EP.TU.193Omental band - A unusual cause of mechanical small bowel obstruction in a virgin abdomen

Introduction The small bowel obstruction in a non-operated abdomen is rare, and the most common causes are hernia and neoplasm. The complete mechanical small bowel obstruction due to an omental band in a patient with no previous abdominal surgery is rare, and less than five cases have been reported in the literature. Case presentation We report a 65 year old male patient presented to the emergency department with complaints of abdominal pain, distension, vomiting and obstipation for four days. On clinical examination, his abdomen was distended, diffusely tender, guarding. The blood investigations showed elevated White blood cells and neutrophils with normal CRP and the Serum lactate. The Abdominal X-ray was suggestive of SBO. The Computed tomography of the abdomen and pelvis showed marked dilatation of the jejunum, the ileum is entirely collapsed, the impression of a double beak sign in the mid-abdomen which would suggest closed-loop obstruction due to a possible internal hernia. We proceeded with emergency diagnostic laparoscopy converted to laparotomy, which showed omental band causing closed-loop proximal small bowel obstruction. The bowel loops appeared congested with the constriction band due to omental band. The omental band was divided, and the obstruction was relieved. Postoperatively patient recovered well and was discharged on day three post-op. Discussion The timely diagnosis and intervention could prevent complications like strangulation, ischemia and gangrene. Though the omental band is rare, it should still be suspected as an aetiology in patients without prior abdominal surgery.

Synchronous Schwannoma and Gastrointestinal Stromal Tumor in Small Intestine – A Rare Case

Introduction/Objective Small bowel Schwannoma is a benign neoplasm of nerve sheath cells. The Gastrointestinal stromal tumor (GIST) constitutes only about 1-2% of small bowel spindle cell tumors. The simultaneous presence of two tumors in the small bowel is extremely uncommon. Methods/Case Report We report a case of small bowel GIST co-existing with Schwannoma. A 64-year-old female with a known history of Neurofibromatosis was admitted for excision of a small bowel tumor. MRI of the abdomen revealed two enhancing lesions in the left upper quadrant adjacent to the small bowel. Differential considerations included GIST versus Neurofibroma. Left hemicolectomy with small bowel resection was performed. The proximal small bowel revealed GIST, spindle cell type, low risk (3.5 cm), low grade (<5 mitoses/ 5mm2). Tumor cells were diffusely reactive to CD34, CD117, and DOG1 immunostains and were nonreactive to S100 and SOX10 immunostains confirming the diagnosis of GIST. Another segment of the small bowel revealed a 1.5 cm well-circumscribed, predominantly spindle cell tumor with abundant myxoid stroma and prominent cyst formation. Tumor cells were diffusely reactive to S100 and SOX10 immunostains but nonreactive to CD34, CD117, and DOG1, favoring a diagnosis of Schwannoma. Gastrointestinal Schwannomas may be associated with Neurofibromatosis in some cases. GIST, a KIT- or PGDFRA-signaling driven mesenchymal tumor has also rarely been reported to be associated with Neurofibromatosis type 1. However, synchronous small bowel Schwannoma and GIST represent a rare co-existence of two different histopathologic subtypes of spindle cell tumors. Results (if a Case Study enter NA) NA Conclusion In summary, we present the rare co-existence of two different spindle cell lesions in Neurofibromatosis patient.

Jejuno-Ileal tumors: a retrospective study

Background: Primary tumors of the jejunum and ileum are rare and this segment of gastrointestinal tract is relatively inaccessible to conventional endoscopy, leading to a delay in diagnosis. Due to its rarity, data of primary jejunoileal tumors is still scarce, especially in India where diagnostic modalities like capsule endoscopy is not widely available. Herein we aim to discuss the clinico-radiologic findings, pathology and surgical management of such tumors. Methods: Of the total 51 small bowel resections done in our institute during the period from year 2012 to 2015, 14 patients were identified who were diagnosed with jejunoileal benign/malignant jejunoileal tumors. Records were analysed with respect to patient demographic data, clinical features, radiologic findings, surgical management, histopathology and postoperative outcomes.Results: Jejunoileal tumors are more common in males (77%) and first presentation was intestinal obstruction (50%) in majority of patients. A definite preoperative diagnosis based on radiologic/endoscopic means was possible in six patients (46%). Patients were operated and laparoscopic group showed superior outcomes in terms of postoperative complications. Conclusions: Jejunoileal tumors are an infrequent finding in surgical practice. In our study malignant tumors were more common in proximal small bowel. Computed tomography (CT) enterography can detect small bowel lesions with low sensitivity but allows evaluation of lymphadenopathy/distant metastasis. Laparoscopic resection allows initial staging and has the advantage of early recovery, less wound infection rates and better cosmesis.

1074 Gallstone Ileus: Two Decades After Cholecystectomy

Introduction Gallstone ileus is a rare complication of gallstones that occurs in 1%-4% of all cases of bowel obstruction. We present a surprising case of gallstone ileus causing small bowel obstruction 19 years after open cholecystectomy. Case Report A 77-year-old male presented with a 3-day history of abdominal pain, 4 episodes of vomiting and absolute constipation. He had a surgical background of an open cholecystectomy and open appendicectomy 19 years and 45 years ago respectively. Medically, he had well-controlled hypertension and experienced a TIA 5 years prior. Computed Tomography Scan of the abdomen and pelvis revealed features consistent with an obstructing, heterogenous opacity in the distal small bowel without pneumobilia. The patient subsequently underwent diagnostic laparoscopy. Intraoperatively, an obstructing gallstone, measuring 4 cm, was found 50cm proximal to the ileocaecal junction, with dilatation of the proximal small bowel and distal collapse. Enterotomy and removal of the stone was done. Post-operatively, this gentleman recovered without complications and was discharged home two days later after being able to tolerate a solid diet. Conclusions This is the second reported case of gallstone ileus in a patient with previous cholecystectomy about two decades ago, according to our literature search. Although extremely rare, absence of the gallbladder does not exclude the possibility of gallstone ileus.

Jejuno-jejunal intussusception in an adult – a rare presentation of abdominal pain in the Emergency Department

Background Abdominal pain is a common presentation to the emergency department (ED) and the differential diagnoses is broad. Intussusception is a more common diagnosis in children, with only 5% of cases reported in adults. 80–90% of adult intussusception is due to a well-defined lesion resulting in a lead point, whereas in children, most cases are idiopathic. Adult intussusception is also more commonly associated with malignancy, compared to children. In adults, malignancy is more common in intussusception involving the large bowel compared to intussusception in the small bowel. Case presentation We present a case of a 54-year-old lady who presented to our ED with abdominal pain and vomiting. She had multiple abdominal surgeries in the past. On examination, she had epigastric and peri-umblical tenderness. In view of her persistent abdominal pain that was refractory to analgesia, she had computed tomography (CT) of the abdomen which revealed a jejuno-jejunal intussusception and proximal small bowel obstruction. The patient had an urgent laparoscopy and small bowel resection of the intussusception segment was performed. No pathological lead point was identified on imaging or intra-operatively. The patient made a full recovery post operatively. Conclusion Our case report illustrates a rare diagnosis of abdominal pain and vomiting, presenting to the Emergency Department. With increasing accessibility to CT, most cases of adult intussusception are found incidentally on contrast CT of the abdomen and pelvis. While there is no consensus on management, it is more common for adult intussusception patients to have operative intervention, compared to childhood intussusception.

P096 Which patients with known Crohn’s disease after an ileo-colonoscopy will benefit most from small bowel capsule endoscopy?

Background Ileo-colonoscopy with biopsies is considered the gold standard for the diagnosis and management of Crohn’s disease (CD). In contrast, the role of small bowel capsule endoscopy (SBCE) is limited currently in cases where ileo-colonoscopy and imaging techniques raise doubts on the diagnosis or cannot explain certain clinical manifestations of Crohn’s disease. The aim of our study was to determine whether there are patients with endoscopically confirmed established CD who could get additional benefit by SBCE. Methods Retrospective analysis of prospectively collected data from 6301 patients subjected to SBCE in our department from 1st March 2003 to 18th February 2021. Patients with CD diagnosed by ileo-colonoscopy or total colonoscopy only (because the ileo-caecal valve could not be intubated) prior to SBCE were included in the study and biopsies. SBCE had been performed only in patients who lacked any clinical and/or imaging (CT/MRE) evidence of bowel obstruction. The presence and extent of mucosal lesions, namely local and/or diffuse erythema, erosions and ulcers (aphthous, superficial and/or deep) throughout the small intestine, which may be difficult to identify by traditional imaging, could either explain clinical manifestations unrelated to the findings of colonoscopy or led onto reassessment of applied treatments were sought by SBCE. Results The study sample consisted of 1002 patients (males/females: 511/491, mean age ± SD: 52.6±27.3). Among these, CD had been diagnosed with colonoscopy (and not ileo-colonoscopy) in 293 (29.2%) subjects and small bowel involvement was seen in 104 (35.5%) patients. The vast majority of these patients had lesions only in the terminal ileum (n=81, 77.8%), while the remaining patients (n=23, 22.2%) had additional lesions in more proximal parts of the small bowel. Among the 709 (70.8%) patients in whom CD had been diagnosed by ileo-colonoscopy, lesions in the terminal ileum were found in 407 (57.4 %) patients; SBCE revealed more proximal lesions in 104 patients (25.5%). In the remaining 307 patients (43.3%) in whom ileo-colonoscopy did not reveal terminal ileum involvement, more proximal small bowel lesions were seen in 35 (11.4%) patients. These lesions were mainly apthoid ulcers or larger ulcers, findings that led to a change in therapeutic management in 17 patients (48.6%). Conclusion SBCE identifies more proximal small bowel lesions in a substantial number of patients with CD established by traditional endoscopic techniques. When these lesions are more severe and extensive they may lead onto re-evaluation of the personalized therapeutic strategies.

How to manage a high-output stoma

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A high-output enterocutaneous fistula may, if from the proximal small bowel, behave in the same way and its fluid management will be the same as for an HOS.The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction). A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel.If HOS is due to a short bowel, the first step is to rehydrate the patient so stopping severe thirst. When thirst has resolved and renal function returned to normal, oral hypotonic fluid is restricted and a glucose-saline solution is sipped. Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful. Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10–12 hours to infuse. Generally parenteral support is needed when less than 100 cm of functioning jejunum remains. If there is defunctioned bowel in situ, consideration should be given to bringing it back into continuity.

Prospective study of 30 cases of temporary ileostomy and their complication

Background: An intestinal stoma is an opening of the intestine or urinary tract onto the abdominal wall, constructed surgically or appearing inadvertently. An ileostomy involves exteriorization of the ileum on the abdominal skin. In rare instances, the proximal small bowel may be exteriorised as a jejunostomy. A colostomy is a connection of the colon to the skin of the abdominal wall. Methods: Data of patients, who were undergone for ileostomy construction in New Civil Hospital, Surat were collected prospectively regarding complete history, clinical features on examination, investigations and management. Results: The most common indication of ileostomy formation was ileal perforation in 46.6% patients followed by Intestinal obstruction in 16.6% patients, obstruction with gangrene in 13.3% patients, adhesion in 10% patients. In total of 30 patients loop ileostomy was performed in 17 patients and double barrel ileostomy in 13 patients. Peristomal skin irritation was the most common complication (90%) cases, followed by stomal necrosis/retraction (3.3%). Complications were recorded in all patients out which stomal complication seen in 96% of cases (29 out of 30). Of these peristomal skin excoriation was most common (90%) followed by wound related complications, present in 36.6% cases (11 out of 30 patients).Conclusions: In case of a high complication procedure like ileostomy, it is important to know regarding factors which can be avoided and managed. Knowing these factors which can be avoided or managed. Knowing these factors may help in attributing complications to surgical or technical factors, thereby providing opportunity to correct this error. Prediction of ileostomy complication helps in better management before occurrence of complication. It also helps in conservation of resources and better patient outcome.