Small intestine angioleiomyoma as a rare cause of perforation:A case report

BACKGROUND Angioleiomyoma is a rare and benign stromal tumor typically found in subcutaneous tissue.It rarely occurs in the gastrointestinal tract.Among the reported cases,the most common complication was gastrointestinal bleeding.Perforation has only been reported as a complication in the last few decades.CASE SUMMARY This case report detailed the discovery of intestinal angioleiomyoma in a 47-yearold male presenting with abdominal pain that had persisted for 3 d.After suspecting hollow organ perforation,surgical intervention involving intestinal resection and anastomosis was performed.CONCLUSION The report underscores the significance of early surgical intervention in effectively treating angioleiomyoma while emphasizing the pivotal role of timely and appropriate measures for favorable outcomes.

Colon perforation with severe peritonitis caused by erotic toy insertion and treated using vacuum-assisted closure:A case report

BACKGROUND Colorectal foreign bodies are commonly encountered during surgery.They are frequently observed in men 20 to 90 years of age and have bimodal age distribution.Surgical management is necessary for cases of rectal perforation.However,surgical site infections are the most common complications after colorectal surgery.CASE SUMMARY We discuss a case of rectal perforation in a patient who presented to our hospital 2 d after its occurrence.The perforation occurred as a result of the patient inserting a sex toy in his rectum.Severe peritonitis was attributable to delayed presentation.CONCLUSION Vacuum-assisted closure was performed to treat the wound,which healed well after therapy.No complications were noted.

Henoch-Schonlein purpura from vasculitis to intestinal perforation: A case report and literature review

Henoch-Sch?nlein purpura(HSP) is generally a selflimited vasculitis disease and has a good prognosis. We report a 4-year-old Thai boy who presented with palpable purpura, abdominal colicky pain, seizure, and eventually developed intestinal ischemia and perforation despite adequate treatment, including corticosteroid and intravenous immunoglobulin therapy. Imaging modalities, including ultrasonography and contrastenhanced computed tomography, could not detect intestinal ischemia prior to perforation. In this patient, we also postulated that vasculitis-induced mucosal ischemia was a cause of the ulcer, leading to intestinal perforation, and high-dose corticosteroid could have been a contributing factor since the histopathology revealed depletion of lymphoid follicles. Intestinal perforation in HSP is rare, but life-threatening. Close monitoring and thorough clinical evaluation are essential to detect bowel ischemia before perforation, particularly in HSP patients who have hematochezia, persistent localized abdominal tenderness and guarding. In highly suspicious cases, exploratory laparotomy may be needed for the definite diagnosis and prevention of further complications.

Perforation of the colon by invading recurrent gastrointestinal stromal tumors during sunitinib treatment

The molecular targets of sunitinib are receptor tyrosine kinases (RTKs),and this drug has also been known to exert blocking effects on the activation of KIT,which is similar to the mechanism of action of imatinib. Moreover,sunitinib has an additional anti-angiogenic effect through its inhibition of the vascular endothelial growth factor receptor activation. We report here a 70-year-old patient diagnosed with a recurrent gastrointestinal stromal tumor (GIST),which invaded the transverse colon and led to a perforation during sunitinib treatment. A computed tomography scan and 3-dimensional reconstruction showed necrosis of the recurrent hepatic mass and perforation of the invaded transverse colon. After percutaneous drainage of the intraperitoneal abscess,antibiotic treatment and restricted diet,the condition of the patient improved. The present case is the first to report that sunitinib,which is administered to treat GIST resistant to imatinib,can cause unexpected colon perforation and subsequent peritonitis.

Perforation of metastatic melanoma to the small bowel with simultaneous gastrointestinal stromal tumor

The gastrointestinal tract (GIT) is a common site of metastases for malignant melanoma. These metastatic tumors are often asymptomatic. We describe a case of a 58-year-old male who presented with a sudden onset of generalized abdominal pain. The patient's past medical history was significant for lentigo melanoma of the right cheek. Laparotomy was performed and two segments ofsmall bowel, one with a perforated tumor, the other with a non-perforated tumor, were removed. Histology and immunohistochemical staining revealed the perforated tumor to be a metastatic malignant melanoma and the non-perforated tumor was found to be a gastrointestinal stromal tumor (GIST). The patient was discharged 7 d postoperatively. To the best of our knowledge, this is the first reported case in the literature of a simultaneous metastatic malignant melanoma and a GIST. Surgical intervention is warranted in patients with symptomatic GIT metastases to improve the quality of life or in those patients with surgical emergencies.

Outcome of surgical treatment of intestinal perforation in typhoid fever

AIM:To represent our clinical experience in the treatment of intestinal perforation arising from typhoid fever.METHODS:The records of 22 surgically-treated patients with typhoid intestinal perforation were evaluated retrospectively.RESULTS:There were 18 males and 4 females,mean age 37 years(range,8-64 years).Presenting symptoms were fever,abdominal pain,diarrhea or constipation.Sixteen cases were subjected to segmental resection and end-to-end anastomosis,while 3 cases received 2-layered primary repair following debridement,one case with multiple perforations received 2-layered primary repair and end ileostomy,one case received segmental resection and end-to-end anastomosis followed by an end ileostomy,and one case received segmental resection and end ileostomy with mucous fistula operation.Postoperative morbidity was seen in 5 cases and mortality was found in one case.CONCLUSION:Intestinal perforation resulting from Salmonella typhi is an important health problem in Eastern and Southeastern Turkey.In management of this illness,early and appropriate surgical intervention is vital.

Typhoid intestinal perforation in developing countries: Still unavoidable deaths?

Typhoid fever is a public health challenge mostly concentrated in impoverished, overcrowded areas of the developing world, with lack of safe drinking and sanitation. The most serious complication is typhoid intestinal perforation(TIP), observed in 0.8% to 39%, with a striking rate difference between high-income and low-middle-income countries. Although the mortality rate consequent to TIP in resource-poor countries is improved in the last decades, it is still fluctuating from 5% to 80%, due to surgical-and not surgical-related constraints. Huge economic costs and long timelines are required to provide a short-to middle-term solution to the lack of safe water and sanitation. Inherent limitations of the currently available diagnostic tools may lead to under-evaluation as well as over-evaluation of the disease, with consequent delayed treatment or inappropriate, excessive antibiotic use, hence increasing the likelihood of bacterial resistance. There is a need for immunization programs in populations at greatest risk, especially in sub-Saharan Africa. Uniform surgical strategies and guidelines, on the basis of sound or prospective surgical studies and adapted to the local realities, are still lacking. Major drawbacks of the surgical treatment are the frequent delays to surgery, either for late diagnosis or for difficult transports, and the unavailable appropriate intensive care units in most peripheral facilities. As a consequence, poor patient's conditions at presentation, severe peritoneal contamination and unsuitable postoperative care are the foremost determinant of surgical morbidity and mortality.

Intestinal T-cell lymphomas:A retrospective analysis of 68 cases in China

AIM: To investigate the clinical features, diagnosis, treatment and prognosis of intestinal T-cell lymphomas (ITCL) by retrospective analysis.

Isolated ileal perforation due to cytomegalovirus reactivation during management of terbinafine hypersensitivity

We report a case of 71-year-old man who developed a hypersensitivity syndrome associated with terbinafine. He was placed on terbinafine (250 mg/d) for the treatment of tinea pedis due to diabetes mellitus. Following the treatment with terbinafine, he developed druginduced hypersensitivity syndrome (DIHS). Systemic corticosteroid led to transient improvement of his clinical manifestations. Three months after disease onset, he presented with panperitonitis due to ileal perforation, and underwent an emergency operation. The affected ileum was resected and ileostomy was performed in the terminal ileum. Cytomegalovirus (CMV)-specific IgG antibodies were significantly increased, high-titer CMV antigenemia was detected, and pathological examination of the resected ileum confirmed CMV infection. Based onthese observations, we strongly recommend that physicians monitor reactivation of the family of herpesvirus other than herpesvirus 6, to manage DIHS properly.

Free perforation of the small intestine in collagenous sprue

A 67-year-old man with celiac disease developed recurrent diarrhea,profound weakness and weight loss, with evidence of marked protein depletion.His clinical course was refractory to a strict gluten-free diet and steroid therapy.Postmortem studies led to definition of unrecognized collagenous sprue that caused ulceration and small intestinal perforation.Although PCR showed identical monoclonal T-cell populations in antemortem duodenal biopsies and postmortem jejunum,careful pathological evaluation demonstrated no frank lymphoma.Rarely,overt or even cryptic T-cell lymphoma may complicate collagenous sprue,however, small intestinal ulcers and perforation may also develop independently.The dramatic findings here may reflect an underlying or early molecular event in the eventual clinical appearance of overt T-cell lymphoma.

A case of colon perforation due to enteropathy-associated T-cell lymphoma

Enteropathy-associated T-cell lymphoma (EATL) is an extremely rare disease, which is often related to gluten-sensitive enteropathy. It is an uncommon intestinal lymphoma with very poor prognosis and high mortality rate. In the absence of specific symptoms or radiological findings, it is difficult to diagnose early. Major complications of EATL have been known as intestinal perforation or obstruction, and only 5 cases of EATL are reported in South Korea. In this study, we report a case of 71-year-old male with symptoms of diarrhea, which later it progressed into cancer perforation of the colon. The initial colonoscopic findings were normal and computed tomography scan demonstrated a segmental wall thickening of the distal ascending colon with nonspecific multiple small lymphnodes, along the ileocolic vessels, but no signs of mass or obstruction. The histologic findings of resected specimen confirmed EATL type II. Patient expired two weeks after the operation. Therefore, we emphasize the need of random biopsy in the presence of normal mucosa appearance on colonoscopy for the early diagnosis of EATL.

Bilateral pneumothorax and pneumomediastinum during colonoscopy in a patient with intestinal Behcet’s disease:A case report

BACKGROUND Colonoscopy is essential for the diagnosis of intestinal Behcet’s disease(BD),which is characterized by a typical oval-shaped ulcer in the ileocecal region.However,potential risks of colonoscopy have rarely been reported.CASE SUMMARY Herein,we describe a patient with intestinal BD who presented with decreased oxygen saturation and shortness of breath during a diagnostic colonoscopy.Bilateral pneumothorax,pneumomediastinum,pneumoperitoneum,pneumoretroperitoneum and subcutaneous emphysema of the neck,chest,abdomen,back and scrotum were confirmed by computed tomography scan.The sudden change in condition was considered to be associated with iatrogenic bowel perforation.After receiving closed thoracic drainage and conservative therapy,the patient was discharged in stable condition.CONCLUSION Endoscopists should be aware of the risks of colonoscopy in patients with intestinal BD and the possibility of pneumothorax associated with intestinal perforation and make adequate preparations before colonoscopy.

Duodenal Perforation Caused by Distal Migration of Biliary Stent

Background: Migration of endoscopically placed biliary stents is a known complication of endoscopic retrograde cholangiopancreatography, which has a reported incidence of 3% - 6%. Usually, distal migration is asymptomatic and is detected incidentally. Case Presentation: We present a rare case of duodenal perforation caused by distal migration of a biliary stent. A 50 years old gentleman initially presented with cholangitis. ERCP showed a dilated common bile duct with a 9 mm stone and a biliary stent was placed. The patient subsequently presented with biliary peritonitis due to the migration of the stent causing perforation of the anterior wall of the second part of the duodenum. Emergency laparotomy was performed to remove the stent and the perforation was repaired. The patient made an uneventful recovery. Discussion: A brief discussion on stent migration is also conducted. Whilst distal migration of stents is less common than its proximal counterpart, it is important to note that rare complications may arise and be addressed in a timely manner.

Surgical treatment of multiple magnet ingestion in children:A singlecenter study

BACKGROUND Since 2017,the number of magnet ingestion cases has increased year over year in our hospital.Almost all of the ingested magnetic foreign bodies were magnetic beads,and most of the patients experienced intestinal perforations,causing substantial damage.AIM To summarize our experience with surgical treatment of multiple magnet ingestion in children.METHODS The data for general surgeries were collected from January 2010 to April 2020,and the clinical characteristics,treatment methods,and outcomes were summarized and analyzed.Several typical cases were selected and discussed.RESULTS Fifty-six cases of ingested magnetic foreign bodies were collected,of which 47 were magnetic beads.The average patient age was 4.7±3.0 years old.The number of ingested magnetic foreign bodies ranged from 2 to 73.There were 26 cases with symptoms at the time of admission,including two cases of shock.Thirteen patients were discharged successfully following conservative treatment and 43 were treated by surgery.Laparotomy was the main method of operation.Laparoscopy was used in four cases,of which three were converted to open surgery,and one was treated successfully using surgery through the navel.Postoperative complications occurred in seven cases,incision infections were observed in six,and adhesive ileus was observed in one.CONCLUSION Clinicians need to summarize their experiences with treating magnetic foreign body ingestions in detail and carry out clinical research to reduce the damage to children.

Clinical prediction of complicated appendicitis:A case-control study utilizing logistic regression

BACKGROUND Since high-quality evidence on conservative treatment of acute appendicitis using antibiotics has increased,differentiation of patients with complicated appendicitis(CA)from those with simple appendicitis(SA)has become increasingly important.Previous studies have revealed that male gender,advanced age,comorbid conditions,prehospital delay,fever,and anorexia are risk factors of perforated appendicitis.Elevated serum C-reactive protein(CRP)level and hyponatremia have also been reported as predictive biomarkers of CA.However,confounding between various factors is problematic because most previous studies were limited to univariate analysis.AIM To evaluate non-laboratory and laboratory predictive factors of CA using logistic regression analyses.METHODS We performed an exploratory,single-center,retrospective case-control study that evaluated 198 patients(83.9%)with SA and 38 patients(16.1%)with CA.Diagnoses were confirmed by computed tomography images for all cases.We compared age,sex,onset-to-visit interval,epigastric/periumbilical pain,right lower quadrant pain,nausea/vomiting,diarrhea,anorexia,medical history(of previous non-surgically treated appendicitis,diabetes,hypertension,dyslipidemia,liver cirrhosis,hemodialysis,chronic lung diseases,malignant tumors,immunosuppressant use,and antiplatelet use),vital signs,physical findings,and laboratory data to select the explanatory variates for logistic regression.Based on the univariate comparisons,we performed logistic regression for clinical differentiation between CA and SA using only nonlaboratory factors and also including both non-laboratory and laboratory factors.RESULTS The 236 eligible patients consisted of 198 patients(83.9%)with SA and 38 patients(16.1%)with CA.The median ages were 34 years old[interquartile ranges(IR),24-45 years]in the SA group and 49 years old(IR,35-63 years)in the CA group(P<0.001).The median onset-to-visit interval was 1 d(IR,0-1)and 1 d(IR,1-2)in the SA and CA groups,respectively(P<0.001).Heart rate,body temperature,and serum CRP level in the CA group were significantly higher than in the SA group;glomerular filtration rate and serum sodium were significantly lower in the CA group.Anorexia was significantly more prevalent in the CA group.The regression model including age,onset-to-visit interval,anorexia,tachycardia,and fever as non-laboratory predictive factors of CA(Model 1)showed that age≥65 years old,longer onset-to-visit interval,and anorexia had significantly high odds ratios.The logistic regression for prediction of CA including age,onset-to-visit interval,anorexia,serum CRP level,hyponatremia(serum sodium<135 mEq/L),and glomerular filtration rate<60 mL/min/1.73 m2(Model 2)showed that only elevated CRP levels had significantly high odds ratios.Under the curve values of receiver operating characteristics curves of each regression model were 0.74 for Model 1 and 0.87 for Model 2.CONCLUSION Our logistic regression analysis on differentiating factors of CA from SA showed that high CRP level was a strong dose-dependent predictor of CA.

Stercoral colonic diverticulum perforation with jejunal diverticulitis mimicking upper gastrointestinal perforation

Stercoral perforation of the colon is an unusual pathological condition with fewer than 150 cases reported in the literature to date. We present a case of stercoral colonic perforation mimicking upper gastrointestinal perforation, which was diagnosed by computed tomography preoperatively. However, at laparotomy, stercoral colonic diverticulum perforation with jejunal diverticulitis became the most appropriate diagnosis.

Is it possible to adopt the same oncological approach in urgent surgery for colon cancer?

BACKGROUND Locoregional complications may occur in up to 30%of patients with colon cancer.As they are frequent events in the natural history of this disease,there should be a concern in offering an oncologically adequate surgical treatment to these patients.AIM To compare the oncological radicality of surgery for colon cancer between urgent and elective cases.METHODS One-hundred and eighty-nine consecutive patients with non-metastatic colon adenocarcinoma were studied over two years in a single institution,who underwent surgical resection as the first therapeutic approach,with 123 elective and 66 urgent cases.The assessment of oncological radicality was performed by analyzing the extension of the longitudinal margins of resection,the number of resected lymph nodes,and the percentage of surgeries with 12 or more resected lymph nodes.Other clinicopathological variables were compared between the two groups in terms of sex,age,tumor location,type of urgency,surgical access,staging,compromised lymph nodes rate,differentiation grade,angiolymphatic and perineural invasion,and early mortality.RESULTS There was no difference between the elective and urgency group concerning the longitudinal margin of resection(average of 6.1 in elective vs 7.3 cm in urgency,P=0.144),number of resected lymph nodes(average of 17.7 in elective vs 16.6 in urgency,P=0.355)and percentage of surgeries with 12 or more resected lymph nodes(75.6%in elective vs 77.3%in urgency,P=0.798).It was observed that the percentage of patients aged 80 and over was higher in the urgency group(13.0%in elective vs 25.8%in urgency,P=0.028),and the early mortality was 4.9%in elective vs 15.2%in urgency(P=0.016,OR:3.48,95%CI:1.21–10.06).Tumor location(P=0.004),surgery performed(P=0.016)and surgical access(P<0.001)were also different between the two groups.There was no difference in other clinicopathological variables studied.CONCLUSION Oncological radicality of colon cancer surgery may be achieved in both emergency and elective procedures.

Terminal ileum perforation:a rare complication of intestinal endometriosis

Endometriosis is a common benin, disease affecting ,about 10% to 20% of women. The frequency of intestinal endometriosis varies between 3% and 37% in women with proven endometriosis. The most often involved site of the disease is the rectosigmoid, followed by the rectovaginal septum, distal ileum, cecum, and the appendix.2 Perforation rarely happens in patients with intestinal endometriosis. Here, we report 2 cases of terminal ileum perforation owing to endometriosis.

Small bowel malignant melanoma presenting as a perforated jejunal diverticulum:a case report and literature review

Although usually harmless and asymptomatic,jejuno-ileal diverticulae are associated with various non-specific gastrointestinal symptoms,and rarely cause surgical emergencies.This case report describes the presentation and management of a patient with an acute abdomen,whose jejunal diverticulum was perforated.Unexpectedly,histopathological assessment demonstrated malignant melanoma lining the diverticulum.Whether this was primary or metastatic is discussed,together with a synopsis of the literature on small bowel diverticulae.