Comprehensively evaluate the short outcome of small bowel obstruction:A novel medical-economic score system

BACKGROUND Small bowel obstruction(SBO)still imposes a substantial burden on the health care system.Traditional evaluation systems for SBO outcomes only focus on a single element.The comprehensive evaluation of outcomes for patients with SBO remains poorly studied.Early intensive clinical care would effectively improve the short-term outcomes for SBO,however,the full spectrum of the potential risk status regarding the high complication-cost burden is undetermined.AIM We aim to construct a novel system for the evaluation of SBO outcomes and the identification of potential risk status.METHODS Patients who were diagnosed with SBO were enrolled and stratified into the simple SBO(SiBO)group and the strangulated SBO(StBO)group.A principal component(PC)analysis was applied for data simplification and the extraction of patient characteristics,followed by separation of the high PC score group and the low PC score group.We identified independent risk status on admission via a binary logistic regression and then constructed predictive models for worsened management outcomes.Receiver operating characteristic curves were drawn,and the areas under the curve(AUCs)were calculated to assess the effectiveness of the predictive models.RESULTS Of the 281 patients,45 patients(16.0%)were found to have StBO,whereas 236 patients(84.0%)had SiBO.Regarding standardized length of stay(LOS),total hospital cost and the presence of severe adverse events(SAEs),a novel principal component was extracted(PC score=0.429×LOS+0.444×total hospital cost+0.291×SAE).In the multivariate analysis,risk statuses related to poor results for SiBO patients,including a low lymphocyte to monocyte ratio(OR=0.656),radiological features of a lack of small bowel feces signs(OR=0.316)and mural thickening(OR=1.338),were identified as risk factors.For the StBO group,higher BUN levels(OR=1.478)and lower lymphocytes levels(OR=0.071)were observed.The AUCs of the predictive models for poor outcomes were 0.715(95%CI:0.635-0.795)and 0.874(95%CI:0.762-0.986)for SiBO and StBO stratification,respectively.CONCLUSION The novel PC indicator provided a comprehensive scoring system for evaluating SBO outcomes on the foundation of complication-cost burden.According to the relative risk factors,early tailored intervention would improve the short-term outcomes.

Predictors for success of non-operative management of adhesive small bowel obstruction

BACKGROUND Majority of adhesive small bowel obstruction(SBO)cases can be managed nonoperatively.However,a proportion of patients failed non-operative management.AIM To evaluate the predictors of successful non-operative management in adhesive SBO.METHODS A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018.Data collated included basic demographics,clinical presentation,biochemistry and imaging results and management outcomes.The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes.The patients were divided into group A operative(including those that failed initial non-operative management)and group B non-operative for analysis.RESULTS Of 252 patients were included in the final analysis;group A(n=90)(35.7%)and group B(n=162)(64.3%).There were no differences in the clinical features between both groups.Laboratory tests of inflammatory markers and lactate levels were similar in both groups.From the imaging findings,the presence of a definitive transition point[odds ratio(OR)=2.67,95%confidence interval(CI):0.98-7.32,P=0.048],presence of free fluid(OR=2.11,95%CI:1.15-3.89,P=0.015)and absence of small bowel faecal signs(OR=1.70,95%CI:1.01-2.88,P=0.047)were predictive of the need of surgical intervention.In patients that received water soluble contrast medium,the evidence of contrast in colon was 3.83 times predictive of successful non-operative management(95%CI:1.79-8.21,P=0.001).CONCLUSION The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality.

A Far-Out Case of Ascariasis Causing Small Bowel Obstruction in Mauritius

Ascaris lumbricoides (A. lumbricoides), the soil-transmitted helminth is the most prevalent parasitic infection of the gastrointestinal tract in developing countries. Heavy worm loads mainly due to untreated worm infestations are often associated with increased risk of severe sequelae. We report the first complicated case of A. lumbricoides causing small bowel obstruction in a 9-year-old boy that necessitated surgical intervention on a tropical island in the Indian Ocean, where cases of Ascariasis are rarely encountered.

A prospective randomized trial of transnasal ileus tube vs nasogastric tube for adhesive small bowel obstruction

AIM:To study the therapeutic efficacy of a new transnasal ileus tube advanced endoscopically for adhesive small bowel obstruction.METHODS:A total of 186 patients with adhesive small bowel obstruction treated from September 2007 to February 2011 were enrolled into this prospective randomized controlled study.The endoscopically advanced new ileus tube was used for gastrointestinal decompression in 96 patients and ordinary nasogastric tube(NGT) was used in 90 patients.The therapeutic efficacy was compared between the two groups.RESULTS:Compared with the NGT group,the ileus tube group experienced significantly shorter time for relief of clinical symptoms and improvement in the findings of abdominal radiograph(4.1 ± 2.3 d vs 8.5 ± 5.0 d) and laboratory tests(P < 0.01).The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group(P < 0.01).And 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery.For recurrent adhesive bowel obstruction,ileus tube was also significantly more effective than NGT(95.8% vs 31.6%).In the ileus tube group,the drainage output on the first day and the length of hospital stay were significantly different depending on the treatment success or failure(P < 0.05).The abdominal radiographic improvement was correlated with whether or not the patient underwent surgery.CONCLUSION:Ileus tube can be used for adhesive small bowel obstruction.Endoscopic placement of the ileus tube is convenient and worthy to be promoted despite the potential risks.

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.

Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department

BACKGROUND： Emergency physicians frequently encounter patients with acute small bowel obstructions （SBO）. Although computed tomography （CT） imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. METHODS： We evaluated the accuracy of ultrasound performed in the ED by a variety of providers （physicians with various levels of training, physician assistants） compared to CT imaging in 47 patients with suspected SBOs. RESULTS： Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. CONCLUSION： Ultrasound can play an important role in the identification of small bowe obstructions in ED patients.

Safety and efficacy of self-expandable metallic stents in malignant small bowel obstructions

In this report, we present 3 cases of malignant small bowel obstruction, treated with palliative care using endoscopic self-expandable metallic stent(SEMS) placement, with the aim to identify the safety and efficacy of this procedure. Baseline patient characteristics, procedure methods, procedure time, technical and clinical success rates, complications, and patient outcomes were obtained. All 3 patients had pancreatic cancer with small bowel strictures. One patient received the SEMS using colonoscopy, while the other 2 patients received SEMS placement via double balloon endoscopy using the through-the-overtube technique. The median procedure time was 104 min. The technical and clinical success rates were 100%. Post-treatment, obstructive symptoms in all patients improved, and a low-residue diet could be tolerated. All stents remained within the patients until their deaths. The median overall survival time(stent patency time) was 76 d. SEMS placement is safe and effective as a palliative treatment for malignant small bowel obstruction.

Daikenchuto for postoperative adhesive small bowel obstruction:A systematic review and meta-analysis

AIMTo assess the effectiveness of Daikenchuto for patients with postoperative adhesive small bowel obstruction （ASBO）.METHODSA systematic search of PubMed （MEDLINE）, CINAHL, the Cochrane Library and Ichushi Web was conducted, and the reference lists of review articles were hand-searched. The outcomes of interest were the incidence rate of surgery, the length of hospital days and mortality. The quality of the included studies, publication bias and between-study heterogeneity were also assessed.RESULTS Three randomized controlled trials （RCTs） and three retrospective cohort studies were selected for analysis. In the three RCTs, Daikenchuto signifcantly reduced the incidence of surgery （pOR = 0.13; 95%CI： 0.03-0.50）. Similarly, Daikenchuto signifcantly reduced the incidence of surgery （pOR = 0.53; 95%CI： 0.32-0.87） in the three cohort studies. The length of hospital stay and mortality were not measured or described consistently.CONCLUSIONThe present meta-analysis demonstrates that admini-stering Daikenchuto is associated with a lower incidence of surgery for patients with postoperative ASBO in the Japanese population. In order to better generalize these results, additional studies will be needed.

Emergency department patients with small bowel obstruction： What is the anticipated clinical course？

BACKGROUND:Emergency physicians(EPs)often care for patients with acute small bowel obstruction.While some patients require exploratory laparotomy,others are managed successfully with supportive care.We aimed to determine features that predict the need for operative management in emergency department(ED)patients with small bowel obstruction(SBO).METHODS:We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period.We evaluated demographic characters(prior SBO,prior abdominal surgery,active malignancy)and clinical findings(leukocytosis and lactic acid)to determine features associated with the need for urgent operative intervention.RESULTS:Patients with a prior SBO were less likely to undergo operative intervention[20.3%(42/207)]compared to those without a prior SBO[35.2%(57/162)].Abnormal bloodwork was not associated with need for operative intervention.68%of patients with CT scan findings of both an SBO and a hernia,however,were operatively managed.CONCLUSIONS:Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization.Abnormal bloodwork was not associated with operative intervention.The CT finding of a hernia,however,predicted the need for operative intervention,while other findings(ascites,duodenal thickening)did not.Further research would be helpful to construct a prediction rule,which could help community EPs determine which patients may benefit from expedited transfer for operative management,and which patients could be safely managed conservatively as an initial treatment strategy.

Persistent omphalomesenteric duct causing small bowel obstruction in an adult

An extremely rare case of persistent omphalomesenteric duct causing small bowel obstruction is presented. A 20-year-old female patient without medical history presented with colicky abdominal pain, vomiting, absence of passage of gas and feces, and abdominal distension of 24 h duration. Physical examination and blood tests were normal. Abdominal X-ray showed small bowel obstruction. Computed tomography of the abdomen demonstrated dilated small bowel and a band originating from the umbilicus and continuing between the small bowel loops; an omphalomesenteric duct remnant was suspected. In exploratory laparotomy, persistent omphalomesenteric duct causing small bowel obstruction was identified and resected. The patient had an uneventful recovery and was discharged on the 5^th postoperative day. Although persistent omphalomesenteric duct is an extremely infrequent cause of small bowel obstruction in adult patients, it should be taken into consideration in patients without any previous surgical history.

Small bowel obstruction caused by secondary jejunal tumor from renal cell carcinoma: A case report

BACKGROUND Secondary jejunal tumor from renal cell carcinoma(RCC)is extremely rare in clinical practice and is easily missed and misdiagnosed because of the low incidence and atypical symptoms.CASE SUMMARY A 38-year-old male patient was diagnosed pathologically with left RCC after radical nephrectomy in 2012.The patient then suffered multiple lung metastases 2 years later and was treated with oral sorafenib without progression for 6 years.In 2020,an emergency intestinal segmental resection due to intestinal obstruction was required,and postoperative pathology confirmed a jejunal secondary tumor from RCC.The patient had a smooth recovery following surgery.Three months after surgery,the patient was diagnosed with left adrenal metastasis,and subsequent sintilimab therapy has stabilized his condition.CONCLUSION This report is written to remind urologists and pathologists of the potential for small intestinal secondary tumors when a patient with a history of RCC seeks treatment for digestive symptoms.Enteroscopy and abdominal contrast-enhanced computed tomography are essential means of examination,but severe cases require immediate surgical intervention despite the lack of a preoperative examination to distinguish tumor attributes.

Retroperitoneal fibrosis: A rare cause of both ureteral and small bowel obstruction

Retroperitoneal fibrosis (RPF) is a rare condition of unclear etiology. It can cause ureteral obstruction. We present the unique case of a 54 years old female, who initially presented with spontaneous perforation of the cecum. Upon exploring the abdomen, the classical glistening white, unyielding retroperitoneal fibrosis was encountered. A right hemicolectomy was performed. Subsequently, the patient presented with bilateral ureteral obstruction, and later on with small bowel obstruction. Ureteral obstruction was treated with stents, and small bowel obstruction was treated with bypass. To our knowledge no case of idiopathic RPF presenting with features of both bilateral ureteral and small bowel obstruction has been reported in the literature.

Small bowel obstruction caused by a bezoar following an adult simultaneous liver-kidney transplantation:A case report

BACKGROUND Small bowel obstructions(SBOs)are common following a large intra-abdominal operation;however,SBOs caused by bezoars are unreported in patients following liver-kidney transplantation procedures,particularly in adults.CASE SUMMARY A 65-year-old Caucasian female presented with nausea and nonbilious emesis during her postoperative course following a simultaneous liver-kidney transplantation.She developed worsening nausea and vomiting with significant abdominal distension and obstipation.Computed tomography imaging showed a marked abnormal dilation of multiple small bowel loops with a distinct transition point that was suggestive of a small bowel obstruction.An exploratory laparotomy revealed a foreign body in the intestinal track approximately 30 cm from the ileocecal valve.The foreign body was extracted and identified as a bezoar with hair follicles and old digestive contents.Following the operation,the patient demonstrated rapid clinical improvement with resolution of nausea,emesis,and progress in bowel motility.CONCLUSION SBOs caused by bezoars can occur immediately following a liver-kidney transplantation and should not be discounted as a diagnosis.

Small Bowel Obstruction Induced by Phytobezoar: A Case Report in Innocent Abdomen and Literature Review

Introduction: Small bowel obstruction (SBO) is defined as a complete and persistent cessation of the transit of materials and gases. It occurs in a segment of the digestive tract located between the pylorus and the colorectal junction. Herein, we report a case of small bowel obstruction (SBO) following excessive consumption of wild grapes with no previous abdomen medical or surgical history. Presentation of case: A 65-year-old male farmer presented with cessation of materials and gas associated with vomiting of food and then bilious. The abdomen was bloated and painful on palpation with a moving, painful mass in the left iliac fossa. The hypothesis of acute occlusion of the colon was retained and confirmed on the X-Ray which showed a dilation of small bowel with air-fluid levels. The diagnostic of acute SBO was retained. We performed urgently a median laparotomy. We found the dilation of the loops from the jejunum to the sigmoid colon with a compact mass at the sigmoid colon of 15 cm in length and 6 cm in diameter. We proceeded to crush the mass that was made up with wild grape seed fecal, and push it back to the rectum. The phytobezoar made up with wild grape seeds was extracted through the anus with the fingers after anal dilation. After extraction of the bezoar, the patient’s complaints completely subsided. Discussion: SBO is a frequent emergency surgical pathology. SBO induced by phytobezoar often occurs in patients with abdomen surgery history. However, it is particularly rare in virgin abdomen. Conclusion: This case report aims to raise awareness of phytobezoar as a cause of SBO in elderly even though without abdomen surgery history.

Efficacy of ileus tube combined with meglumine diatrizoate in treating postoperative inflammatory bowel obstruction after surgery

BACKGROUND Early postoperative inflammatory small bowel obstruction(EPISBO)is easy to be complicated after colorectal cancer surgery.Both intestinal obstruction catheter and meglumine can treat EPISBO.AIM To investigate the efficacy of an intestinal obstruction tube combined with meg-lumine diazo in treating EPISBO of colorectal cancer.METHODS Data from 60 patients with colorectal cancer and intestinal obstruction admitted to the Proctology Department of our hospital from April 2018 to May 2022 were collected and analyzed and divided into three cohorts according to different treatment regimens.Cohort A(n=20)received a transnasal intestinal obstruction catheter with panumglumine,and cohort B(n=20)received a transnasal intestinal obstruction catheter with liquid paraffin.Cohort C(n=20)received oral treatment with meglumine.The clinical efficacy,first exhaust/defecation time,length of hospital stay,gastrointestinal decompression time,relief time of abdo-minal pain,and relief time of abdominal distension were compared among the three cohorts.The levels of C-reactive protein(CRP),tumor necrosis factor-α(TNF-α),interleukin-6(IL-6),monocyte chemotactic protein-1(MCP-1),serum albumin,and transferrin were compared among the three cohorts before and after treatment.The occurrence of adverse reactions in the three cohorts was compared.RESULTS Compared with cohort C,the successful treatment rate of cohort A was signi-ficantly higher.There were statistically significant variations in the time of first exhaust/defecation,length of hospital stays,gastrointestinal decompression time,relief time of abdominal pain,and relief time of abdominal distention among the three cohorts.Compared with cohort C,cohort A’s first exhaust/defecation time,hospitalization time,gastrointestinal decompression time,abdominal pain relief time,and abdominal distension relief time was reduced(P<0.05).After treatment,serum CRP,TNF-α,IL-6,and MCP-1 expression levels increased,and serum albumin and serum transferrin levels increased in the three cohorts.The serum albumin level in cohort A was higher than in cohort C.Compared with cohort B and cohort C,the serum transferrin level in cohort A increased(P<0.05).Compared with cohort C,the total incidence of adverse reactions in cohorts A and B was significantly higher(P<0.05).The incidence of adverse reactions was similar between cohort A and cohort B.CONCLUSION Using an ileus tube combined with meglumine diatrizoate can effectively treat postoperative inflammatory ileus obstructions after surgery colorectal cancer and improve prognosis,inflammatory response,and nutritional status.

Idiopathic sclerosing mesenteritis presenting with small bowel volvulus in a patient with antiphospholipid syndrome:A case report

BACKGROUND Sclerosing mesenteritis is a rare disorder involving inflammation of the mesentery.Its etiology remains unclear,but it is believed to be associated with previous abdominal surgery,trauma,autoimmune disorders,infection,or malignancy.Clinical manifestations of sclerosing mesenteritis are varied and include chronic abdominal pain,bloating,diarrhea,weight loss,formation of an intra-abdominal mass,bowel obstruction,and chylous ascites.Here,we present a case of idiopathic sclerosing mesenteritis with small bowel volvulus in a patient with antiphospholipid syndrome.CASE SUMMARY A 68-year-old female presented with recurrent small bowel obstruction.Imaging and pathological findings were consistent with sclerosing mesenteritis causing mesenteric and small bowel volvulus.Computed tomography scans also revealed pulmonary embolism,and the patient was started on a high dose of corticosteroid and a therapeutic dose of anticoagulants.The patient subsequently improved clinically and was discharged.The patient was also diagnosed with antiphospholipid syndrome after a hematological workup.CONCLUSION Sclerosing mesenteritis is a rare condition,and patients with no clear etiology should be considered for treatment with immunosuppressive therapy.

Sequential stenotic strictures of the small bowel leading to obstruction

Small bowel obstructions （SBOs） are primarily caused by adhesions, hernias, neoplasms, or inflammatory strictures. Intraluminal strictures are an uncommon cause of SBO. This report describes our findings in a unique case of sequential, stenotic intraluminal strictures of the small intestine, discusses the differential diagnosis of intraluminal intestinal strictures, and reviews the literature regarding intraluminal pathology.

The weekend effect:does time of admission impact management and outcomes of small bowel obstruction?

Aims:To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction.Methods:A retrospective database review was carried out,covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004–2011.Results:A total of 404 patients met the inclusion criteria.One hundred and thirty-nine were admitted during the day,93 at night and 172 on the weekend.Overall 30.2%of the patients were managed operatively with no significant difference between the groups(P=0.89);however,of patients taken to the operating room,patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend,0.79 days vs 1.90 days,respectively(P=0.05).Overall mortality was low at 1.7%,with no difference noted between the groups(P=0.35).Likewise there was no difference in morbidity rates between the three groups(P=0.90).Conclusions:Despite a faster time to operative intervention in those patients admitted during the day,our study revealed that time of admission does not appear to correlate to patient outcome or mortality.

Two cases of small bowel obstruction due to a shiitake mushroom

The shiitake mushroom(Lentinula edodes),known as Xiang-gu in China,has been an important component of Asian cuisine for hundreds of years.Although not easily digestible,there are few reports of them causing bowel obstruction.We present two cases of small bowel obstruction due to a shiitake mushroomrequiring surgical intervention.Two patients who did not have any teeth and did not use dentures presented with intestinal bowel obstruction and were referred to the Emergency Department of our hospital after eating a meal including shiitake mushrooms without cutting.The first patient underwent an emergency laparotomy and a semental small bowel resection and the other underwent laparoscopic small bowel incision for removal of a foreign body.The causes of the small bowel obstruction for the two patients were uncut shiitake mushrooms in the small bowel.The two patients recovered uneventfully post-operatively.

Decompression of the small bowel by endoscopic long-tube placement

AIM:To investigate and compare the decompression effect on small bowel obstruction of a long tube inserted using either endoscopic or fluoroscopic placement.METHODS:Seventy-eight patients with small bowel obstruction requiring decompression were enrolled in the study and divided into two groups.Intubation of a long tube was guided by fluoroscopy in one group and by endoscopy in the other.The duration of the procedure and the success rate for each group were evaluated.RESULTS:A statistically significant difference in the mean duration of the procedure was found between the fluoroscopic group(32.6±14.6 min)and the endoscopic group(16.5±7.8 min)among the cases classified as successful(P<0.05).The success rate was significantly different between the groups:88.6%in the fluoroscopic group and 100%in the endoscopic group(P <0.05).CONCLUSION:For patients with adhesive small bowel obstruction,long-tube decompression is recommended and long-tube insertion by endoscopy was superior to fluoroscopic placement.