New application of intestinal obstruction catheter in enterocutaneous fistula:A case report

BACKGROUND Enterocutaneous fistula(ECF)is an abnormal connection between the gastrointestinal tract and the skin.ECF can lead to massive body fluid loss,hypercatabolism,and malnutrition.Therefore,nutritional support plays a crucial role in managing ECFs and promoting the healing of fistulas.For nutritional support,enteral nutrition(EN)is the preferred method when gastrointestinal function is recovering.Currently,various EN approaches have been applied for different anatomical positions of the ECF.However,the effectiveness of administering EN support for treating lower ECFs still needs further exploration and improvement.CASE SUMMARY We present the case of a 46-year-old male who underwent gastrointestinal stromal tumour resection.Six days after the surgery,the patient presented with fever,fatigue,severe upper abdominal pain,and septic shock.Subsequently,lower ECFs were diagnosed through laboratory and imaging examinations.In addition to symptomatic treatment for homeostasis,total parenteral nutrition support was administered in the first 72 h due to dysfunction of the intestine.After that,we gradually provided EN support through the intestinal obstruction catheter in consideration of the specific anatomic position of the fistula instead of using the nasal jejunal tube.Ultimately,the patient could receive optimal EN support via the catheter,and no complications were found during the treatment.CONCLUSION Nutritional support is a crucial element in ECF management,and intestinal obstruction catheters could be used for early EN administration.

Pharmacodynamic Experiment of Dachengqi Decoction and Separated Decoction on Incomplete Intestinal Obstruction in Rats

[Objectives]To investigate the effect and mechanism of Dachengqi Decoction and separated decoction on incomplete intestinal obstruction in rats.[Methods]80 healthy SD rats were selected to establish incomplete intestinal obstruction model by silk ligation.The dosage was 20 mL/kg for 3 d,and the damage index of ileocecal mucosa was analyzed;the morphology of ileocecal mucosa was observed by HE staining;the serum levels of IL-1α,IL-1β,IL-6,IL-18,Ach,NO,ET,IL-1,TNF-αand ultra-micro Na+-K+-ATPase were detected by ELISA.[Results]Compared with the model group,the mucosal damage index of Dachengqi Decoction and each separated decoction group decreased significantly(P<0.05);compared with the normal group and sham operation group,the serum level of IL-1,IL-6,TNF-αand other factors in the model group increased significantly(P<0.05);compared with the model group,the serum IL-1,IL-6 and TNF-αsecretion levels of rats in Dachengqi Decoction group and separated decoction group decreased(P<0.01).[Conclusions]Dachengqi Decoction and each separated decoction can effectively improve intestinal tissue pathological damage in the incomplete intestinal obstruction model rats,and reduce the inflammatory reaction in the rat body.

Relevance of Medical Imaging in the Pre-Therapeutic Evaluation of Acute Intestinal Obstruction at CIMED

Objective: We initiated this work with the aim of studying the contribution of imaging in the diagnosis of acute intestinal obstruction at CIMED. Patients and methods: This was a prospective, descriptive and analytical study involving 96 patients collected at the radiology and medical imaging department of CIMED, from January 2022 to January 2023. Result: The age of our patients varied between 11 and 86 years with an average age of 36 years. There was a male predominance of 64.6% compared to 35.4% for women, i.e. a sex ratio of 1.82. The notion of previous surgery was found in 61.5% of our patients. Pain was present in all patients. Radiography of the ASP was performed in 89.6% of patients. It showed hydro-aerial levels in 96.5% of patients. Abdominopelvic CT was performed in 12 patients and made it possible to make the diagnosis of occlusion in all patients. The results of the positive diagnosis were concordant with those intraoperatively in 92% of cases. 8% of our patients, compared to the treatment, spontaneously resumed their transit, 91% benefited from surgical treatment and 1% died before surgery. The outcome was favorable in 80 patients or 83.3%, poor with death in 16 patients or 16.7% of cases. Conclusion: Acute intestinal obstruction remains a serious pathology for which ASP radiography often remains the only radiological examination performed urgently. However, abdominopelvic CT seems widely indicated thanks to its contribution both for the positive diagnosis and for the serious and etiological diagnoses. However, this imaging technique is largely underused in our practice due to its high cost and lack of availability.

Comparison of different methods of intestinal obstruction in a rat model

AIM:To investigate different methods of creating incomplete intestinal obstruction in a rat model and to compare their electrophysiologic,morphologic and histologic characteristics. METHODS:Rat ileum was partially obstructed by the respective application of:braided silk(penetrated the mesentery and surrounded intestine);half ligation (penetrated directly and ligated 1/2 cross-section of the intestine);wide pipe(6 mm in width,surrounded the intestine);narrow pipe(2 mm in width,surrounded the intestine).A control was also included(no obstruction). Various behavioral and electrophysiologic variables, as well as morphologic and immunohistochemical observations were recorded by blinded investigators at different time points(12,24,48,72 h),including daily general condition,ileal wet weight and circumference, macromorphous and micromorphous intestine,bowel movement capability in vivo and in vitro,slow wave and neural electrical activity,and the number of c-Kit positive interstitial cells of Cajal(ICC). RESULTS:Despite being of a similar general condition, these methods resulted in different levels of obstruction in each group compared with the control at different time points(12,24,48,72 h).However,these fields of the wide pipe rat showed significantly differences when compared with the other three obstructed groups at 12 to 72 h,including macroscopic and histological presentation,intestinal transit ratio and contractility,circumference and wet weight,amplitude and frequency of nerve electrical discharge and slow wave,and ICC numbers(all P<0.01). CONCLUSION:The wide pipe rat method is significantly more reliable and stable than the other methods of obstruction,demonstrating that use of the wide pipe method can be a useful model of incomplete intestinal obstruction.

Long-term follow-up of distal intestinal obstruction syndrome in cystic fibrosis

AIM: To investigate the long-term follow-up of distal intestinal obstruction syndrome(DIOS) in Israeli cystic fibrosis(CF) patients.METHODS: This is a multi-center,comparative,retrospective study in which we reviewed the medical records of all CF patients from three major CF centers in Israel who were treated in the period from 1980 to 2012.Patients diagnosed with DIOS were defined as the study group.The patients were diagnosed with DIOS based on their clinical presentation and typical findings on either abdominal X-ray or computerized tomography scan.For the control group,CF patients with no DIOS were matched to the patients in the study group for age,sex,and cystic fibrosis transmembrane conductance regulator(CFTR) mutations.For both groups,the collected data included age,sex,CFTR genotype,weight,height,and body mass index.Clinical data included respiratory function tests in the last five years prior to the study,respiratory function test immediately before and after the DIOS event,number of hospitalizations,sputum culture results,and CFrelated conditions diagnosed according to the CF clinical practice guidelines.In the study group,data on the DIOS treatment and tendency for DIOS recurrence were also analyzed.RESULTS: The medical charts for a total of 350 CF patients were reviewed.Of the 350 CF patients,26(7.4%) were diagnosed with DIOS.The control group included 31 CF patients with no DIOS diagnosis.The mean follow-up period was 21.6 ± 8.2 years.The total of DIOS episodes in the follow-up period was 60.The distribution of DIOS episodes was as follows: 6/26(23.1%) study patients had one episode of DIOS intheir lifetime,7/26(26.9%) had two episodes,7/26(26.9%) had three episodes,and 6/26(23.1%) had four or more episodes.Compared to the control group,DIOS patients had a significantly higher incidence of meconium ileus in the past(65.4% vs 0%,respectively,P < 0.02),more Aspergillus spp.colonization(34.6% vs 3.2%,respectively,P < 0.02),and a higher number of hospitalizations due to respiratory exacerbations(8.6 vs 6.2 mean total hospitalizations per follow-up period,respectively,P < 0.02).No other significant differences were found between the control and study groups.The conservative treatment of DIOS,which mainly includes hydration and stool softeners,was successful in 82% of the episodes.The survival rate was similar for both groups.CONCLUSION: CF patients with DIOS suffer from recurrent hospitalizations and airway pathogen acquisition.Although recurrence of DIOS is common,conservative treatment is successful in most patients.

Rare etiology of mechanical intestinal obstruction: Abdominal cocoon syndrome

Abdominal cocoon syndrome is a rare cause of intestinal obstruction with unknown etiology. Diagnosis of this syndrome, which can be summarized as the small intestine being surrounded by a fibrous capsule not containing the mesothelium, is difficult in the preoperative period. A 47-year-old male patient was referred to the emergency department with complaints of abdominal pain, nausea, and vomiting for two days. The abdominal computed tomography examination detected dilated small intestinal loops containing air-fluid levels clustered in the left upper quadrant of the abdomen and surrounded by a thick, saclike, contrast-enhanced membrane. During exploratory surgery, a capsular structure was identified in the upper left quadrant with a regular surface that was solid-fibrous in nature. Ab-dominal cocoon syndrome is a rarely seen condition, for which the preoperative diagnosis is difficult. The combination of physical examination and radiological signs, and the knowledge of "recurrent characteristics of the complaints" that can be learned by a careful history, may be helpful in diagnosis.

Pathophysiology of increased intestinal permeability in obstructive jaundice

Despite advances in preoperative evaluation and postoperative care, intervention, especially surgery, for relief of obstructive jaundice still carries high morbidity and mortality rates, mainly due to sepsis and renal dysfunction. The key event in the pathophysiology of obstructive jaundice-associated complications is endotoxemia of gut origin because of intestinal barrier failure. This breakage of the gut barrier in obstructive jaundice is multi-factorial, involving disruption of the immunologic, biological and mechanical barrier. Experimental and clinical studies have shown that obstructive jaundice results in increased intestinal permeability. The mechanisms implicated in this phenomenon remain unresolved, but growing research interest during the last decade has shed light in our knowledge in the field. This review summarizes the current concepts in the pathophysiology of obstructive jaundice-induced gut barrier dysfunction, analyzing pivotal factors, such as altered intestinal tight junctions expression, oxidative stress and imbalance of enterocyte proliferation and apoptosis. Clinicians handling patients with obstructive jaundice should not neglect protecting the intestinal barrier function before, during and after intervention for the relief of this condition, which may improve their patients’ outcome.

Phasic study of intestinal homeostasis disruption in experimental intestinal obstruction

AIM: To investigate the phasic alteration of intestinal homeostasis in an experimental model of intestinal obstruction.

Experimental obstructive jaundice alters claudin-4 expression in intestinal mucosa: Effect of bombesin and neurotensin

AIM： To investigate the influence of experimental obstructive jaundice and exogenous bombesin （BBS） and neurotensin （NT） administration on the expression of the tight junction （TJ）-protein claudin-4 in intestinal epithelium of rats. METHODS： Forty male Wistar rats were randomly divided into five groups： Ⅰ = controls, Ⅱ = sham operated,Ⅲ = bile duct ligation （BDL）,Ⅳ = BDL＋BBS （30μg/kg per d）, V = BDL＋NT （300μg/kg per d）. At the end of the experiment on d 10, endotoxin was measured in portal and aortic blood. Tissue sections of the terminal ileum were examined histologically and immunohistochemically for evaluation of claudin-4 expression in intestinal epithelium. RESULTS： Obstructive jaundice led to intestinal barrier failure demonstrated by significant portal and aortic endotoxemia. Claudin-4 expression was significantly increased in the upper third of the villi in jaundiced rats and an upregulation of its lateral distribution was noted. Administration of BBS or NT restored claudin-4 expression to the control state and significantly reduced portal and aortic endotoxemia. CONCLUSION： Experimental obstructive jaundice increases claudin-4 expression in intestinal epithelium,which may be a key factor contributing to the disruption of the mucosal barrier. Gut regulatory peptides BBS and NT can prevent this alteration and reduce portal and systemic endotoxemia.

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.

Intestinal obstruction due to phytobezoars: An update

The term bezoar refers to an intraluminal mass in the gastrointestinal system caused by the accumulation of indigestible ingested materials, such as vegetables, fruits, and hair. Bezoars are responsible for 0.4%-4% of cases of mechanical intestinal obstruction. The clinical findings of bezoar-induced ileus do not differ from those of mechanical intestinal obstruction due to other causes. The appearance and localization of bezoars can be established with various imaging methods. Treatment of choice depends on the localization of the bezoar which makes the clinical findings.

Placement of a Long Intestinal Tube in Patients with Early Postoperative Small Bowel Obstruction under Fluoroscopic Guidance

Objective To investigate the placement of a long tube into the small intestine under fluoroscopic guidance and to evaluate its decompression effect on early postoperative small bowel obstruction(EPSBO).Methods Fifty-four patients with EPSBO requiring decompression between April 2010 and July 2014 were enrolled in the study.Insertion of a long tube was guided by fluoroscopy.We first used the guide wire to pass the pylorus and then used the 10 Fr feeding tube as an exchangeable tube to put the superstiff wire into the duodenum.Finally the long tube could be passed over the guide wire through the pylorus into the intestine.The total procedure time,the radiation exposure time,and the incidence of complications were evaluated.Results The long tubes passed into the jejunum on initial insertion for all patients,so the success rate of this technique was 100%.The long tube was inserted into ileum in 18 patients.The mean total procedure time was 34.4±8.6 minutes,and the mean radiation exposure time 18.9±6.8 minutes.A total of 47 patients(87%) experienced full recovery following long-tube decompression and without the need for surgical intervention.Conclusions Using the wire-exchange technique,it is easy to place a long tube into the small bowel under fluoroscopic guidance.This decompression method is safe and effective for management of EPSBO.

Partial intestinal obstruction secondary to multiple lipomas within jejunal duplication cyst: A case report

Lipoma within jejunal duplication presenting as abdominal bloating and partial intestinal obstruction is an exceptional clinical entity.We report a case of 68-year-old man complaining of abdominal bloating for 10 d due to multiple lipomas arising from jejunal duplication cysts.Only a few cases of a single lipoma within a Meckel’s diverticulum giving rise to this clinical scenario have been reported in the English language literature.However,no case of multiple lipomas within jejunal duplication cysts has been reported.We present a case in which doubleballoon endoscopy revealed a small intestinal structure changed into Meckel’s diverticulum-like cavities containing several lipomas.This case highlights intestinal lipoma as an uncommon cause of adult intussusceptions,which should be included in the differential diagnosis of small intestinal obstruction and appropriate examinations should be chosen.

Effect of Dachengqi Decoction on NF-κB p65 Expression in Lung of Rats with Partial Intestinal Obstruction and the Underlying Mechanism

To investigate the effect of Dachengqi decoction on NF-κB p65 expression in lung of rats with partial intestinal obstruction and the underlying mechanism, 30 SD rats were randomly divided into three groups： sham-operation group, model group and Dachengqi decoction treatment group （Dachengqi group）, with 10 animals in each group. The models were made by partially ligating their large intestines outside the body. The pathological changes were analyzed by HE staining. The expression of NF-κB p65 in rats lung were measured by using real-time polymerase chain reaction and immunohistochemistry respectively. Moreover, the expression of caveolin-1 in rats lung was also measured to. Increased edema, interstitial thickening, hemorrhage, and infiltration of inflammatory cells were found in the model group. In contrast, this change was significantly reduced in Dachengqi group as compared with model group. In addition, the up-regulated caveolin-1 and NF-κB p65 were also suppressed by Dachengqi decoction in lung of rats with partial intestinal obstruction. We are led to concluded that the caveolin-l-NF-κB pathway plays an important role in the development of lung injury of rats with partial intestinal obstruction and Dachengqi decoction could down-regulate the expression of caveolin-1 and NF-κB p65 in lung of rats with partial intestinal obstruction.

Biliary phytobezoar resulting in intestinal obstruction

Phytobezoar is the most common type of bezoar.It is composed of indigestible vegetable matter and is usually found in the stomach.Biliary phytobezoar is extremely rare and difficult to diagnose preoperatively.The pathogenesis is not clear,and there have been only a few reports of biliary bezoars associated with sphincteric impairmentat the ampulla of Vater.Here,we present a report of biliary bezoar that resulted in jejunal obstruction.We were unable to identifythe bezoar in the extrahepatic bile duct until it obstructed the small bowel lumen.To our knowledge,this is the first report of small bowel obstruction resulting frommigration of a biliary bezoar.

Intestinal obstruction caused by torsed gangrenous Meckel's diverticulum encircling terminal ileum

Meckel's diverticulum(MD)is considered the most prevalent congenital anomaly of the gastrointestinal tract. It may result in a number of complications including hemorrhage,obstruction,and inflammation.Obstruction of various types is the most common presenting symptom in the adult population.Loop formations with the end of an MD and adjacent mesentery constricting the distal ileum is an uncommon cause of obstruction. Axial torsion and gangrene of MD is the rarest of the complications.The correct diagnosis of complicated MD before surgery is often difficult because this condition may mimic other acute abdominal pathologies.Delay in the diagnosis of a complicated MD can lead to signifi- cant morbidity and mortality.Here we describe the case of a patient with a very rare form of acute small bowel obstruction secondary to giant torsed gangrenous MD encircling the terminal ileum.To our knowledge, this co-occurrence of axial torsion and a loop-forming mechanism of obstruction has been reported only once in English medical literature.

Lipoma within inverted Meckel’s diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: A case report and review of literature

Lipoma within an inverted Meckel's diverticulum presen- ting with hemorrhage and partial intestinal obstruction is an exceptional clinical entity. We report a case of 47-year-old male with a history of recurrent episodes of partial intestinal obstruction and melena due to a subserosal lipoma located in the base of an inverted Meckel's diverticulum. According to our knowledge, this is the first case of a lipoma within a Meckel's diverticulum giving rise to this clinical scenario without the existence of heterotrophic gastric or pancreatic tissues.

Total colorectal and terminal ileal duplication presenting as intussusception and intestinal obstruction

Colonic intussusception and gastrointestinal duplication are diseases that arise in young children. The clinical presentation of adult cases of intussusception and enteric duplication is non-specific and thus poses a diagnostic challenge. A computed tomography (CT) scan is recommended in adult cases as the most sensitive diagnostic tool and the pathognomonic finding of outer intussuscepiens and central intussusceptum is diagnostic. A septum of a duplicated colon in a non-intussuscepted segment has been rarely reported in the literature. With advancements in radiological imaging technology and the increased availability of CT scanners, the capacity for a correct pre-operative diagnosis has been significantly enhanced. Our current case report illustrates the importance of considering an uncommon etiology for enteric intussusception and duplication as a differential diagnosis of acute abdomen in an adult patient. Our analyses of this patient also highlight the successful use of CT scanning to make this diagnosis.

Intestinal failure in obstructive jaundice

TO THE EDITORWe read with great interest the article by Ding LA and LiJS, which aimed to review the current knowledge on the physiology of normal intestinal barrier function and highlight the role of intestinal failure after various injurious insults in the development of septic complications or multiple organ failure with subsequent rapid clinical deterioration or even death.

Combined Use of Single-balloon Enteroscope and Colonoscope for Self-expandable Metal Stent Placement in Patients with Malignant Small Intestinal Obstruction: a Single-center Comparative Clinical Observation

Small intestinal obstruction is a common complication of primary gastrointestinal cancer or metastatic cancers. Patients with this condition are often poor candidates for surgical bypasses, and placement of self-expanding metal stent(SEMS) can be technically challenging. In this study, we examined the feasibility of combined application of single-balloon enteroscope(SBE) and colonoscope for SEMS placement in patients with malignant small intestinal obstruction. Thirty-four patients were enrolled in this study, among which 22 patients received SEMS placement by using SBE and colonoscope, while the other 12 patients received conservative medical treatment. The patients were followed up for one year. Stent placement was technically feasible in 95.5%(21/22). Clinical improvement was achieved in 86.4%(19/22). For the 19 clinical success cases, the average time of benefits from a gastric outlet obstruction scoring system(GOOSS) increase ≥1 was 111.9±89.5 days. For the 12 patients receiving conservative medical treatment, no significant improvement in GOOSS score was observed. Moreover, a significant increase of Short-Form-36 health survey score was observed in the 19 patients at time of 30 days after stent placement. By Kaplan-Meier analysis, a significant survival improvement was observed in patients with successful SEMS placement, compared with patients receiving conservative medical treatment. Taken together, combined use of SBE and colonoscope makes endoscopic stent placement feasible in patients with malignant small intestinal obstruction, and patients can benefit from it in terms of prolonged survival and improved quality of life.