers around the lesion in dogs with experimental colonic stenosis and in patients with congenital intestinal obstruction. Mg2+-ATPase activity of the myosin B was compared between the proximal dilated segment and distal segment to obstruction. Experimental colonic stenosis: In early period after surgery, proximal colons showed higher activity of myosin B ATPase than distal colons, decreasing to less than distal colon as time passed. Congenital intestinal obstruction: In three cases, whose atresia might have occurred at earlier period of gestation, proximal bowels showed less activity of myosin B ATPase than distal bowels. However, in two cases, whose atresia might have occurred at later period of gestation, and two cases with intestinal stenosis, proximal bowels indicated higher activity of myosin B ATPase than distal bowels. These data suggested that the contractibility of the proximal intestine was depending on the duration of obstruction, and it was depressed in the former patients and was accelerated in the latter patients. These results suggested that the extensive resection of dilated proximal bowel in the congenital atresia is not always necessary to obtain good postoperative intestinal dynamics at the operation of the atresial lesions which may be induced at later period of gestation. They also suggested that surgery for intestinal obstruction should be performed before the depression of intestinal contractibility to get good bowel function.     

Trichobezoar presenting as a gastric outlet obstruction: A case report

IntroductionRapunzel syndrome is a rare intestinal condition that starts with the ingestion of a trichobezoar. The condition is predominately found in females and can be associated with trichotillomania, or the compulsive urge to pull one’s own hair out. There are less than 40 cases described in the literature with the prevention of recurrence aimed at psychological treatment.Presentation of caseThe patient is a 7 year-old girl with a history of trichotillomania with trichophagia as a young child who presented with abdominal pain, nausea, and vomiting, consistent with a gastric outlet obstruction. She had an exploratory laparotomy with gastrostomy performed revealing a 18 cm by 18 cm trichobezoar with extension into the small bowel.DiscussionBezoars, an already rare entity, can occasionally lead to gastric and small bowel obstructions. Small collections of ingested hair build up in the intestinal tract causing significant symptoms. These obstructions can sometimes be treated through minimally invasive techniques but, in our case described, it is unlikely to have been treated any other way due to the substantial size of the trichobezoar.ConclusionEarly consideration of Rapunzel syndrome is important in young females presenting with a gastric outlet obstruction.     

Hepatic portal vein gas detected by point of care ultrasound

IntroductionPortal venous gas is a rare finding in adults and is typically associated with underlying intestinal ischemia. Portal venous gas can be detected by a bedside point of care ultrasound (POCUS) examination in adult patients in critical care units (CCU). Findings include echogenic bubbles flowing centrifugally throughout the portal venous system.Case presentationWe present the case of a 73-year-old female with advanced ischemic cardiomyopathy and cardiorenal syndrome who was managed in the CCU. She developed vague abdominal pain and respiratory depression requiring intubation and dialysis during her course of treatment in the CCU. Her findings were consistent with portal venous gas upon POCUS, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have nonobstructive mesenteric ischemia.Clinical discussionPVG is an ominous radiological sign and reflects intestinal ischemia in up to 72% of cases. Acute mesenteric ischemia of the small bowel could be due to occlusive or nonocclusive obstruction of the arterial blood supply or obstruction of venous outflow. Nonocclusive obstruction accounts for 5% to 15% of patients with acute mesenteric ischemia.ConclusionWith the increasing use of POCUS, critical care physicians should be aware of findings consistent with portal venous gas as a bedside tool for directing the treating physician toward an ominous diagnosis in patients with shock.     

Gastrointestinal motility following small bowel obstruction in the opossum

The motility of the gastrointestinal tract of six opossums with total and four with partial small bowel obstruction was evaluated. Following the establishment of small bowel obstruction, the migrating myoelectric complex was substituted by a new pattern which was characterized by periods of intense spike activity interspersed with quiescent periods. In the experiments with total intestinal obstruction, the frequency and duration of the periods of intense spike activity were related to the recording site and the time after establishment of intestinal obstruction. The frequency of spike bursts in the ileum proximal and distal to the obstruction was the greatest in the first 2 days after the establishment of the obstruction, while in the antrum and proximal small bowel, the frequency of bursts of spike potentials increased gradually from the first to the fourth postobstruction day (P less than 0.01). However, there was no change in the frequency, duration, and localization of periods of intense spike activity during the 5 days following the establishment of partial intestinal obstruction. We concluded that following intestinal obstruction, the migrating myoelectric complex is substituted by a myoelectric pattern that is characterized by periods of intense spike activity interspersed with quiescent periods. In the animals with total intestinal obstruction, the periods of increased motility are initially more frequent in the bowel proximal and distal to the obstruction and afterwards in the stomach and upper small bowel.