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Concept: Bowel obstruction

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INTRODUCTION: Although blunt trauma to a hernia-containing bowel is known to cause bowel perforation, this report documents the first incident of a small bowel transection following a non-traumatic event. CASE PRESENTATION: We report the case of a 49-year-old African American man with a chronic incarcerated inguinal hernia awaiting elective repair. He presented to the Emergency Department with abdominal pain following an episode of coughing. On examination, he was found to have peritonitis. He underwent exploratory laparotomy, and had a complete small bowel transection. A bowel resection with primary anastomosis was performed, as well an inguinal hernia repair. CONCLUSION: Chronic hernia incarceration can lead to weakening and ischemia of the bowel, and minimal trauma can lead to perforation of the weakened segment. In such presentations, bowel resection and repair of the defect with a biological material is safe and feasible.

Concepts: Asthma, Surgery, Abdominal pain, Inguinal hernia, Hernia, Bowel obstruction, African American, Gastrointestinal perforation

166

Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.

Concepts: Abdominal pain, Small intestine, Bowel obstruction, Abdomen, Jejunum, Volvulus, Intestinal malrotation, Ladd's bands

156

A 62-year-old female with neurofibromatosis type 1 (NF1; also von Recklinghausen’s disease) was diagnosed with a giant, thick-walled tubular mass, mainly located in the right abdominal area on computed tomography, following an examination for intermittent abdominal pain and increasing abdominal distension. According to the clinical manifestations and imaging features, the giant tubular mass was considered most likely to be a dilated fallopian tube associated with infection, while the possibility of obstructed bowel loops was excluded. However, the subsequent laparotomy revealed a giant appendix, caused by a large neurofibroma in the root region of the appendix, which occluded the lumen. Neurofibroma of the appendix is extremely rare, even in patients with NF1. To the best of our knowledge, only three such cases have previously been reported in the English literature to date.

Concepts: Neurology, Abdominal pain, Bowel obstruction, Neurofibromatosis type I, Neurofibromatosis, Abdominal distension, Friedrich Daniel von Recklinghausen, Café au lait spot

144

Formation of intra-abdominal adhesions is a common consequence of abdomino-pelvic surgery, radiation therapy, and inflammatory processes. In a small but clinically significant proportion of patients, adhesive disease may develop, wherein adhesions lead to a variety of chronic symptoms such as abdominal distension, pain, nausea, and abnormal bowel movement pattern which can be daily, intermittent, or episodic. Due to the chronic and troublesome nature of these symptoms, adhesive disease may be life-altering in many patients, particularly when not recognized and appropriately addressed, as is the case not infrequently. In addition, there is a paucity of literature regarding the evaluation and management of patients with suspected abdominal adhesive disease. Therefore, in this concise review, we provide a clinically practical synopsis of the etiopathogenesis, symptoms, differential diagnosis, evaluation, and treatment of abdominal adhesive disease.

Concepts: Medicine, Cancer, Medical terms, Chemotherapy, Medical diagnosis, Bowel obstruction, Differential diagnosis, Kanye West

29

The use of mesh has become the gold standard in hernia operations recently due to advantages such as lower recurrence rates, lower post-surgical pain and earlier return to work. Plug mesh application, first described by Robins and Rutkow [Robbins AW, Rutkow IM (1993) The mesh-plug hernioplasty. Surg Clin North Am 73:501-512], is a popular method of hernia repair. Although rare, there may be complications of surgery using plug mesh. This report presents a case of mechanic bowel obstruction due to mesh migration, 3 years after a left inguinal hernia repair with plug mesh method.

Concepts: Surgery, Engineering, Inguinal hernia, Hernia, Gold, Bowel obstruction, Hernias, Herniorrhaphy

28

In 2009, an estimated 565,000 Americans had Crohn’s disease (1), an inflammatory bowel disorder that can affect any part of the gastrointestinal tract. Symptoms include persistent diarrhea, abdominal cramps and pain, constipation leading to bowel obstruction, and rectal bleeding.* Symptoms sometimes intensify in severity and require hospitalization and surgeries of the small intestine, colon, or rectum (2). Hospital discharge data from the National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) were used to estimate U.S. hospitalizations(†) for Crohn’s disease as both the first-listed and any-listed(§) discharge diagnosis and common surgical procedures during hospitalizations with Crohn’s disease as first-listed diagnosis from 2003 to 2013, the most recent decade of data. Despite new therapies that were expected to improve remission and reduce hospitalizations, estimated numbers (and age-adjusted rates per 100,000 U.S. population) of hospitalizations for Crohn’s disease as the first-listed diagnosis did not change significantly from 2003 to 2013. The proportion of these hospitalizations during which small bowel resection was performed decreased from 4.9% in 2003 to 3.9% in 2013 (p<0.05); however, colorectal resection and fistula repair rates remained stable. Hospital stays for any-listed Crohn's disease increased from >120,000 (44.2 per 100,000) in 2003 to >196,000 (59.7 per 100,000) in 2013 (p<0.05). Patient education initiatives should focus on increasing awareness of exacerbating factors and medication compliance to prevent hospitalizations.

Concepts: Ulcerative colitis, Crohn's disease, Colon, Abdominal pain, Large intestine, Gastroenterology, Small intestine, Bowel obstruction

28

Best practices promulgated by the Eastern Association for the Surgery of Trauma suggest that delay in surgery for adhesive small bowel obstruction (ASBO) should not exceed 5 days. This study aimed to probe the relationship between operative delay and adverse outcomes, defined as occurrence of a complication, requirement for bowel resection, prolonged postoperative stay, or death in ASBO using the Nationwide Inpatient Sample.

Concepts: Crohn's disease, Constipation, Hernia, Bowel obstruction, General surgery, Best practice, Nationwide Building Society

28

Iatrogenic diaphragmatic hernias are a rarely reported complication of abdominal surgery. We present a case of an iatrogenic diaphragmatic hernia diagnosed 2 years after an adrenalectomy. Corrective laparoscopic surgery was performed, and the postoperative course was uneventful. The patient remained asymptomatic 6 months after the repair. To our knowledge, this is the first such case to be reported.

Concepts: Medicine, Medical terms, Surgery, Hernia, Bowel obstruction, Laparoscopic surgery, Congenital diaphragmatic hernia, Diaphragmatic hernia

28

Background/Purpose Malrotation with a common mesentery is the classical pathology allowing midgut volvulus to occur. There are only a few reports of small bowel volvulus without malrotation or other pathology triggering volvulation. We describe three cases of small bowel volvulus in very premature newborns with a perfectly normal intra-abdominal anatomy and focus on the question, what might have set off volvulation.Methods In 2005 to 2008, three patients developed small bowel voluvulus without any underlying pathology. Retrospective patient chart review was performed with special focus on clinical presentation, preoperative management, intraoperative findings, and potential causative explanations. Mean follow-up period was 46 months.Results All patients were born between 27 and 31 weeks (mean 28 weeks) with a birth weight between 800 and 1,000 g (mean 887 g). They presented with an almost identical pattern of symptoms including sudden abdominal distension, abdominal tenderness, erythema of the abdominal wall, high gastric residuals, and radiographic signs of ileus. All of them were treated with intensive abdominal massage or pelvic rotation to improve bowel movement before becoming symptomatic.Conclusions Properistaltic maneuvers including abdominal massage and pelvic rotation may cause what we term a “manufactured” volvulus in very premature newborns. Thus, this practice was stopped.

Concepts: Digestive system, Abdominal pain, Small intestine, Bowel obstruction, Peritoneum, Abdomen, Volvulus, Intestinal malrotation

27

Video capsule endoscopy (VCE) is being increasingly used to investigate small bowel pathology. It is the gold standard for obscure gastrointestinal bleeding and iron deficiency anemia. VCE has been in use since 2001 and indications for its use are expanding. VCE is also a useful diagnostic tool in small bowel Crohn’s disease, celiac disease, surveillance of polyps, small bowel malignancy and drug-induced small bowel injury. Although VCE is considered a safe and easy procedure, there are a few limitations. These include cost, capsule retention and inability to take a biopsy and perform any therapeutic maneuvers. Contraindications for VCE include pregnancy, patients with a swallowing disorder, history of previous abdominal surgery or concurrent abdomino-pelvic irradiation. This is an overview of VCE, its role and indications in clinical practice, potential complications and contraindications, as well as the ongoing and expected advances in the field.

Concepts: Medical terms, Crohn's disease, Colonoscopy, Gastroenterology, Small intestine, Bowel obstruction, Iron deficiency anemia, Malabsorption