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1.  A case report of small bowel obstruction secondary to congenital peritoneal band in adult 
Highlights
•A case of small bowel obstruction due to peritoneal congenital band is presented.•Computed tomography is effective for diagnosis.•The laparoscopic approach for surgical treatment should be intended initially for its feasibility and benefits.•A quick management is necessary to avoid intestinal necrosis.
Introduction
Small bowel obstruction (SBO) is common in adult surgical procedures, mainly due to postoperative adhesions. Acute SBO in adults without history of abdominal surgery, trauma or clinical hernia is less common and has various etiologies. Congenital band is an extremely rare cause.
Presentation of case
A 56-year-old man was admitted to our hospital with a two-day history of abdominal pain and bilious vomiting. He had no history of abdominal surgery or any other medical problems. A contrast-enhanced CT of the abdomen showed a distention of small bowel loops with transition point in the right hypochondrium. Distended loops of small bowel were located in the left side of the abdomen, whereas collapsed loops was located in the right side. The normal bowel wall enhancement was preserved. After initial treatment with intravenous fluid and nasogastric suction, he was operated. At laparoscopy a band obstructing the ileum was clearly observed. This anomalous band extending from gallbladder to transverse mesocolon caused a small window leading to internal herniation of the small bowel and obstruction. The band was coagulated and divided. Postoperative outcome was uneventful and the patient was discharged on the second postoperative day. There was no recurrence of symptoms on subsequent follow-up.
Discussion
Congenital peritoneal bands are not frequently encountered in surgical practice and these bands are often difficult to classify and define. Diagnosis of acute intestinal obstruction due to CPB must be included in the differential diagnosis in any patient with no history of abdominal surgery, trauma, clinical hernia, inflammatory bowel disease or peritoneal tuberculosis.
Conclusion
Despite technological advances in radiology preoperative diagnosis remains difficult, however the diagnosis of SBO due to CPB must be considered in any patient with no history of abdominal surgery, Trauma or clinical hernia consulting for occlusive syndrome. The laparoscopic approach should be intended initially for its feasibility and benefits.
doi:10.1016/j.ijscr.2016.11.007
PMCID: PMC5128824  PMID: 27898351
Small bowel obstruction; Congenital band; Laparoscopy
2.  Post traumatic acquired multiple mesenteric defects 
INTRODUCTION
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.
DISCUSSION
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
CONCLUSION
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.
doi:10.1016/j.ijscr.2013.03.028
PMCID: PMC3650254  PMID: 23624198
Mesenteric defect; Internal hernia; Intestinal obstruction
3.  Seatbelt sign in a case of blunt abdominal trauma; what lies beneath it? 
BMC Surgery  2015;15:121.
Background
The reported incidence of hollow viscus injuries (HVI) in blunt trauma patients is approximately 1 %. The most common site of injury to the intestine in blunt abdominal trauma (BAT) is the small bowel followed by colon, with mesenteric injuries occurring three times more commonly than bowel injuries. Isolated colon injury is a rarely encountered condition. Clinical assessment alone in patients with suspected intestinal or mesenteric injury after blunt trauma is associated with unacceptable diagnostic delays.
Case presentation
This is a case of a 31-year-old man, admitted to the emergency department after being the restrained driver, involved in a car accident. After initial resuscitation, focused assessment with sonography for trauma examination (FAST) was performed revealing a subhepatic mass, suspicious for intraperitoneal hematoma. A computed tomography scan (CT) that followed showed a hematoma of the mesocolon of the ascending colon with active extravasation of intravenous contrast material. An exploratory laparotomy was performed, hemoperitomeum was evacuated, and a subserosal hematoma of the cecum and ascending colon with areas of totally disrupted serosal wall was found. Hematoma of the adjacent mesocolon expanding to the root of mesenteric vessels was also noted. A right hemicolectomy along with primary ileocolonic anastomosis was performed. Patient’s recovery progressed uneventfully.
Conclusion
Identifying an isolated traumatic injury to the bowel or mesentery after BAT can be a clinical challenge because of its subtle and nonspecific clinical findings; meeting that challenge may eventually lead to a delay in diagnosis and treatment with subsequent increase in associated morbidity and mortality. Isolated colon injury is a rare finding after blunt trauma and usually accompanied by other intra-abdominal organ injuries. Abdominal ‘seatbelt’ sign, ecchymosis of the abdominal wall, increasing abdominal pain and distension are all associated with HVI. However, the accuracy of these findings remains low. Diagnostic peritoneal lavage, ultrasound, CT and diagnostic laparoscopy are used to evaluate BAT. Although CT has become the main diagnostic tool for this type of injuries, there are few pathognomonic signs of colon injury on CT. Given the potential for devastating outcomes, prompt diagnosis and treatment is necessary and high clinical suspicion is required.
doi:10.1186/s12893-015-0108-z
PMCID: PMC4628356  PMID: 26518620
Blunt abdominal trauma; Colon injury; Hollow viscus injury
4.  Postoperative pneumatosis intestinalis (PI) and portal venous gas (PVG) may indicate bowel necrosis: a 52-case study 
BMC Surgery  2016;16:42.
Background
The significance of pneumatosis intestinalis (PI) and portal venous gas (PVG) is controversial. This retrospective study evaluated the risk factors for bowel necrosis in patients with PI and/or PVG.
Methods
Between 2002 and 2015, 52 patients were diagnosed with PI and/or PVG and were included in this study. The patients were classified according to the presence or absence of bowel necrosis in surgical findings or at autopsy. Patient characteristics and clinical findings related to bowel necrosis were investigated.
Results
Bowel necrosis was diagnosed in 17 (32.7 %) patients. Amongst these 17, 10 patients received salvage surgical intervention, and seven of those diagnosed with bowel necrosis survived after the operation. The remaining 35 patients received conservative treatment with or without exploratory laparotomy. Between patients with and without bowel necrosis, laboratory data revealed significant differences in the levels of C-reactive protein (P = 0.0038), creatinine (P = 0.0054), and lactate (P = 0.045); clinical findings showed differences in abdominal pain (P = 0.019) and peritoneal irritation signs (P = 0.016); computed tomography detected ascites (P = 0.011) and changes of bowel wall enhancement (P = 0.03) that were significantly higher in patients with bowel necrosis. The rate of PI and/or PVG detected in patients postoperatively was significantly higher in patients with bowel necrosis (P < 0.0001). Multivariate analysis showed that bowel necrosis was significantly more likely when PI or PVG was detected in postoperative patients than in patients who had not had surgery (P = 0.003).
Conclusions
PI and/or PVG, alone, are not automatically indicative of bowel necrosis. However, when these conditions occur postoperatively, they indicate bowel necrosis requiring reoperation.
doi:10.1186/s12893-016-0158-x
PMCID: PMC4938969  PMID: 27391125
Bowel necrosis; Pneumatosis intestinalis; Hepatic portal venous gas
5.  Treatment of delayed jejunal perforation after irreducible femoral hernia repair with open abdomen management and delayed abdominal closure with skin flap approximation 
Highlights
•Delayed bowel perforation may develop after irreducible femoral hernia surgery especially in elderly patients with comorbid disease.•Open abdomen management with negative pressure therapy and delayed open abdomen closure with skin flap approximation is optimum treatment modality for hemodynamically instable patient.
Introduction
We show the management of a delayed jejunal perforation, after irreducible femoral hernia operation with the help of negative pressure therapy (NPT) and delayed abdominal closure (DAC) with skin flap approximation in an elderly woman for the first time in the literature.
Presentation of case
A 76 year-old woman was admitted to the emergency department with irreducible femoral hernia and ileus. After examining the femoral hernia sac and noting the presence of viable intestine within the hernia sac, a femoral hernia repair with mesh was performed. At postoperative day 1 she started to defecate and oral intake was started. The patient was discharged on postoperative day 3. On postoperative day 8, she was re-admitted to the emergency department with septic shock. The patient underwent reoperation. Septic abdomen and delayed perforation from strangulated part of the jejunum were seen. A jejunostomy was opened and patient was treated with open abdomen management and delayed abdominal closure with skin flap. The ostomy was closed 4 months later.
Discussion
The exact mechanism of delayed presentation of small bowel perforation remains controversial. Delayed intestinal perforation has rarely been reported after blunt abdominal trauma (BAT), conductive burn injuries of the bowel with cautery, or necrosis of strangulated bowel in a hernia sac. Open abdomen (OA) management is a life-saving and challenging strategy in severe generalized peritonitis.
Conclusion
Delayed bowel perforation may develop after irreducible femoral hernia surgery. OA management with NPT and DAC with skin flap approximation are optimal treatment modalities for the hemodynamically instable patient.
doi:10.1016/j.ijscr.2015.09.008
PMCID: PMC4643348  PMID: 26408935
Delayed bowel perforation; Open abdomen; Delated abdominal closure; Femoral hernia
6.  Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy 
Background
Hyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy.
Materials and methods
All patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes × 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed.
Results
Eight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula.
Conclusion
The use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.
doi:10.1186/1477-7819-8-72
PMCID: PMC2931502  PMID: 20727181
7.  Intestinal Injury from Blunt Abdominal Trauma: A Study of 47 Cases 
Oman Medical Journal  2009;24(4):256-259.
Objectives
To determine the cause, presentation, anatomical distribution, diagnostic method, management and outcome of intestinal injuries from blunt abdominal trauma.
Methods
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.
Results
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.
Conclusion
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.
doi:10.5001/omj.2009.52
PMCID: PMC3243872  PMID: 22216378
8.  Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report 
BMC Surgery  2015;15:37.
Background
Hepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture.
Case presentation
A 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident.
Conclusion
While non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.
doi:10.1186/s12893-015-0028-y
PMCID: PMC4392740  PMID: 25885337
Non-occlusive mesenteric ischemia; Hepatic portal venous gas; Delayed stricture; Stenosis
9.  Laparotomy for blunt abdominal trauma-some uncommon indications 
Trauma laparotomy after blunt abdominal trauma is conventionally indicated for patients with features of hemodynamic instability and peritonitis to achieve control of hemorrhage and control of spillage. In addition, surgery is clearly indicated for the repair of posttraumatic diaphragmatic injury with herniation. Some other indications for laparotomy have been presented and discussed. Five patients with blunt abdominal injury who underwent laparotomy for nonroutine indications have been presented. These patients were hemodynamically stable and had no overt signs of peritonitis. Three patients had solid organ (spleen, kidney) infarction due to posttraumatic occlusion of the blood supply. One patient had mesenteric tear with internal herniation of bowel loops causing intestinal obstruction. One patient underwent surgery for traumatic abdominal wall hernia. In addition to standard indications for surgery in blunt abdominal trauma, laparotomy may be needed for vascular thrombosis of end arteries supplying solid organs, internal or external herniation through a mesenteric tear or anterior abdominal wall musculature, respectively.
doi:10.4103/0974-2700.173866
PMCID: PMC4766762  PMID: 26957824
Abdomen; blunt; indications; internal hernia; laparotomy; trauma; traumatic abdominal wall hernia; vascular injury
10.  Peritonitis secondary to traumatic duodenal laceration in the presence of a large pancreatic pseudocyst: a case report 
Introduction
A pancreatic pseudocyst is a common sequela of severe acute pancreatitis. Commonly, it presents with abdominal pain and a mass in the epigastrium several weeks after the acute episode and can be managed conservatively, endoscopically or surgically. We report a patient with a pancreatic pseudocyst awaiting endoscopic therapy who developed a life-threatening complication following a rather innocuous trauma to the abdomen.
Case presentation
A 23-year-old Asian male student presented as an emergency with an acute abdomen a week after a minor trauma to his upper abdomen. The injury occurred when he was innocently punched in the abdomen by a friend. He experienced only moderate discomfort briefly at the time. His past medical history included coeliac disease and an admission four months previously with severe acute pancreatitis. He was hospitalized for 15 days; his pancreatitis was thought to be due to alcohol binge drinking on weekends. Ultrasound scanning showed no evidence of gallstone disease. Five days after the trauma, he became anorexic, lethargic and feverish and started vomiting bilious content. Seven days post-trauma, he presented to our emergency department with severe abdominal pain. An emergency laparotomy was performed where a transverse linear duodenal laceration was found at the junction of the first and second part of his duodenum, with generalized peritonitis. His stomach and duodenum were stretched over a large pancreatic pseudocyst posterior to his stomach. It was postulated that an incomplete duodenal injury (possibly a serosal tear) occurred following the initial minor trauma, which was followed by local tissue necrosis at the injury site resulting in a delayed presentation of generalized peritonitis.
Conclusion
This is the first reported case of a traumatic duodenal laceration following minor blunt trauma in the presence of a large pancreatic pseudocyst. Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in a significant duodenal injury. In the presence of a large pseudocyst, however, the stretching of the duodenum over the pseudocyst had probably predisposed the duodenum to this injury. Patients awaiting therapeutic interventions for their pancreatic pseudocysts should be warned about this unusual but life-threatening risk following minor blunt abdominal trauma.
doi:10.1186/1752-1947-5-528
PMCID: PMC3215995  PMID: 22029762
11.  Perforation of small bowel caused by Schistosoma japonicum: A case report 
A 67-year-old man from Jingzhou was admitted to the First Hospital Affiliated to Yangtze University in July 2013 with sudden onset of abdominal pain with dizziness for 12 h. The patient had sign of peritoneal irritation. Ultrasonography of the abdomen and pelvis showed hepatic fibrosis due to schistosomiasis. Computed tomography showed free gas in the peritoneal cavity. Plain abdominal radiography showed bilateral subdiaphragmatic accumulation of gas, perforation of the viscus, and radio-opacity in the left renal area. The patient underwent emergency exploratory laparotomy. At laparotomy, a moderate amount of muddy yellow pus was found in the intra-abdominal cavity. At the junction of the jejunum and ileum, about 250 cm from Treitz’s ligament, there was an about 10-cm length of inflamed small bowel with perforation (3 mm in diameter) along the mesenteric border at the middle of the lesion. The patient underwent resection of the affected intestinal segment, along with end-to-end intestinal anastomosis. Histopathological examination revealed mucosal necrosis and hemorrhage with a large number of infiltrating eosinophils and neutrophils, and acute submucosal inflammation with a large number of infiltrating eosinophils and neutrophils associated with Schistosoma japonicum (S. japonicum) eggs. No intravascular adult parasite was found. Postoperatively, the patient was treated with praziquantel (30 mg/kg daily) for 4 d. The patient progressed well. To the best of our knowledge, this is the first case of small bowel perforation associated with eggs of S. japonicum.
doi:10.3748/wjg.v21.i9.2862
PMCID: PMC4351245  PMID: 25759563
Schistosoma japonicum; Intestinal perforation; Small bowel
12.  Ischemic Necrosis of Small Bowel Following Laparoscopic Surgery 
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.
Methods:
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.
Results:
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).
Discussion:
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.
Conclusion:
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.
PMCID: PMC3015534  PMID: 15119662
Small bowel ischemia; Pneumoperitoneum
13.  Aberrant Mucin Assembly in Mice Causes Endoplasmic Reticulum Stress and Spontaneous Inflammation Resembling Ulcerative Colitis 
PLoS Medicine  2008;5(3):e54.
Background
MUC2 mucin produced by intestinal goblet cells is the major component of the intestinal mucus barrier. The inflammatory bowel disease ulcerative colitis is characterized by depleted goblet cells and a reduced mucus layer, but the aetiology remains obscure. In this study we used random mutagenesis to produce two murine models of inflammatory bowel disease, characterised the basis and nature of the inflammation in these mice, and compared the pathology with human ulcerative colitis.
Methods and Findings
By murine N-ethyl-N-nitrosourea mutagenesis we identified two distinct noncomplementing missense mutations in Muc2 causing an ulcerative colitis-like phenotype. 100% of mice of both strains developed mild spontaneous distal intestinal inflammation by 6 wk (histological colitis scores versus wild-type mice, p < 0.01) and chronic diarrhoea. Monitoring over 300 mice of each strain demonstrated that 25% and 40% of each strain, respectively, developed severe clinical signs of colitis by age 1 y. Mutant mice showed aberrant Muc2 biosynthesis, less stored mucin in goblet cells, a diminished mucus barrier, and increased susceptibility to colitis induced by a luminal toxin. Enhanced local production of IL-1β, TNF-α, and IFN-γ was seen in the distal colon, and intestinal permeability increased 2-fold. The number of leukocytes within mesenteric lymph nodes increased 5-fold and leukocytes cultured in vitro produced more Th1 and Th2 cytokines (IFN-γ, TNF-α, and IL-13). This pathology was accompanied by accumulation of the Muc2 precursor and ultrastructural and biochemical evidence of endoplasmic reticulum (ER) stress in goblet cells, activation of the unfolded protein response, and altered intestinal expression of genes involved in ER stress, inflammation, apoptosis, and wound repair. Expression of mutated Muc2 oligomerisation domains in vitro demonstrated that aberrant Muc2 oligomerisation underlies the ER stress. In human ulcerative colitis we demonstrate similar accumulation of nonglycosylated MUC2 precursor in goblet cells together with ultrastructural and biochemical evidence of ER stress even in noninflamed intestinal tissue. Although our study demonstrates that mucin misfolding and ER stress initiate colitis in mice, it does not ascertain the genetic or environmental drivers of ER stress in human colitis.
Conclusions
Characterisation of the mouse models we created and comparison with human disease suggest that ER stress-related mucin depletion could be a fundamental component of the pathogenesis of human colitis and that clinical studies combining genetics, ER stress-related pathology and relevant environmental epidemiology are warranted.
Michael McGuckin and colleagues identify two mutations that cause aberrant mucin oligomerization in mice. The resulting phenotype, including endoplasmic reticulum stress, resembles clinical and pathologic features of human ulcerative colitis.
Editors' Summary
Background.
Inflammatory bowel diseases (IBD) are common disorders in which parts of the digestive tract become inflamed. The two main types of IBD are Crohn's disease, which mainly affects the small bowel, and ulcerative colitis (UC), which mainly affects the large bowel (colon). Both types tend to run in families and usually develop between 15 and 35 years old. Their symptoms include diarrhea, abdominal cramps, and unintentional weight loss. These symptoms can vary in severity, can be chronic (persistent) or intermittent, and may start gradually or suddenly. There is no cure for IBD (except removal of the affected part of the digestive tract), but drugs that modulate the immune system (for example, corticosteroids) or that inhibit “proinflammatory cytokines” (proteins made by the immune system that stimulate inflammation) can sometimes help.
Why Was This Study Done?
Although the clinical and pathological (disease-associated) features of Crohn's disease and UC are somewhat different, both disorders are probably caused by an immune system imbalance. Normally, the immune system protects the body from potentially harmful microbes in the gut but does not react to the many harmless bacteria that live there or to the food that passes along the digestive tract. In IBD, the immune system becomes overactive for unknown reasons, and lymphocytes (immune system cells) accumulate in the lining of the bowel and cause inflammation. In this study, the researchers use a technique called random mutagenesis (the random introduction of small changes, called mutations, into the genes of an organism using a chemical that damages DNA) to develop two mouse models that resemble human UC and that throw new light on to how this disorder develops.
What Did the Researchers Do and Find?
The researchers establish two mutant mouse strains—Winnie and Eeyore mice—that develop mild spontaneous inflammation of the colon and chronic diarrhea and that have more proinflammatory cytokines and more lymphocytes in their colons than normal mice. 25% and 40% of the Winnie and Eeyore mice, respectively, have severe clinical signs of colitis by 1 year of age. Both strains have a mutation in the Muc2 gene, which codes for MUC2 mucin, the main protein in mucus. This viscous substance (which coats the inside of the intestine) is produced by and stored in intestinal “goblet” cells. Mucus helps to maintain the intestine's immunological balance but is depleted in UC. The researchers show that the manufacture and assembly of Muc2 molecules is abnormal in Winnie and Eeyore mice, that less mucin is stored in their goblet cells than in normal mice, and that their intestinal mucus barrier is reduced. In addition, an incompletely assembled version of the molecule, called Muc2 precursor, accumulates in the endoplasmic reticulum (ER; the cellular apparatus that prepares newly manufactured proteins for release) of goblet cells, leading to overload with abnormal protein and causing a state of cellular distress known as the “ER stress response.” Finally, the researchers report that MUC2 precursor also accumulates in the goblet cells of people with UC and that even the noninflamed intestinal tissue of these patients shows signs of ER stress.
What Do These Findings Mean?
These findings indicate that mucin abnormalities and ER stress can initiate colitis in mice. Results from animal studies do not always reflect what happens in people, but these findings, together with those from the small study in humans, suggest that ER stress-related mucin depletion could be a component in the development of human colitis. The results do not identify the genetic changes and/or environmental factors that might trigger ER stress in human colitis, but suggest that once initiated, ER stress might interfere with MUC2 production, which would lead to a diminished mucus barrier, expose the lining of the intestine to more toxins and foreign substances, and trigger local mucosal inflammation. The release of inflammatory cytokines would then damage the intestine's lining and exacerbate ER stress, thus setting up a cycle of intestinal damage and inflammation. Clinical studies to look for genetic changes and environmental factors capable of triggering ER stress and for ER-stress related changes in human UC should now be undertaken to test this hypothesis.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050054.
The MedlinePlus Encyclopedia has pages on Crohn's disease and on ulcerative colitis (in English and Spanish)
The US National Institute of Diabetes and Digestive and Kidney Diseases provides information on Crohn's disease and ulcerative colitis
Information and support for patients with inflammatory bowel disease and their caregivers is provided by the Crohn's and Colitis Foundation of America and by the UK National Association for Colitis and Crohn's Disease
Wikipedia has pages on mucins and on mucus (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.0050054
PMCID: PMC2270292  PMID: 18318598
14.  Traumatic rupture of a type IVa choledochal cyst in an adult male 
Choledochal cyst (CC) is a rare, congenital anomaly of the bile ducts. We describe a 26-year-old male patient who was transferred to our hospital with a reported traumatic rupture of cystic liver lesions following a fall. At the time of injury, the patient experienced severe abdominal pain. He was found to have peritonitis and abdominal hemorrhage, which is quite rare. Laparotomy revealed 3000 mL fluid consisting of a mixture of blood, bile and inflammatory effusion in the peritoneal cavity. The liver, gallbladder, spleen, stomach, duodenum, small intestine, and colon appeared normal. A large cystic mass was discovered near the porta hepatis. This mass, which connected to the hepatic bifurcation and gallbladder had a 5 cm rupture in the right wall with active arterial bleeding. Abdominal computed tomography (CT) and emergency laparotomy revealed rupture of a huge type IVa CC. The patient was successfully managed by primary cyst excision, cholecystectomy, and Roux-en-Y end-to-side hepaticojejunostomy reconstruction. The postoperative course was uneventful and the patient was discharged on the 12th day of hospitalization. Four weeks after surgery, abdominal CT scan showed pneumatosis in the intrahepatic bile duct, and intrahepatic dilatation which decreased following adequate biliary drainage. The patient has remained well in the close follow-up period for 9 mo.
doi:10.3748/wjg.v19.i24.3911
PMCID: PMC3699050  PMID: 23840134
Biliary tract; Choledochal cyst; Trauma; Rupture; Peritonitis; Hemorrhage
15.  Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden 
Background
Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital.
Methods
This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009.
Results
The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days.
Conclusions
Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals.
doi:10.1186/s13049-014-0048-0
PMCID: PMC4237946  PMID: 25124882
Abdominal injuries; Low trauma volume hospital; Non-operative management
16.  Do Patients with Penetrating Abdominal Stab Wounds Require Laparotomy? 
Archives of Trauma Research  2013;2(1):21-25.
Background
The optimal management of hemodynamically stable asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe cost-effective manner. Common evaluation strategies are local wound exploration (LWE), diagnostic peritoneal lavage (DPL), serial clinical assessment (SCAs) and computed tomography (CT) imaging. Making a decision about the right time to operate on a patient with a penetrating abdominal stab wound, especially those who have visceral evisceration, is a continuing challenge.
Objectives
Until the year 2010, our strategy was emergency laparotomy in patients with penetrating anterior fascia and those with visceral evisceration. This survey was conducted towards evaluating the results of emergency laparotomy. So, better management can be done in patients with penetrating abdominal stab wounds.
Patients and Methods
This retrospective cross-sectional study was performed on patients with abdominal penetrating trauma who referred to Al- Zahra hospital in Isfahan, Iran from October 2000 to October 2010. It should be noted that patients with abdominal blunt trauma, patients under 14 years old, those with lateral abdomen penetrating trauma and patients who had unstable hemodynamic status were excluded from the study. Medical records of patients were reviewed and demographic and clinical data were collected for all patients including: age, sex, mechanism of trauma and the results of LWE and laparotomy. Data were analyzed with PASW v.20 software. All data were expressed as mean ± SD. The distribution of nominal variables was compared using the Chi-squared test. Also, diagnostic index for LWE were calculated. A two-sided P value less than 0.05 was considered to be statistically significant.
Results
During the 10 year period of the study, 1100 consecutive patients with stab wounds were admitted to Al-Zahra hospital Isfahan, Iran. In total, about 150 cases had penetrating traumas in the anterior abdomen area. Sixty-three (42%) patients were operated immediately due to shock, visceral evisceration or aspiration of blood via a nasogastric tube on admission. Organ injury was seen in 78% of patients with visceral evisceration. Among these 87 cases, 29 patients’ (33.3%) anterior fascia was not penetrated in LWE. So, they were observed for several hours and discharged from the hospital without surgery. While for the remaining 58 patients (66.6%), whose LWE detected penetration of anterior abdominal fascia, laparotomy was performed which showed visceral injuries in 11 (18%) cases.
Conclusions
All in all, 82 percent of laparotomies in patients with penetrated anterior abdominal fascia without visceral evisceration, who had no signs of peritoneal irritation, were negative. So, we recommended further evaluation in these patients. However, visceral evisceration is an indication for exploratory laparotomy, since in our study; the majority of patients had organ damages.
doi:10.5812/atr.6617
PMCID: PMC3876513  PMID: 24396785
Anterior Abdominal Stab Wound; Patients; Urgent Laparotomy
17.  SMALL INTESTINAL OBSTRUCTION FROM PERITONEAL ADHESIONS IN CHILDREN SMALL INTESTINAL OBSTRUCTION FROM PERITONEAL ADHESIONS IN CHILDREN  
Abstract
Purpose: The purpose of this study was to assess the incidence of peritoneal adhesions leading to small intestinal obstruction after laparotomy in children in a tertiary paediatric surgical centre.
Methods: A retrospective review of 430 children aged <15 years who had trans-abdominal procedures over a 7 year period.
Results: Four hundred and fifty nine abdominal procedures were performed in 430 children during the study period. The follow up period ranged from 4 months – 7 years (Median 33 months). 22 (4.8%) had intra-operative confirmation of small intestinal obstruction. Their ages ranged from 21 days – 14 years (median 7 years). Postoperative adhesions due to laparotomy for typhoid perforation were the commonest, occurring in 10 (45%). Children undergoing emergency laparotomy were more likely to develop post operative small intestinal obstruction compared to elective laparotomy (p<0.025). Six (27.3%) children had bowel gangrene at laparotomy requiring bowel resection and anastomosis. Post-operative small intestinal obstruction developed in 6 (27.3%). One child died due to sepsis from intestinal gangrene. Conclusion: Small bowel obstruction due to adhesions requiring operative intervention in children in our setting is not un-common. Bowel gangrene is a common complication of postoperative small intestinal obstruction in children in our setting and should be suspected to avoid serious postoperative mortality and morbidity.
PMCID: PMC4170251  PMID: 25452942
Adhesions; Intestinal obstruction; children
18.  Mechanical small bowel obstruction following a blunt abdominal trauma: A case report 
Annals of Medicine and Surgery  2015;4(4):338-340.
Introduction
Intestinal obstruction following abdominal trauma has previously been described. However, in most reported cases pathological finding was intestinal stenosis.
Presentation of the case
A 51-year-old male was admitted after a motor vehicle accident. Initial focused abdominal sonogram for trauma and enhanced computerized tomography were normal, however there was a fracture of the tibia. Three days later, he complained of abdominal pain, constipation, and vomiting. An exploratory laparotomy showed bleeding from the omentum and mechanical small bowel obstruction due to a fibrous band.
Discussion
The patient had prior abdominal surgery, but clinical and radiological findings indicate that the impact of the motor vehicle accident initiated his condition either by causing rotation of a bowel segment around the fibrous band, or by formation of a fibrous band secondary to minimal bleeding from the omentum.
Conclusion
High index of suspicion of intestinal obstruction is mandatory in trauma patients presenting with complaints of abdominal pain, vomiting, and constipation despite uneventful CT scan.
Highlights
•A 51-year old male with a history of previous abdominal surgery admitted after trauma.•The patient had an open tibia fracture but uneventful diagnostic imaging.•Explorative laparotomy 3 days after showed mechanical small bowel obstruction.•Fibrous adhesion's band can cause intestinal obstruction following abdominal trauma.•High index of suspicion in trauma patients with abdominal pain, vomiting and constipation.
doi:10.1016/j.amsu.2015.09.010
PMCID: PMC4600941  PMID: 26566436
Intestinal obstruction; Ileus; Abdominal trauma; Adhesions; Trauma CT
19.  Torsion of Meckel's diverticulum as a cause of small bowel obstruction: A case report 
Axial torsion and necrosis of Meckel’s diverticulum causing simultaneous mechanical small bowel obstruction are the rarest complications of this congenital anomaly. This kind of pathology has been reported only eleven times. Our case report presents this very unusual case of Meckel’s diverticulum. A 41-year-old man presented at the emergency department with complaints of crampy abdominal pain, nausea and retention of stool and gases. Clinical diagnosis was small bowel obstruction. Because the origin of obstruction was unknown, computer tomography was indicated. Computed tomography (CT)-scan revealed dilated small bowel loops with multiple air-fluid levels; the oral contrast medium had reached the jejunum and proximal parts of the ileum but not the distal small bowel loops or the large bowel; in the right mid-abdomen there was a 11 cm × 6.4 cm × 7.8 cm fluid containing cavity with thickened wall, which was considered a dilated bowel-loop or cyst or diverticulum. Initially the patient was treated conservatively. Because of persistent abdominal pain emergency laparotomy was indicated. Abdominal exploration revealed distended small bowel loops proximal to the obstruction, and a large (12 cm × 14 cm) Meckel’s diverticulum at the site of obstruction. Meckel’s diverticulum was axially rotated by 720°, which caused small bowel obstruction and diverticular necrosis. About 20 cm of the small bowel with Meckel’s diverticulum was resected. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day. We recommend CT-scan as the most useful diagnostic tool in bowel obstruction of unknown origin. In cases of Meckel’s diverticulum causing small bowel obstruction, prompt surgical treatment is indicated; delay in diagnosis and in adequate treatment may lead to bowel necrosis and peritonitis.
doi:10.4240/wjgs.v6.i10.204
PMCID: PMC4208045  PMID: 25346803
Meckel’s diverticulum; Axial torsion; Gangrene; Bowel obstruction; Emergency surgery
20.  Giant primary angiosarcoma of the small intestine showing severe sepsis 
World Journal of Gastroenterology : WJG  2014;20(43):16359-16363.
Primary malignant tumors of the small intestine are rare, comprising less than 2% of all gastrointestinal tumors. An 85-year-old woman was admitted with fever of 40  °C and marked abdominal distension. Her medical history was unremarkable, but blood examination showed elevated inflammatory markers. Abdominal computed tomography showed a giant tumor with central necrosis, extending from the epigastrium to the pelvic cavity. Giant gastrointestinal stromal tumor of the small intestine communicating with the gastrointestinal tract or with superimposed infection was suspected. Because no improvement occurred in response to antibiotics, surgery was performed. Laparotomy revealed giant hemorrhagic tumor adherent to the small intestine and occupying the peritoneal cavity. The giant tumor was a solid tumor weighing 3490 g, measuring 24 cm × 17.5 cm × 18 cm and showing marked necrosis. Histologically, the tumor comprised spindle-shaped cells with anaplastic large nuclei. Immunohistochemical studies showed tumor cells positive for vimentin, CD31, and factor VIII-related antigen, but negative for c-kit and CD34. Angiosarcoma was diagnosed. Although no postoperative complications occurred, the patient experienced enlargement of multiple metastatic tumors in the abdominal cavity and died 42 d postoperatively. The prognosis of small intestinal angiosarcoma is very poor, even after volume-reducing palliative surgery.
doi:10.3748/wjg.v20.i43.16359
PMCID: PMC4239530  PMID: 25473196
Angiosarcoma; Small intestine; Prognosis; Sepsis; Immunohistological marker
21.  Factors Affecting Morbidity in Solid Organ Injuries 
Disease Markers  2016;2016:6954758.
Background and Aim. The aim of this study was to investigate the effects of demographic characteristics, biochemical parameters, amount of blood transfusion, and trauma scores on morbidity in patients with solid organ injury following trauma. Material and Method. One hundred nine patients with solid organ injury due to abdominal trauma during January 2005 and October 2015 were examined retrospectively in the General Surgery Department of Dicle University Medical Faculty. Patients' age, gender, trauma interval time, vital status (heart rate, arterial tension, and respiratory rate), hematocrit (HCT) value, serum area aminotransferase (ALT) and aspartate aminotransferase (AST) values, presence of free abdominal fluid in USG, trauma mechanism, extra-abdominal system injuries, injured solid organs and their number, degree of injury in abdominal CT, number of blood transfusions, duration of hospital stay, time of operation (for those undergoing operation), trauma scores (ISS, RTS, Glasgow coma scale, and TRISS), and causes of morbidity and mortality were examined. In posttraumatic follow-up period, intra-abdominal hematoma infection, emboli, catheter infection, and deep vein thrombosis were monitored as factors of morbidity. Results. One hundred nine patients were followed up and treated due to isolated solid organ injury following abdominal trauma. There were 81 males (74.3%) and 28 females (25.7%), and the mean age was 37.6 ± 18.28 (15–78) years. When examining the mechanism of abdominal trauma in patients, the following results were obtained: 58 (53.3%) traffic accidents (22 out-vehicle and 36 in-vehicle), 27 (24.7%) falling from a height, 14 (12.9%) assaults, 5 (4.5%) sharp object injuries, and 5 (4.5%) gunshot injuries. When evaluating 69 liver injuries scaled by CT the following was detected: 14 (20.3%) of grade I, 32 (46.4%) of grade II, 22 (31.8%) of grade III, and 1 (1.5%) of grade IV. In 63 spleen injuries scaled by CT the following was present: grade I in 21 (33.3%), grade II in 27 (42.9%), grade III in 11 (17.5%), and grade IV in 4 (6.3%). The mean length of hospital stay after trauma was 6.46 days in the medically followed patients. This ratio was 8.13 days in 22 patients with morbidity and 5.98 days in 78 patients without morbidity. There was a morbidity in 22 (22%) patients medically followed after trauma. In this study, nonoperative treatment was observed to be performed safely in solid organ injuries after trauma in case of absence of hemodynamic stability and peritoneal irritation. It has been emphasized that injury of both liver and spleen (p < 0.01), high respiratory rate (p < 0.01), trauma scores (GKS, ISS, RTS) (p < 0.0001), and elevation of ALT AST values (p < 0.01) are stimulants for morbidity that may occur during follow-up. Conclusion. Medical follow-up can be considered in patients with high grade injuries similar to patients with low-grade solid organ injury after trauma. The injury of both liver and spleen, high respiratory rate, high GCS and ISS, low RTS, and elevation of ALT AST values were found to increase morbidity again in the follow-up of these patients.
doi:10.1155/2016/6954758
PMCID: PMC4916281  PMID: 27375316
22.  Isolated double gastric rupture caused by blunt abdominal trauma in an eighteen months old child: A case report 
Hippokratia  2008;12(1):50-52.
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.
PMCID: PMC2532966  PMID: 18923758
blunt abdominal trauma; gastric rupture; children
23.  Resuscitation with hydroxyethyl starch 130/0.4 attenuates intestinal injury in a rabbit model of sepsis 
Indian Journal of Pharmacology  2015;47(1):49-54.
Objective:
Improvement of mucosal barrier function and reduction of bacterial translocation are important in the management of sepsis. The mechanisms that underlie the protective effects of colloids on the intestinal mucosal barrier are unclear. The study aims to investigate the effect of fluid resuscitation with hydroxyethyl starch (HES) 130/0.4 against intestinal mucosal barrier dysfunction in a rabbit model of sepsis.
Materials and Methods:
Thirty healthy rabbits were randomly and equally divided into a sham-operated control, a sepsis model, or a sepsis + HES treatment group. The sepsis model and sepsis + HES treatment groups were subjected to a modified colon ascendens stent peritonitis (CASP) procedure to induce sepsis. Four hours after the CASP procedure, fluid resuscitation was performed with 6% HES 130/0.4. Arterial and superior mesenteric vein blood samples were collected 4 and 8 h after the CASP procedure for blood gas analysis and measuring tumor necrosis factor-α, interleukin-10, and D-lactate levels. The rabbits were euthanized 8 h after CASP, and sections of the small intestine were stained to evaluate histopathological changes.
Results:
Respiratory rate and blood pressure were stable during the resuscitation period. Fluid resuscitation with 6% HES 130/0.4 alleviated pathological changes in the abdominal cavity, improved blood gas parameters and inflammatory mediator levels, decreased plasma D-lactate levels, and reduced intestinal mucosal injury compared with the non-treated sepsis model.
Conclusions:
Fluid resuscitation with 6% HES 130/0.4 protects against intestinal mucosal barrier dysfunction in rabbits with sepsis, possibly via mechanisms associated with improving intestinal oxygen metabolism and reducing the release of inflammatory mediators.
doi:10.4103/0253-7613.150333
PMCID: PMC4375819  PMID: 25821311
HES 130/0.4; intestinal mucosal barrier; inflammatory mediators; resuscitation; sepsis
24.  Sclerosing mesenteritis affecting the small and the large intestine in a male patient with non-Hodgkin lymphoma: a case presentation and review of the literature 
Introduction
Sclerosing mesenteritis is a rare disease resembling a mesenteric tumour. We present here a case of sclerosing mesenteritis that affected both the large and the small intestine of the patient. Therapeutic and diagnostic issues are discussed.
Case presentation
A 62-year-old man with a history of non-Hodgkin lymphoma presented with fatigue, a palpable tender abdominal mass and clinical signs of progressing intestinal obstruction. The preoperative evaluation failed to prove recurrence of the lymphoma or any other definite diagnosis. A laparotomy was performed through a midline incision. The mesentery resembled a tumour-like thickened and fibrotic mass. Abundant, rigid intestinal loop adhesions were observed. Diffuse fibrotic infiltration of the ileum and of the sigmoid colon, which obviously affected the intestinal vascular supply, were identified. A right colectomy and partial sigmoidectomy were performed. Pathological evaluation revealed extensive myofibroblastic reaction of the mesentery with accompanying loci of fat necrosis and areas of inflammation. A diffuse fibrotic infiltration that focally showed a ground-glass appearance was observed. The post-operative course was complicated by respiratory insufficiency and infections and the patient died 2 months after the operation.
Conclusion
Sclerosing mesenteritis that affects both the small and the large intestine is extremely rare. The disease is characterized by myofibroblastic reaction, fat necrosis and diffuse fibrosis of the mesentery. Pathological confirmation may be required for definite diagnosis. If the disease is characterized by severe and diffuse fibrosis, then the application of surgical therapy may be problematic.
doi:10.1186/1752-1947-2-388
PMCID: PMC2615039  PMID: 19091063
25.  Evisceration of gallbladder at the site of a Pezzer drain: a case report 
Cases Journal  2009;2:8601.
Introduction
The drainage of abdominal cavity by means of tube drains is the oldest method. The herniation of gallbladder through the abdominal wall is very rare. Although there are studies informing evisceration of organs such as small intestines and ovary from drain site; at the literature scanning, no publication has been met with advising gallbladder evisceration from the Pezzer drain site so far.
Case presentation
We describe here the first case in the literature of gallbladder evisceration from the Pezzer drain site. A male case with a history of operated incarcerated right inguinal hernia presented with a surgical abdomen. With a diagnosis of intestinal ischemia, the patient underwent laparotomy. About 200 cc fluid with serous quality has been determined in the abdomen and aspirated. Patchy ischemia zones were observed in ileum, over serous face. No. 30 Pezzer’s drain was placed for the intention of drainage, extending from the right side of navel towards rectovesical area. After the drainage stopped patient was discharged from hospital with recovery on the 8th postoperative day. One day after the discharge, applied to another general surgery center, by complaining that the intestine protruded through an opening in its surrounding walls of the drain place and that has been gradually enlarged. During the operation it was determined that proximal 2/3 of gallbladder has been protruded to outside of abdomen. Cholecystectomy was performed, and patient recovery was uneventful.
Conclusions
Gallbladder herniation is a pathology requires emergency operation.
doi:10.4076/1757-1626-2-8601
PMCID: PMC2740142  PMID: 19830090

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