RICHTER'S TYPE FEMORAL HERNIA, A RARE ENTITY AND DIFFICULT DIAGNOSIS

The Richter hernia is a rare condition characterized by the incarceration or strangulation of the intestinal antimesenteric border through a small defect of the abdominal wall, being able to progress rapidly for necrosis and perforation. The Richter hernia is more frequent between the sixth and seventh decades of life, representing 5-20% of all hernia strangles and occurs mainly associated with femoral hernias. We report a case of imprisoned Richter's femoral hernia with signs of distress in the elderly male patient.

Hypermagnesaemia causing mesenteric ischaemia and small bowel infarction

We present a case of mesenteric ischaemia caused by hypermagnesaemia after ingestion of a large oral dose of magnesium citrate, which resulted in smooth muscle relaxation, hypotension and bowel infarction. The patient had a history of chronic bowel dysmotility and renal impairment. On operative exploration, the bowel was noted to have a distinct pattern of ischaemia along its antimesenteric border. Small bowel resection was performed, and the patient was left in discontinuity, with definitive repair and anastomosis performed 24 hours later. The patient’s magnesium level was 8.39 mg/dL, which was treated with intermittent haemodialysis and eventually normalised over several sessions. Our patient recovered and was discharged after a month-long hospitalisation. She returned shortly after with respiratory failure and died. On review of the literature, we identified similar cases and present a pathophysiological mechanism of hypermagnesaemia causing mesenteric ischaemia, consistent between our cases and those already reported.

JEJUNAL PERFORATION AFTER BLUNT ABDOMINAL TRAUMA: A SERIES OF 3 CASE

Jejunal perforation caused by blunt abdominal trauma is uncommon and mostly seen after road traffic accident due to high energy deceleration injury. And it is also seen after bicycle handle injury, fall from height, and assault. Solid organ injuries are very much common after blunt abdominal trauma. Isolated jejunal perforations are very rare after blunt abdominal trauma. Therefore, if not identified early, it increases morbidity and mortality. Jejunal perforation are mainly due to increased intraluminal pressure in air and fluid filled bowel loops mainly on antimesenteric border. These perforations are called “Blowout” injury, mucosa will be protruding from perforation site and surrounding tissue destruction is less. It is also caused by shearing forces and also due to compression between the abdominal wall and vertebral column. Deceleration mechanism can result in a shearing of the serosa and muscularis throughout a segment of small bowel. Blunt abdominal trauma causing gastrointestinal perforation is very rare ranging from less than 1% to 8.5%, out of which isolated jejunal perforation occurs in less than 1% of cases.

An atypical presentation of a mesenteric Meckel’s diverticulum in a 7-year-old warmblood mare: case report

Background Meckel’s diverticula are a rare cause of small intestinal strangulation, diagnosed at laparotomy or necropsy. This congenital anomaly of the gastrointestinal tract originates from a remnant of the vitelline duct. In reported equine cases, they present as a full-thickness diverticulum on the antimesenteric border of the distal jejunum or proximal ileum. Case presentation On laparotomy a Meckel’s diverticulum positioned at the mesenteric side was found to be the cause of small intestinal strangulation. This position is very uncommon and to the best knowledge of the authors there is no unambiguous description of another case. Conclusions Meckel’s diverticula should be on the list of differential diagnoses in cases of small intestinal strangulation. As in humans, equine Meckel’s diverticula can have the standard antimesenteric as well as a more exceptional mesenteric location. This case adds to the series of anecdotal reports of anomalies with regard to Meckel’s diverticula in the horse.

A rare scenario of perforated gastrointestinal stromal tumours of ileum

Gastro-intestinal stromal tumours (GIST) are among the common mesenchymal tumours of the gastro-intestinal (GI) tract. It varies in location and presentation. GIST are reported in the stomach frequently (60-70%), followed by small intestine (20-25%). Mainly GIST manifest typically with bleeding or vague abdominal pain and discomfort. The spontaneous perforation of GIST is very rare. We report case of a middle-age male patient who presented in emergency with pain in right lower abdomen associated with features of peritonism. After clinical evaluation and preliminary radiological investigations, a working diagnosis of perforated appendix was made. Patient was undertaken for emergency surgery. A diagnostic laparoscopy followed by midline laparotomy was done. Intra-operatively, a perforated and necrotic outpouching at antimesenteric border of terminal ileum was found. Histopathological examination of the resected part of ileum revealed compatibility with GIST. It was strongly positive for cluster of differentiation 117 (CD117) and smooth muscle actin. Patient received adjuvant therapy with Imatinib. A complete surgical resection without extensive lymph node sampling is the primary treatment option. As GIST are rare, a high index of suspicion is warranted for diagnosis and appropriate treatment.

“Meckel’s Diverticulum” – A diagnostic bizarre of abdominal pain in adults

A 30-year-old male presented to the emergency room with complaints of periumbilical abdominal pain and vomiting. A contrast-enhanced computed tomography scan of the abdomen revealed subacute intestinal obstruction with dilated small bowel loops and associated bowel wall thickening of mid and distal ileal bowel loops. There was a fairly large small bowel diverticulum arising from the antimesenteric border of distal ileum. Findings were suggestive of small bowel diverticulitis or possibly focal enteritis. The patient was then immediately taken to the operating room for emergency laparotomy and was intra-operatively found to have a thickened Meckel’s diverticulitis with adjacent small bowel obstruction. Meckel’s diverticulectomy was performed in continuity with the adjacent inflamed small bowel. The patient had a stable post-operative course without any complications and was discharged within a week.

Jejunum and Ileum

During development, there is physiologic herniation of the midgut into the umbilical cord, and it then slips back in with a counterclockwise rotation. Jejunum and ileum occupy the mid abdomen and pelvis. The jejunum is involved in calcium and magnesium absorption. The ileum contains lymphoid tissue at the antimesenteric border. Small bowel infections present with a range of symptoms from diarrhea to severe dehydration to sepsis. Suspected SBO can be evaluated with plain radiography, upper GI studies, or CT. The treatment of SBO is initially nonoperative. Paralytic ileus occurs in many patients after abdominal surgery and is treated with IV fluids, nothing by mouth, and electrolyte replacement.

Early outcomes of tapering jejunoplasty by antimesenteric seromuscular stripping and mucosal inversion for proximal jejunal atresia

Background High jejunal atresia is associated with significant dilatation of the proximal segment. This poses two problems: (a) calibre discrepancy with the distal unused segment and (b) hypomotility causing stasis. Tapering jejunoplasty/enteroplasty could offer a practical solution in selected cases, leading to early establishment of feeds. This work aims to evaluate the outcome of tapering jejunoplasty including its effect on establishing enteral feeding in neonates with proximal jejunal atresia. Results Twenty-two neonates with jejunal atresia (types I, II and IIIa) were reviewed. Cases with multiple atresia, apple-peel variant and meconium ileus were excluded. The included cases fell retrospectively into two groups: group A (13 cases)—very proximal atresia and significant dilatation and group B (9 cases)—mid/distal jejunal atresia. For group A, we excised only the distal tip of the dilated bowel and stripped a seromuscular triangle up to the duodenojejunal flexure and inverted the mucosa along the antimesenteric border, followed by an end-to-oblique anastomosis. For group B, we performed a standard excision of a short proximal segment and an end-to-oblique anastomosis. There was no significant difference in the gestation age or birth weight between both groups. The mean operative time was 90 min for group A and 60 min for group B. The duration until full enteral feeds became tolerated, and parenteral nutrition was weaned accordingly was shorter in group A (mean 10.8 days) as compared to group B (mean 14.5 days), p = 0.045. Conclusion Tapering jejunoplasty by seromuscular stripping and mucosal inversion facilitates early establishment of feeds in proximal jejunal atresia.

Adult intussusception associated with mesenteric Meckel’s diverticulum and antimesenteric ileal polyp

Meckel’s diverticulum is the most common congenital abnormality affecting the gastrointestinal tract, affecting 4% of the general population. It is classically located on the antimesenteric border of the ileum within 100 cm of the ileocaecal valve. Complications may include haemorrhage, bowel obstruction, diverticulitis, perforation and malignancy. This report explores the case of intussusception in an adult, in association with a mesenteric Meckel’s diverticulum and adjacent benign polyp. A 40-year-old man presented with acute abdominal pain, affecting the central abdomen and both flanks. CT imaging revealed small bowel intussusception, with either a Meckel’s diverticulum or polyp acting as a lead point. Intraoperatively, the intussusception had already resolved; however, an inflamed outpouching was identified on the mesenteric border of the ileum, with a firm mass palpable within the bowel lumen. A 70 mm small bowel resection and primary anastomosis were performed. Histopathological analysis confirmed an inflamed Meckel’s diverticulum as well as an adjacent diverticulum comprising a benign polyp.

ASSESSMENT OF THE SURGICAL PROFILE AMONG PATIENTS OF ILEAL PERFORATION

Background: In various researches it was reported that perforations of gastrointestinal tract had been surgical emergencies. Some studies also reported that the proof of gastrointestinal tract perforations in ancient mummies. Gastrointestinal tract perforation occurs when a pathology of any specific disease involves the entire depth of the gastrointestinal tract Material & Methods: Patients who were diagnosed as perforation and peritonitis on the basis of laboratory diagnosis and clinical examination were enrolled by simple random sampling. Clearance from Institutional Ethics Committee was taken before start of study. Written informed consent was taken from each study participant. Results: In the present study, out of total study participants abdominal pain was the most common presenting symptom present in patients which was followed by fever, abdominal distension and vomiting. On the basis of time of perforation, 4% cases presented within 12 hour, between 12 and 24 hour was reported among in 50% cases, in the rage of 24 and 48 hour seen in 24% patients, in the range of 48 and 72 hour reported in 12% cases, in range of 72 and 96 hour reported in 8% cases, and in range of 96 and 120 hour reported in 2% case. Near about all patients were operated in the range of 12 hours of hospitalization. Conclusion: The most common presenting symptoms present among patients were abdominal pain, abdominal distension, vomiting, fever and obstipation. We found that majority of cases had circular perforation of typhoid at antimesenteric border which was followed by tubercular elliptical perforation on the antimesenteric border and traumatic type perforation. Key words: Ileal perforation. primary closure, loop ileostomy