Intestinal necrosis and perforation is a clinical and pathological presentation of the infrequently seen mesenteric venous thrombosis in women using oral contraceptives.
We report a case of a previously healthy 31-year-old female patient, who presented with a 3-day history of abdominal pain.
Although chest and abdomen radiographs showed small bowel obstruction, conservative treatment failed and the patient developed peritonism. Contrast-enhanced Tomography of the abdomen revealed free air associated with dilated and thickened small bowel. A laparotomy was performed and segmental resection of both small and large bowel was required. The pathological examination showed intestinal ischemia and mesenteric venous thrombosis. There were no further predisposing factors and mesenteric venous thrombosis was ascribed to oral contraceptives.
Inflammatory fibroid polyps (Vanek's tumor) are rare benign localized lesions originating in the submucosa of the gastrointestinal tract. Intussusceptions due to inflammatory fibroid polyps are uncommon; moreover, ileo-ileal intussusception with small bowel necrosis and perforation has rarely been reported. We report a 56-year-old woman who was admitted two days after complaints of nausea and vomiting. Abdominal examination revealed distension, signs of gastrointestinal perforation and clanging intestinal sounds. The patient underwent a emergency laparotomy which found a 17-cm invaginated mid-ileal segment with necrosis, perforation and fecal peritonitis. The ileal segment was resected and single-layer end-to-end anastomosis was performed. Histopathological analysis showed an ulcerative lesion with variable cellularity, formed by spindle cells with small number of mitosis and an abundant inflammatory infiltrate comprising mainly eosinophils. Immunohistochemistry confirmed the diagnosis of ileal Vanek's tumor. Although inflammatory fibroid polyps are seen very rarely in adults, they are among the probable diagnoses that should be considered in obstructive tumors of the small bowel causing intussusception with intestinal necrosis and perforation.
Intestinal polyps; Polyps; Ileal neoplasm; Intussusception; Intestinal obstruction; Intestinal perforation; Immunohistochemistry
This 67-year-old woman, with numerous previous abdominal operations, presented to her general practitioner 3 years ago with generalised abdominal pain and diarrhoea. With unremarkable haematology tests and a CT scan at that time she was given the diagnosis of irritable bowel syndrome. During the next 3 years her symptoms continued intermittently and now associated with vomiting and weight loss. This time both a barium follow-through followed by a CT scan demonstrated a small bowel intussusception. A laparotomy was done but surprisingly no intussusception was found, only a single adhesional band which was divided. She was discharged 5-days postoperative but re-admitted 3 days later with abdominal discomfort, bloating and vomiting. A repeat CT scan again showed the presence of a small bowel intussusception and a second laparotomy was performed, this time demonstrating a jejuno-ileal intussusception which was reduced and resected with primary anastomosis. Her postoperative course was without incidents.
Background and Objective:
Small bowel ischemia following laparoscopy was described recently as a rare fatal complication of the CO2 pneumoperitoneum. Of the 8 cases reported in the surgical literature, 7 were fatal, 1 was not. In this report, we describe the first gynecological case.
A 34-year-old woman who underwent laparoscopy with extensive adhesiolysis and myolysis was re-admitted with an acute abdomen on postoperative day 4. Immediate laparotomy revealed acute peritonitis, extensive adhesions, and a 3-cm defect in the small bowel. Tissue examination showed ischemic necrosis of edematous, but essentially normal, bowel mucosa. The postoperative course was extremely complicated. She was discharged after a 2-month hospital stay in the intensive care unit for rehabilitation.
Data are available on 7 patients (including ours). All procedures were described as uneventful. The intraabdominal pressure was set at 15 mm Hg when specified. Some abdominal pain occurred in all, nausea and vomiting in 4, diarrhea in 2, abdominal distention in 1, fever in none. Quick reintervention laparotomy was performed in 2 and delayed in 5 (up to 4 days).
The CO2 pneumoperitoneum is a predisposing factor for intestinal ischemia as it reduces cardiac output and splanchnic blood flow. However, critical ischemia relies on underlying vasculopathy or an inciting event.
Patient selection, maintaining intraabdominal pressure at 15 mm Hg or less, and intermittent decompression of the gas represent the best options for preventing this complication.
Small bowel ischemia; Pneumoperitoneum
Phytobezoar, a concretion of indigestible fibers derived from ingested vegetables and fruits, is the most common type of bezoar. Diospyrobezoar is a subtype of phytobezoar formed after excessive intake of persimmons (Diospyros kaki). We report the case of a diabetic man with a 5-day history of abdominal pain after massive ingestion of persimmons who developed signs of complicated small bowel obstruction. The patient had a previous history of Billroth II hemigastrectomy associated with truncal vagotomy to treat a chronic duodenal ulcer 14 years earlier. Since intestinal obstruction was suspected, he underwent emergency laparotomy that revealed an ileal obstruction with small bowel perforation and local peritonitis due to a phytobezoar that was impacted 15 cm above the ileocecal valve. After segmental intestinal resection, the patient had a good recovery and was discharged on the 6th postoperative day. This report provides evidence that diospyrobezoar should be considered as a possible cause of small bowel obstruction in patients who have previously undergone gastric surgery.
Bezoars; Diospyros kaki; Persimmon; Intestinal obstruction; Operative surgical procedure
Gas in the portal venous system was detected on plain roentgenograms of the abdomen in two women aged 61 and 72 years, respectively. Both patients had intestinal necrosis, due in one instance to a small bowel volvulus around a mesenteric band, and in the second instance to occlusion of the celiac axis, superior and inferior mesenteric arteries. In the first patient, the portal venous gas was detected before surgery, and in the second case the gas was observed at laparotomy and was visualized on radiographs of the abdomen taken shortly after death. Both patients died. Portal venous gas can be distinguished radiologically from air in the bile ducts by its characteristic slender branching gas pattern in the periphery of the liver substance. The presence of portal gas in the adult indicates intestinal necrosis in the majority of cases and should lead to early operative intervention.
To determine the cause, presentation, anatomical distribution, diagnostic method, management and outcome of intestinal injuries from blunt abdominal trauma.
The study included 47 patients who underwent laparotomy for intestinal injuries from blunt abdominal trauma over a period of 4 years. A retrospective study was conducted and the patients were analyzed with respect to the cause, presentation, anatomical distribution, diagnostic methods, associated injuries, treatment and mortality.
47 patients with 62 major injuries to the bowel and mesentery due to blunt abdominal trauma were reviewed. The male to female ratio was 8.4: 1 and the average age was 34.98 years. There were 44 injuries to the small intestine including 1 duodenal injury, 11 colonic injuries and 7 injuries to the mesentry. 26 patients were injured in road traffic accidents. Out of 29 patients with intestinal perforation, free peritoneal air was present on plain abdominal and chest radiography in 23 patients. 18 patients underwent laparotomy on the basis of clinical findings alone. The commonest injury was a perforation at the antimesentric border of the small bowel. Treatment consisted of simple closure of the perforation, resection and anastomosis and repair followed by protective colostomy for colonic perforations. 3 (6.38%) deaths were recorded, while 8 (17.02%) patients developed major complications.
Although early recognition of intestinal injuries from blunt abdominal trauma is difficult, it is very important due to its tremendous infectious potential. Intestinal perforations are often associated with severe injuries which are probably be the determining factors in survival.
Here we present the case of a 79-year-old woman who complained of acute abdominal pain, vomiting and diarrhoea. Laboratory exams demonstrated a severe metabolic imbalance. Abdominal X-rays showed bowel overdistension and pneumatosis of the stomach wall. Abdominal tomography revealed infarction of the stomach, duodenum and small bowel due to thrombosis of the celiacomesenteric trunk. Exploratory laparotomy revealed ischemia of the liver, spleen infarction and necrosis of the gastro-intestinal tube (from the stomach up to the first third of the transverse colon). No further surgical procedures were performed. The patient died the following day. To our knowledge, this is the first reported case about severe gastro-intestinal ischemia due to thrombosis of the celiacomesenteric trunk, a rare anatomic variation of the gastrointestinal vascularisation.
Celiacomesenteric trunk; Celiac trunk; Thr-ombosis; Anomalies; Gastrointestinal vascularisation
Superior mesenteric injury is a rare entity but when it occurs, short bowel syndrome is one of the uninvited results of the emergency surgical procedures.
We present a 19-year-old boy with blunt abdominal trauma which caused serious mesenteric injury. Because ultrasound revealed free intraabdominal fluid, he underwent emergency laparotomy. Adequate vascularization of approximately 20 cm of proximal jejunal segment and approximately 20 cm of terminal ileum was observed. Nevertheless, the mesentery of the rest of the small intestine segments was ruptured completely. We performed an end-to-end anastomosis between a distal branch of the superior mesenteric artery in the mesentery of the ileal segment and a branch of the superior mesenteric artery using separate sutures of 7.0 monofilament polypropylene. The patient's gastrointestinal passage returned to normal on the postoperative day 2. He recovered without any complication and was discharged from hospital on the postoperative day seven.
In this case report, we emphasize the importance of preservation of injured mesenteric artery due to abdominal trauma which could have resulted in short bowel syndrome.
Acute thromboembolic occlusion of the superior mesenteric artery is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine, surgical resection of the necrotic bowel and supportive intensive care. In this report, we describe a case of a 39-year-old woman who developed a small bowel infarct because of an acute thrombotic occlusion of the superior mesenteric artery, also involving the splenic artery.
A 39-year-old Caucasian woman presented with acute abdominal pain and signs of intestinal occlusion. The patient was given an abdominal computed tomography scan and ultrasonography in association with Doppler ultrasonography, highlighting a thrombosis of the celiac trunk, of the superior mesenteric artery, and of the splenic artery. She immediately underwent an explorative laparotomy, and revascularization was performed by thromboendarterectomy with a Fogarty catheter. In the following postoperative days, she was given a scheduled second and third look, evidencing necrotic jejunal and ileal handles. During all the surgical procedures, we performed intraoperative Doppler ultrasound of the superior mesenteric artery and celiac trunk to control the arterial flow without evidence of a new thrombosis.
Acute mesenteric ischemia is a rare abdominal emergency that is characterized by a high mortality rate. Generally, acute mesenteric ischemia is due to an impaired blood supply to the intestine caused by thromboembolic phenomena. These phenomena may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thromboendarterectomy, although some prefer an endovascular approach. A second-look laparotomy could be required to evaluate viable intestinal handles. Some authors support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.
The purpose of this study was to investigate the histological and morphological changes in the first two postoperative weeks on a rat intraperitoneal adhesion model induced by duodenum clamping trauma.
The rat model of postoperative intraperitoneal adhesions was established in 48 male Wistar rats by laparotomy, followed by the duodenum clamping trauma. Rats were sacrificed respectively on 1st, 3rd, 5th, 7th and 14th day after the operation. The control rats were sacrificed immediately after the operation (0 day). Then the intraperitoneal adhesions were assessed macroscopically. Histopathology and immunohistochemistry were performed to evaluate the fibrosis, inflammatory responses, neovascularization, and cells infiltration in adhesion tissues. In addition, the changes of the mesothelium covering the surgical sites were examined by scanning electron microscopy.
Our study revealed that duodenum clamping trauma induced by mosquito hemostat can result in significant postoperative intraperitoneal adhesions formation. The extent and tenacity of intraperitoneal adhesions reached their peaks on 3rd and 5th days, respectively. Histopathological examination showed that all rats developed inflammatory responses at the clamped sites of duodenum, which was most prominent on 1st day; the scores of fibrosis and vascular proliferation increased slowly from 3rd to 5th day. Myofibroblasts proliferated significantly in the adhesion tissues from 3rd day, which were examined by immunohistochemical method. And the mesothelium covering the surgical sites and the adhesion tissues healed on 7th day.
This study suggests that clamping trauma to the duodenum can result in significant postoperative intraperitoneal adhesions formation, which represents an ideal rat model for intraperitoneal adhesions research and prevention. And myofibroblasts may play an important role in the forming process of intraperitoneal adhesions.
Volvulus of the intestine has recently been observed in three patients with idiopathic steatorrhea in relapse. Two patients gave a history of intermittent abdominal pain, distension and obstipation. Radiographic studies during these attacks revealed obstruction at the level of the sigmoid colon. Reduction under proctoscopic control was achieved in one instance, spontaneous resolution occurring in the other. The third patient presented as a surgical emergency and underwent operative reduction of a small intestinal volvulus. Persistence of diarrhea and weight loss postoperatively led to further investigation and a diagnosis of idiopathic steatorrhea. In all cases, treatment resulted in clinical remission with a coincident disappearance of obstructive intestinal symptoms. The pathogenesis of volvulus in sprue is poorly understood. Atonicity and dilatation of the bowel and stretching of the mesentery likely represent important factors. The symptoms of recurrent abdominal pain and distension in idiopathic steatorrhea necessitate an increased awareness of intestinal volvulus as a complication of this disease.
We report a case of an isolated double gastric rupture, resulted from blunt abdominal trauma, that we successfully repaired by primary closure. A 18-month-old girl injured in a motorvehicle accident was admitted to our hospital where the plain X-ray and the CT findings revealed the presence of free abdominal air. An immediate performed exploratory laparotomy disclosed two full-thickness ruptures of the stomach (on the greater curvature and the posterior wall). The ruptures were closed primarily by a two-layer closure. Twenty-four hours post-operatively the patient developed delayed shock as a result of chemical peritonitis. On the 8th postoperative day the girl developed septic shock and gastrorrhagia. She underwent a gastroscopy which revealed stress-ulcer, and was treated conservatively in the children intesive care unit of our hospital. She was discharged home on 20th postoperative day. At 3-month follow up, she was doing well with normal growth and eating a regular regimen about her age. Gastric rupture following blunt abdominal trauma is rare, with a reported incidence of 0.02-1.7%. The morbidity and mortality are directly related to the number of associated injuries, the delay in diagnosis and the development of intraabdominal sepsis. In this paper we emphasise the need for early diagnosis and the aggressive surgical treatment as a key to decreasing the mortality and morbidity from this relatively rare injury, especially in this age group of children.
blunt abdominal trauma; gastric rupture; children
Internal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.1 Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2–0.9%.2
PRESENTATION OF CASE
In this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.
In the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.11 Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries.
In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. 16
The diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.
Mesenteric defect; Internal hernia; Intestinal obstruction
AIM: To investigate the efficacy of acellular dermal matrix (ADM) for intestinal elongation in animal models.
METHODS: Japanese white big-ear rabbits (n = 9) and Wuzhishan miniature pigs (n = 5) were used in the study. Home-made and commercial ADM materials were used as grafts, respectively. A 3-cm long graft was interposed in continuity with the small bowel and a side-to-side anastomosis, distal to the graft about 3-4 cm, was performed. The animals were sacrificed at 2 wk, 4 wk, 8 wk and 3 mo after surgery and the histological changes were evaluated under light microscope and electron microscope.
RESULTS: The animals survived after the operation with no evidence of peritonitis and sepsis. Severe adhesions were found between the graft and surrounding intestine. The grafts were completely absorbed within postoperative two or three months except one. Histological observation showed inflammation in the grafts with fibrinoid necroses, infiltration of a large amount of neutrophils and leukomonocytes, and the degree varied in different stages. The neointestine with well-formed structures was not observed in the study.
CONCLUSION: It is not suitable to use acellular dermal matrix alone as a scaffold for the intestinal elongation in animal models.
Acellular dermal matrix; Intestine; Elongation
Visceral myopathy is a rare chronic disease affecting the peristalsis of the bowel causing intermittent pseudoobstruction. We report an atypical case of an eighty-nine-year-old woman with no prior history of abdominal illness who was admitted to our hospital with 2 days of increasing nausea, abdominal distension, and abdominal pain. On arrival at the hospital, she was critically ill. Abdominal X-ray showed distended loops of the colon and liquid levels resembling colonic obstruction. A subsequent abdominal CT scan confirmed the colonic obstruction. A suspicion of sigmoid volvulus was raised, that is why a barium enema was performed but no lower colonic obstruction could be confirmed. Acute laparotomy showed perforated cecum without intestinal obstruction. Postoperatively, the patient became septic which was fatal for the patient. Pathology gave the diagnosis visceral myopathy. It is very difficult to make the diagnosis clinically and radiologically since visceral myopathy mimics other more common gastrointestinal diseases. It is important to consider visceral myopathy as a possible diagnosis in cases with recurrent episodes of abdominal pain, vomiting, and abdominal distension, but without actual intestinal obstruction.
Sclerosing encapsulating peritonitis (SEP) is a rare but serious complication of abdominal surgery, recurrent peritonitis, and continuous ambulatory peritoneal dialysis with a high morbidity and mortality. The etiology of this condition is largely unknown. Diagnosis is usually established at laparotomy in patients with recurrent attacks of non-strangulating, small bowel obstruction. We report a case of a patient who presented with intestinal obstruction and who showed typical CT findings of SEP which was diagnosed pre-operatively on a CT scan and confirmed at surgery. The interest of this case lies in its rarity and difficult pre-operative diagnosis.
sclerosing encapsulating peritonitis; abdominal surgery; peritoneal dialysis
The presentation of two cases with tuberculous enteritis and tuberculous peritonitis respectively.
Patients and methods: Cases 1
Α 53 year old immigrant male, with a past medical history of pulmonary tuberculosis and previous treatment, presented with anorexia, fatigue, intermittent abdominal pain, hoarseness and loss of weight during the past month. Chest radiography showed fibrotic scars and volume loss of the left upper lobe, while laryngoscopy revealed ulceration and oedema at the left aryepiglottic fold. On day 2 of his hospitalization in ENT clinic, patient presented acute abdominal pain, requiring surgical intervention. Surgical findings were a perforation of the small intestine, an edematous and friable mucosa and a widespread of ulcers. Bowel resection and end-to-end anastomosis were performed. Pathology results of the obtained biopsy samples from the small intestine and larynx revealed the presence of chronic caseating granuloma. Anti-tuberculous treatment with INH, RIF, PZ and EMB was administrated and patient improved gradually. Case 2. A 69 year old female with a medical history of end-stage renal disease treated with continuous ambulatory peritoneal dialysis, presented with fever, fatigue and abdominal pain during the past weeks. Chest radiography showed fibrotic scars of the upper lobes and CT of the abdomen was normal. The number of cells in peritoneal dialysis fluid was increased with a predominance of polymorphonuclear cells. An initial diagnosis of bacterial peritonitis was made and broad-spectrum antibiotics were administrated, without improvement. The cultures of the peritoneal fluid were negative for common bacteria. Tuberculin sensitivity test was positive. The Ziehl-Neelsen stain of the peritoneal fluid was positive for acid-fast bacilli and culture identified Mycobacterium Tuberculosis. Αnti-tuberculous treatment with INH, RIF, PZ and EMB was started and patient responded promptly with resolution of abdominal pain and remission of fever.
A high index of suspicion must be maintained for abdominal tuberculosis in high-risk for tuberculosis patients who present with abdominal symptoms.
Background and Objectives:
We present a case of small bowel volvulus around an endotack applied during total extraperitoneal laparoscopic hernia repair (TEP). This complication prompts reconsideration of the role of tacks during extraperitoneal laparoscopic hernia repairs.
We undertook a chart review and provide a case presentation with review of the literature.
A 66-year-old male with bilateral inguinal hernias underwent elective, bilateral, total extraperitoneal laparoscopic hernia repair. During dissection, a small peritoneal tear occurred. The tear was closed with a spiral tack. On postoperative day 22, the patient developed an acute abdomen. Exploratory laparotomy revealed a volvulus rotated around an adhesion to the spiral tack.
Volvulus can cause vascular compromise leading to bowel ischemia and necrosis. A tack resulting in adhesion and volvulus is an unusual, but serious, complication. Repair of a peritoneal tear during preperitoneal hernia repair is advocated to improve visualization obstructed by a pneumoperitonuem and decrease adhesions to the abdominal wall.
The use of blunt Endoloops or crimps may prove safer than tacks for repairing the peritoneum and placement in proximity to delicate or thin tissues. Additionally, careful placement of foreign bodies to ensure their stability and to minimize protrusion may decrease the risk of erosion of the hardware.
Laparoscopic surgery; Volvulus; Complications; Hernia
A patient with a fulminant amebic colitis coexisting with intestinal tuberculosis had a sudden onset of crampy abdominal pain, mucoid diarrhea, anorexia, fever and vomiting with signs of positive peritoneal irritation. Fulminant amebic colitis occurring together with intestinal tuberculosis is an uncommon event and may present an interesting patho-etiological relationship. The diagnosis was proven by histopathologic examination of resected specimen. Subtotal colectomy including segmental resection of ileum, about 80 cm in length, followed by exteriorization of both ends, was performed in an emergency basis. Despite all measures, the patient died on the sixth postoperative day. The exact relationship of fulminant amebic colitis and intestinal tuberculosis is speculative but the possibility of a cause and effect relationship exists. Fulminant amebic colitis may readily be confused with other types of inflammatory bowel disease, such as idiopathic ulcerative colitis, Crohn's disease, perforated diverticulitis and appendicitis with perforation. This report draws attention to the resurgence of tuberculosis and amebiasis in Korea, and the need for the high degree of caution required to detect it.
Malrotation of the midgut is generally regarded as paediatric pathology with the majority of patients presenting in childhood. The diagnosis is rare in adults, which sometimes leads to delay in diagnosis and treatment. A high index of suspicion is therefore required when dealing with patients of any age group with abdominal symptoms. We present a case of a 55-year old man who presented with an acute abdomen with preoperative computed tomography scan and operative findings confirming midgut rotation. The duodenum, small bowel, caecum and appendix were abnormally located, with the presence of classical Ladd's bands. There was no evidence of intestinal volvulus. The patient underwent an emergency laparotomy with an uneventful postoperative recovery.
A review of the literature is presented to highlight the rarity of intestinal malrotation and the controversies surrounding its management in the adult population.
Midgut malrotation; acute abdomen; Ladd's bands; computed tomography scan; laparoscopy
Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life-threatening and require early surgical treatment. Small bowel perforation secondary to jejunal diverticulitis by enteroliths is rare. The aim of this study was to report a case of small intestinal perforation caused by a large jejunal enterolith. An 86-year-old woman was admitted with signs of diffuse peritonitis. After initial fluid recovery the patient underwent emergency laparotomy. The surgery showed that she had small bowel diverticular disease, mainly localized in the proximal jejunum. The peritonitis was due to intestinal perforation caused by an enterolith 12 cm in length, localized inside one of these diverticula. The intestinal segment containing the perforated diverticulum with the enterolith was removed and an end-to-end anastomosis was done to reconstruct the intestinal transit. The patient recovered well and was discharged from hospital on the 5th postoperative day. There were no signs of abdominal pain 1 year after the surgical procedure. Although jejunal diverticular disease with its complications, such as formation of enteroliths, is difficult to suspect in patients with peritonitis, it should be considered as a possible source of abdominal infection in the elderly patient when more common diagnoses have been excluded.
Diverticulum; Intestines; Lithiasis; Intestinal perforation; Diverticulitis
In irritable bowel syndrome (IBS), disturbance of bowel motility is associated with infiltration of inflammatory mediators and cytokines into the intestine, such as neutrophils, myeloperoxidase (MPO), tumor necrosis factor alfa (TNF-α), and lipid peroxide.
Regarding promising anti-inflammatory and anti-oxidative effects of Hypericum perforatum (HP) extract, besides its anti-depressant effect, this study was designed to evaluate the effects of HP in an experimental model of IBS.
Settings and Design:
IBS was induced by a 5-day restraint stress in rats. The HP extract was administered by gavage in doses of 150, 300, and 450 mg/kg for 26 days. Fluoxetine and loperamide were used as positive controls. Gastric emptying and small bowel and colon transit, besides the levels of TNF-α, MPO, lipid peroxidation, and antioxidant power, were determined in colon homogenates.
Statistical Analysis Used:
Data were analyzed by one-way ANOVA followed by Tukey's post hoc test for multiple comparisons.
A significant reduction in small bowel and colonic transit (450 mg/kg), TNF-α, MPO, and lipid peroxidation and an increase in antioxidant power in all HP-treated groups (150, 300, and 450 mg/kg) were seen as compared with the control group. Gastric emptying did not alter significantly when compared with the control group. Treatment with loperamide (10 mg/kg) significantly inhibited gastric emptying and small bowel and colonic transit, while flouxetine (10 mg/kg) decreased gastric emptying, TNF-α, MPO, and lipid peroxidation and increased the antioxidant power of the samples in comparison with the control group.
HP diminished the recruitment of inflammatory cells and TNF-α following restraint stress not in a dose-dependent manner, possibly via inhibition of MPO activity and increasing colon antioxidant power, without any difference with fluoxetine. The HP extract inhibits small bowel and colonic transit acceleration like loperamide but has minimal effect on gastric emptying.
Hypericum perforatum; irritable bowel syndrome; oxidative stress
We report a case of an 84-year-old male patient with primary small intestinal angiosarcoma. The patient initially presented with anemia and melena. Consecutive endoscopy revealed no signs of upper or lower active gastrointestinal bleeding. The patient had been diagnosed 3 years previously with an aortic dilation, which was treated with a stent. Computed tomography suggested an aorto-intestinal fistula as the cause of the intestinal bleeding, leading to operative stent explantation and aortic replacement. However, an aorto-intestinal fistula was not found, and the intestinal bleeding did not arrest postoperatively. The constant need for blood transfusions made an exploratory laparotomy imperative, which showed multiple bleeding sites, predominately in the jejunal wall. A distal loop jejunostomy was conducted to contain the small intestinal bleeding and a segmental resection for histological evaluation was performed. The histological analysis revealed a less-differentiated tumor with characteristic CD31, cytokeratin, and vimentin expression, which led to the diagnosis of small intestinal angiosarcoma. Consequently, the infiltrated part of the jejunum was successfully resected in a subsequent operation, and adjuvant chemotherapy with paclitaxel was planned. Angiosarcoma of the small intestine is an extremely rare malignant neoplasm that presents with bleeding and high mortality. Early diagnosis and treatment are essential to improve outcome. A small intestinal angiosarcoma is a challenging diagnosis to make because of its rarity, nonspecific symptoms of altered intestinal function, nonspecific abdominal pain, severe melena, and acute abdominal signs. Therefore, a quick clinical and histological diagnosis and decisive measures including surgery and adjuvant chemotherapy should be the aim.
Gastrointestinal bleeding; Small intestine; Angiosarcoma; Small intestinal neoplasm
This study aimed to examine extended postoperative ileus and its risk factors in patients who have undergone abdominal surgery, and discuss the techniques of prevention and management thereof the light of related risk factors connected with our study.
This prospective study involved 103 patients who had undergone abdominal surgery. The effects of age, gender, diagnosis, surgical operation conducted, excessive small intestine manipulation, opioid analgesic usage time, and systemic inflammation on the time required for the restoration of intestinal motility were investigated. The parameters were investigated prospectively.
Regarding the factors that affected the restoration of gastrointestinal motility, resection operation type, longer operation period, longer opioid analgesics use period, longer nasogastric catheter use period, and the presence of systemic inflammation were shown to retard bowel motility for 3 days or more.
Our study confirmed that unnecessary analgesics use in patients with pain tolerance with non-steroid anti-inflammatory drugs, excessive small bowel manipulation, prolonged nasogastric catheter use have a direct negative effect on gastrointestinal motility. Considering that an exact treatment for postoperative ileus has not yet been established, and in light of the risk factors mentioned above, we regard that prevention of postoperative ileus is the most effective way of coping with intestinal dysmotility.
Ileus; Abdominal surgery; Intestinal complications