Small bowel obstruction caused by a true ileo-ileal knot: a rare case successfully treated by prior ligation of mesenteric vessels

Background Intestinal knot formation, in which two segments of the intestine become knotted together, can result in intestinal obstruction. An ileo-ileal knot refers to knot formation between two ileal segments and is a very rare benign disease. We report a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Case presentation An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home. Conclusion We encountered a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Resection of the necrotic small intestine without releasing the knot could be performed safely, and might be considered as an option of surgical procedure.

Abdominotransanal resection of a strangulated rectal carcinosarcoma

This is a case of a 75-year-old man who presented with a 7-month history of a reducible rectal mass. The patient came to the emergency department with a prolapsed necrotic bowel involving a strangulated segment with the rectal mass. He underwent an abdominotransanal resection through a combined abdominal and perineal approach. His postoperative course was unremarkable. Histopathological and immunohistochemical studies showed a rectal carcinosarcoma. Because of a state-mandated lockdown due to the COVID-19 pandemic, the patient failed to follow-up. He was later seen to have metastatic progression. Owing to the poor functional status of the patient, the shared decision of the multidisciplinary team, the patient and his family was to manage him with palliative intent.

The presence of trapped fluid on ultrasound as high predictive value for intestinal necrosis in pediatric intussusception

Introduction: Intussusception is a pediatric emergency. If it is not treated immediately, the obstruction process can cause arterial obstruction and leads to intestinal necrosis. Not all patient shows classic syndrome triad. Thus, imaging is needed to make the diagnosis. Ultrasonography is the first choice of imaging in children because it is easy, without radiation and sedation. It has high accuracy for the diagnosis of intussusception. Ultrasonographic features of intussusception including target or doughnut sign and pseudo kidney sign. The presence of trapped fluid in intussusception, correlated with intestinal ischemia and necrosis found in surgery. This research aimed to assess sensitivity, specificity, and accuracy of trapped fluid in ultrasound examination compared with the intra-operative findings reported by surgeons in the form of intestinal necrosis in pediatric patients with intussusception in Saiful Anwar Hospital, Malang. Material and Methods: This research was observational analytic with a cross-sectional design. It used retrospective data of abdominal ultrasound results and surgical operating reports in 30 patients who were diagnosed with intussusception. Results: Trapped fluid depiction on ultrasound has a sensitivity of 80%, a specificity of 75%, and an accuracy of 76% with regards to necrotic bowel as compared to intra-operative findings. Conclusion: Trapped fluid in intussusception is a good predictor of intestinal necrosis in cases of intussusception in children.

Case of Incarcerated Femoral Hernia Treated with Laparoscopic Surgery after Groin Hernia Repair

An 81-year-old man was brought to our hospital due to a suspicion of left incarcerated femoral hernia. He was previously diagnosed with incarcerated left groin hernia and was treated using the mesh plug method 1 month back at another hospital. Abdominal computed tomography scan revealed small bowel obstruction, incarcerated bowel, and compression of the left femoral vein. Thus, the patient was diagnosed with incarcerated femoral hernia. An emergency laparoscopic surgery was then performed, and we found that the small bowel was incarcerated into the let femoral ring and was necrotic. However, there was no recurrence of left inguinal hernia. The small necrotic bowel was resected and the femoral ring was repaired. The patient was discharged 8 days after the surgery, and there was no recurrence of femoral hernia after 1 year.

Primary Segmental Small Bowel Volvulus in an Adolescent Female

Small bowel volvulus is a rare but important cause of abdominal pain and small bowel obstruction in children and adults. In the neonate, small bowel volvulus is a well-known complication of malrotation. Segmental small bowel volvulus is a lesser-known condition, which occurs in children and adults alike and can rapidly progress to bowel ischemia. Primary segmental small bowel volvulus occurs in the absence of rotational anomalies or other intraabdominal lesions and is rare in Europe and North America. Clinical presentation can be misleading, causing a delay in diagnosis and treatment, in which case the resection of necrotic bowel may become necessary.We report on a 14-year-old girl who presented with severe colicky abdominal pain but showed no other signs of peritoneal irritation or bowel obstruction. An emergency magnetic resonance imaging was highly suspicious for small bowel volvulus. Emergency laparotomy revealed a 115 cm segment of strangulated distal ileum with no underlying pathology. We performed a detorsion of the affected bowel segment. Despite the initial markedly ischemic appearance of the affected bowel segment, the patient achieved full recovery without resection of bowel becoming necessary.

Necrotising enterocolitis in an adult with anorexia nervosa

Necrotising enterocolitis (NEC) is a rare cause of the acute abdomen in adults and carries one of the highest mortality rates in gastroenterology. However, its rarity confines research to small case reports. Both its pathogenesis and aetiology remain enigmatic in adult patients, proving timely diagnosis and management a challenge. This paper reports on one case of NEC in an adult patient with underlying anorexia nervosa, following a seven-day period of starvation. She underwent emergency laparotomy for resection of necrotic bowel and subsequently made a good recovery. To date, there have only been eight reports linking NEC with anorexia nervosa. We review our patient in the context of plausible mechanisms hypothesised in these cases. Successful management depends on prompt diagnosis, resuscitation and surgical intervention.

Pneumatosis intestinalis: cost paid for rheumatoid arthritis treatment

A 75-year-old woman with rheumatoid arthritis on rituximab presented with a 1-week history of constipation and abdominal distension. Subsequent workup showed presence of air in the bowel wall without perforation initially. Due to positive blood cultures, worsening leucocytosis and high suspicion for perforation, an exploratory laparotomy was performed revealing necrotic bowel, walled off perforation and abscess. Patient underwent right hemicolectomy with diversion loop ileostomy. Clinicians must recognise that monoclonal antibodies like rituximab can mask signs of inflammation and therefore should maintain a high index of suspicion for intestinal perforation when evaluating patients with minimal symptoms and pneumatosis intestinalis.

Fracture and dislocation of lumbar vertebrae with entrapment of small bowel: A case report and literature review

Traumatic incarceration of the small bowel accompanied by vertebral fractures and dislocation is rare and usually misdiagnosed until laparotomy. This report presents a rare case of jejunum entrapment between lumbar spine fractures. A 43-year-old man was clamped between two railway tracks on the upper abdomen and lower back. Following ineffective conservative treatment, he underwent a laparotomy due to the development of guarding and rebound tenderness. Loss of vitality of the jejunal loop, which was incarcerated between the L3 and L4 vertebrae, was observed. The necrotic bowel was removed and end-to-end anastomosis was performed. When his condition was stable, anterior and posterior lumbar fixation surgery was performed. The patient had no abdominal complications and lower limb nerve function deficiency during the follow-up period. A review of the literature since 1979 on incarceration of the bowel associated with lumbar fracture and dislocation identified 12 cases: five patients showed persistent neurological symptoms, but none of the patients died as a result of their injuries. It should be borne in mind that patients with hyperextension or flexion-distraction injury of the lumbar spine could show symptoms of intestinal obstruction and bowel incarceration. Enhanced computed tomography or magnetic resonance imaging will be helpful for diagnosis.

Ultrasound in the evaluation of necrotic bowel in children: A pictorial essay

Necrotic bowel is a serious condition involving death of gastrointestinal tissue. The diagnosis is difficult to make clinically, and plain radiography is often inconclusive. Ultrasonography is an inexpensive, portable and readily available complementary diagnostic tool. In some cases, ultrasonography can detect features of necrotic bowel earlier than plain radiography or when plain radiography is equivocal and does not correlate with the clinical findings. This pictorial essay aims to compare the ultrasonography features of normal bowel and necrotic bowel in children. The role of ultrasonography and the ultrasonographic features of necrotic bowel will be illustrated by discussing some of the causes of necrotic bowel in children. Correlation with plain radiographs and pathological specimens is made. Frequent causes of necrotic bowel in neonates include necrotising enterocolitis, malrotation with small bowel volvulus and incarcerated inguinal hernias. Causes in older children include intussusception, complications of Meckel’s diverticulum, post-surgical adhesions, internal hernias and vasculitic abnormalities. Ultrasonography features suggestive of necrotic bowel include persistently dilated loops of aperistaltic bowel, increase or decrease of bowel wall thickness, intramural or portal venous gas, loss of bowel wall perfusion, and free intraperitoneal gas and fluid. The diagnosis of necrotic bowel may be made earlier on ultrasonography than on abdominal radiographs alone. This pictorial essay will familiarise the reader with the role of ultrasonography and the ultrasonographic features of necrotic bowel through a wide range of conditions that may cause necrotic bowel in children. Familiarity with these findings will facilitate timely imaging diagnosis of necrotic bowel before complications develop.