Large Duodenal Hematoma Causing an Ileus after an Endoscopic Duodenal Biopsy in a 6-Year-Old Child: A Case Report

Intramural duodenal hematoma (IDH) in children is a rare complication after esophagogastroduodenoscopy. It is commonly described in patients with additional disorders or risk factors, such as coagulopathy. We present a case of a previously healthy 6-year-old boy with a large obstructing intramural duodenal hematoma and concomitant pancreatitis after an elective esophagogastroduodenoscopy. The patient presented with typical symptoms of an IDH, such as abdominal pain and distension, nausea and vomiting. IDH was diagnosed using ultrasound and magnetic resonance imaging examination. Conservative management with gastric decompression using a nasogastric feeding tube, bowel rest, total parenteral nutrition and analgesia was performed. After three weeks, the patient was discharged from the hospital without any complaints. Interventional management of IDH in pediatric patients with a lack of response to conservative therapy or complicating IDH should be discussed in an interdisciplinary team.

The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus

Background Postoperative ileus (POI) is a surgical complication resulting in increased morbidity and length of stay (LOS). Usual care for POI includes bowel rest and gastric decompression. It has been questioned if methylnaltrexone (MNTX), a peripheral opioid antagonist, could be used as treatment for POI. The purpose of this study was to determine if MNTX is effective and safe for POI treatment. Methods This single-center, retrospective cohort study included patients ⩾ 18 years with a POI. Patients with acute colonic pseudo-obstruction, small bowel obstruction, and gastrointestinal malignancy were excluded. The intervention was MNTX administration. The primary outcome was time to ileus resolution. Secondary outcomes included LOS, duration of nasogastric tube, total parenteral nutrition requirement, and incidence of gastrointestinal perforations. Results 110 patients were included in the analysis; 28 received MNTX. Time to ileus resolution was 9.9 days for the MNTX group and 11.4 days for the control group ( P = .38). Duration of gastric decompression was 4.6 days for the MNTX group and 4.2 days for the control group ( P = .71). Length of stay was 19.9 days for the MNTX group and 19.7 days for the control group ( P = .96). The percentage of TPN requirement was 17.9% in the MNTX group and 22.0% in the control group ( P = .65). No gastrointestinal perforations were observed in either group. Conclusion For the treatment of POI, MNTX did not significantly reduce time to resolution of ileus, LOS, duration of gastric decompression, or TPN requirements. However, no gastrointestinal perforations were seen, indicating that MNTX may be safely used in these patients.

Bowel Ischemia in COVID-19: A Systematic Review

Background: Gastrointestinal complications of this COVID-19 have been reported over the last year. One such manifestation is bowel ischemia. This study thus aims to provide a more holistic review of our current understanding of COVID-19 induced bowel ischemia. Method and Results: A meticulous search was performed using different keywords in PubMed, EMBASE, and Google Scholar. Fifty-two articles were included in our study after applying inclusion and exclusion criteria and performing the qualitative assessment of the studies. A total of 25,702 patients were included in our study after the completion of the qualitative assessment. Discussion: COVID-19 commonly presents in the GIT as diarrhea, vomiting, and nausea. The mechanism of bowel ischemia is associated with the formation of emboli which is related to COVID-19’s high affinity for angiotensin-converting enzyme-2 on enterocytes, affecting the superior mesenteric vessels. Clinically, patients presented with abdominal pain and vomiting. CT angiography of the abdomen and pelvis showed acute mesenteric ischemia. Management was usually initiated with gastric decompression, fluid resuscitation, and hemodynamic support. Surgical intervention was also sought. Conclusion: Mesenteric ischemia presenting in patients with COVID-19 has to be considered when symptoms of severe abdominal pain are present. More research and guidelines are required to be able to triage patients with COVID-19 to suspect mesenteric ischemia and to help in diagnosis and management.

Novel Technique: Noninvasive Ventilation Support Flexible Endoscopy for Preoperative Manage Neonates of Esophageal Atresia with Tracheoesophageal Fistula and Respiratory Distress

Introduction Pre-operative management of neonates with esophageal atresia and tracheoesophageal fistula (EA/TEF) requiring positive pressure ventilation (PPV) support is clinically challenging. This study evaluates the safety, feasibility and value of flexible endoscopy with noninvasive ventilation and sustained pharyngeal inflation (FE-NIV-SPI) in diagnosis and placing a naso-tracheo-fistula-gastric (NTFG) tube before surgery. Methods A retrospective study conducted from 2017 to 2020 in neonates with Type-C EA/TEF and respiratory distress, where FE-NIV-SPI performed with NTFG tube placement before surgery. Results Five neonates were collected, one with duodenal atresia and one with transposition of great artery. At FE-NIV-SPI, median body weight was 2,399 g and mean age was 15.2 hours. Four neonates yielded severe (>80% collapsed) tracheomalacia. With this FE-NIV, all tracheal, fistulas and esophageal lumens could clearly assess and manage. All fistulas were less than 8mm proximal to carina with mean orifice width of 5 mm. All NTFG tubes placed successfully after confirmed the EA/TEF. Three neonates had co-intubated with nasal endotracheal tube and 2 neonates had received nasal prongs PPV. Mean procedural time of FE-NIV was 13.6±4.5 minutes. All neonates received gastric decompression and feeding via NTFG tubes for mean of 11.4±18.2 days and had stable pre-surgical courses. No adverse associated complication noted. Conclusion FE-NIV-SPI technique enables safe and accurate measurement of EA/TEF anatomy and placing NTFG tube. It could avert emergent gastrostomy, aid gastric decompression, feeding, and ETT intubation, improve PPV, provide pre-surgical stabilization and identify the fistula location during the surgical correction.

Comminuted nasogastric tube fracture: a rare complication

A nasogastric tube is commonly used as a method of enteral feeding or gastric decompression in clinical practice and its insertion is occasionally associated with local complications. In this case report, we present an extremely rare complication of a comminuted nasogastric tube fracture in a 54-year-old male patient receiving enteral feeding in hospital secondary to a diagnosis of haemophagocytic lymphohistiocytosis.

CISOL: el dispositivo de cierre para sonda nasogástrica tipo Levin, en un estudio aleatorio controlado que evalúa su efectividad y seguridad

Background: The Levin-type nasogastric tube is indicated for gastric decompression, but due to its economic cost it is used to feed and administer medications in patients who cannot do it by themselves; its proximal end does not have a closure system. The study determined the effectiveness and safety of a device (Cisol), specially created for the proximal closure of the Levin-type nasogastric tube for adults compared to the conventional device (syringe). Methods: Study of experimental design, randomized of preventive type applied outside the clinical context, through which the effectiveness and safety of both devices were estimated and compared taking into account as markers: their weight, size and shape. Results: According to the evaluation of the participants, Cisol is considered effective and safe for the proposed purposes since its weight, size and shape would significantly favor patient comfort and handling compared to the syringe. Conclusions: The new CISOL design is safe to use, and has the potential to reduce risks related to traction and overweight at the proximal end of the probe, as well as contributing to patient comfort. The effectiveness and safety of the CISOL device differs from the effectiveness and safety of the conventional device (syringe) used to close the Levin catheter.

Nasogastric- vs. percutaneous gastrostomy tube for prophylactic gastric decompression after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Objectives Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with postoperative gastroparesis and ileus. In 2015, our practice shifted from using percutaneous gastrostomy tubes (PGT), to nasogastric tubes (NGT) for prophylactic gastric decompression after CRS-HIPEC. This study aimed to compare these methods for length of stay (LOS) and associated complications. Methods Patients that underwent CRS-HIPEC for peritoneal metastases from colorectal cancer between 2014 and 2019 were included. Cases were grouped based on receiving NGT or PGT postoperatively. Multivariable linear regression determined the independent effect of decompression method on LOS, thereby adjusting for confounders. Results In total, 179 patients were included in the analyses. Median age was 64 years [IQR:54–71]. Altogether, 135 (75.4%) received a NGT and 44 (24.6%) received a PGT. Gastroparesis occurred significantly more often in the PGT group (18.2 vs. 7.4%, p=0.039). Median LOS was significantly shorter for patients with a NGT (15 [IQR:12–19] vs. 18.5 [IQR:17–25.5], p<0.001). PGT was independently associated with longer LOS in multivariable analysis (Beta=4.224 [95%CI 1.243–7.204]). There was no difference regarding aspiration, pneumonia and postoperative mortality between groups. Conclusions NGT should be preferred over PGT for gastric decompression after CRS-HIPEC as it is associated with fewer gastroparesis and shorter LOS.

Abdominal Wall Defects—Current Treatments

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

Acute gastric dilatation in a patient with severe anorexia nervosa: a case report

Background Acute gastric dilatation (AGD) leading to gastric necrosis and perforation has been reported to be a rare but fatal complication in young patients with eating disorders, particularly anorexia nervosa. Case presentation We report a case of a Canadian female patient presenting with mild abdominal pain, with a history of anorexia nervosa, the binge/purge subtype, who was found to have severe acute gastric dilatation on subsequent computed tomography imaging. Her clinical course was uncomplicated after gastric decompression. The cause of her AGD was thought to be secondary to dysmotility disorder caused by her anorexia nervosa. Conclusion Our case report demonstrates the importance of clinical identification of AGD and subsequent diagnosis and management. Because of the urgency to rule out obstruction or perforation through consultation or additional imaging modalities, recognition and correct diagnosis of this condition is necessary for appropriate patient management. In addition, our case report adds to an underreported but important complication of anorexia nervosa.