Primary Midgut Volvulus: An Unusual Case of a Young Adult Necessitating Extensive Bowel Resection.

Primary small bowel volvulus (SBV), commonly known as midgut volvulus, is an uncommon condition in which the small intestine rotates around its own mesenteric axis. This case report details the diagnostic and management challenges encountered in a rare presentation of primary SBV in a previously healthy 19-year-old male. Our patient presented with acute abdominal pain, vomiting, and signs of shock, prompting urgent medical attention. He was sent for exploratory laparotomy and underwent extensive resection of the gangrenous bowel. Diagnosis involved an abdominal computed tomography scan revealing the characteristic "whirl sign." According to the World Society of Emergency Medicine, surgical intervention should be done to address the SBV through resection of the gangrenous bowel segments. Despite efforts, the patient's prognosis remained guarded, necessitating ongoing supportive measures. This case highlights the complex challenges associated with primary SBV, emphasizing the need for continued research to enhance diagnostic precision and refine management strategies.

An Internal Hernia With Small Bowel Volvulus From an Inferior Vena Cava Filter Wire Strut: A Rare Cause of Acute Abdomen.

The use of inferior vena cava (IVC) filters has been increasingly prevalent. Although they are relatively safe with clear indications, they are not without complications. Late-onset complications include IVC filter migration, IVC wire fracture, wire strut penetration, and perforation of organs in its vicinity. In this report, we present the case of a patient with small bowel volvulus secondary to an IVC wire strut migration, causing tethering of the mesentery and vascular compromise to the small bowel.

Understanding CT imaging findings based on the underlying pathophysiology in patients with small bowel ischemia.

Because acute small bowel ischemia has a high mortality rate, it requires rapid intervention to avoid unfavorable outcomes. Computed tomography (CT) examination is important for the diagnosis of bowel ischemia. Acute small bowel ischemia can be the result of small bowel obstruction or mesenteric ischemia, including mesenteric arterial occlusion, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. The clinical significance of each CT finding is unique and depends on the underlying pathophysiology. This review describes the definition and mechanism(s) of bowel ischemia, reviews CT findings suggesting bowel ischemia, details factors involved in the development of small bowel ischemia, and presents CT findings with respect to the different factors based on the underlying pathophysiology. Such knowledge is needed for accurate treatment decisions.

Diabetic Ketoacidosis and Acute Mesenteric Ischemia in Adults: An Underreported Association.

Acute mesenteric ischemia (AMI) is a rapidly fatal abdominal process that has been associated with diabetic ketoacidosis (DKA). This association has been reported among pediatric patients but has rarely been reported in adult patients. This case series presents two adult patients who presented with DKA and were subsequently found to have AMI. The first case is that of a 60-year-old male with a history of insulin-dependent type II diabetes mellitus who had a presentation and laboratory values consistent with DKA. He developed hypovolemic shock and worsening acidosis, and computed tomography angiography (CTA) revealed superior mesenteric artery occlusion. The second case is that of a 41-year-old male with a history of type I diabetes mellitus who presented with DKA and had no improvement despite aggressive resuscitation with fluids and insulin therapy. Computed tomography (CT) imaging of the abdomen revealed pneumatosis of the small bowel, indicative of ischemia. Both patients underwent bowel resection in the operating room. Given the high mortality and morbidity of AMI, it is an important diagnosis to consider in patients with DKA who have unresolving acidosis.

Evaluation of Suspected Small Bowel Ischemia Using Contrast-Enhanced Ultrasound with Computed Tomography Fusion.

Small bowel ischemia can lead to fatal complications such as necrosis, perforation, and sepsis. Clinical examinations and laboratory tests are usually inconclusive in critically ill patients. The need for surgical exploration is decided based on imaging, examination, and clinical judgment. The decision to operate is time-critical and can be lifesaving, but surgical intervention has the potential to cause additional morbidity, especially in unstable patients. Contrast-enhanced computed tomography (CECT) is the study of choice in suspected small bowel ischemia but has poor specificity. Contrast-enhanced ultrasound (CEUS) provides real-time visualization of the bowel wall vascularity. In this case report, we used a CEUS with CT fusion examination to rule out small bowel ischemia in a critically ill patient with suspected closed loop small bowel obstruction on CECT and in whom surgical exploration would have not been well tolerated. The patient's condition later improved, and an abdominal CT showed no evidence of obstruction.

Comprehensive review of acute small bowel ischemia: CT imaging findings, pearls, and pitfalls.

Acute small bowel ischemia is a life-threatening condition with a high mortality rate due to its lack of specific symptoms and laboratory profile, which render difficulty in establishing early diagnosis. The etiology of acute small bowel ischemia includes occlusive forms (arterial embolism, arterial thrombosis, and venous thrombosis) and nonocclusive mesenteric ischemia, of which arterial causes are far more common than venous causes. CT, the mainstay of accurate diagnoses, allows the identification of the features of vascular abnormalities and intestinal ischemic injuries, and helps clinicians to restore intestinal blood flow. Without treatment, the prognosis for acute small bowel ischemia is poor. A high index of suspicion and familiarity with the CT spectral findings of bowel ischemia are required to ensure rapid recognition of this condition.

Small bowel obstruction and intestinal ischemia: emphasizing the role of MDCT in the management decision process.

The objective of this article is to assess the computed tomography (CT) findings of small bowel obstruction (SBO) complicated by ischemia. SBO is a frequent clinical entity characterized by high morbidity and mortality. The radiologic aim is not just to diagnose the obstruction itself but to rule out the presence of complications related to SBO. This is crucial for differentiating which patients can be safely treated non-operatively from the ones who may need an urgent surgical approach. The main complication of SBO is intestinal ischemia. In the emergency setting, CT imaging is the modality of choice for SBO because of its ability to assess the bowel wall, the supporting mesentery and peritoneal cavity all in one. On the other hand, the radiologist who documents an intestinal ischemia should think about SBO as possible cause. In this case, the main finding which helps the radiologist in the identification of SBO is the presence of multiple and packed valvulae conniventes in the dilated bowel wall and the "transition zone" that indicates the passage between compressed and decompressed small bowel, otherwise the localization of the obstruction cause. Once the site of obstruction has been recognized, the other issue is to assess the cause of obstruction, considering that the most common cause of SBO remains "unidentified" and related to intra-abdominal adhesions. After that, the following most important point is to rule out the presence of an ischemic bowel and mesenteric changes associated to SBO. CT signs of bowel ischemia include reduced or increased bowel wall enhancement, mesenteric edema or engorgement, fluid or free air in the peritoneal cavity. This condition usually leads to an urgent laparotomy and, in some cases, to a surgical resection.

Mesenteric ischemia in patients with COVID-19: an updated systematic review of abdominal CT findings in 75 patients.

BACKGROUND: Acute mesenteric ischemia (AMI) is a less common but devastating complication of COVID-19 disease. The aim of this systematic review was to assess the most common CT imaging features of AMI in COVID-19 and also provide an updated review of the literature on symptoms, treatment, histopathological and operative findings, and follow-up of these patients. METHODS: A systematic literature search of four databases: Pubmed, EMBASE, WHO database, and Google Scholar, was performed to identify all the articles which described abdominal CT imaging findings of AMI in COVID-19. RESULTS: A total of 47 studies comprising 75 patients were included in the final review. Small bowel ischemia (46.67%) was the most prevalent abdominal CT finding, followed by ischemic colitis (37.3%). Non-occlusive mesenteric ischemia (NOMI; 67.9%) indicating microvascular involvement was the most common pattern of bowel involvement. Bowel wall thickening/edema (50.9%) was more common than bowel hypoperfusion (20.7%). While ileum and colon both were equally involved bowel segments (32.07% each), SMA (24.9%), SMV (14.3%), and the spleen (12.5%) were the most commonly involved artery, vein, and solid organ, respectively. 50% of the patients receiving conservative/medical management died, highlighting high mortality without surgery. Findings on laparotomy and histopathology corroborated strikingly with CT imaging findings. CONCLUSION: In COVID-19 patients with AMI, small bowel ischemia is the most prevalent imaging diagnosis and NOMI is the most common pattern of bowel involvement. Contrast-enhanced CT is a powerful decision-making tool for prompt diagnosis of AMI in COVID-19, thereby potentially improving time to treat as well as clinical outcomes.

Intestinal ischemic manifestations of SARS-CoV-2: Results from the ABDOCOVID multicentre study.

BACKGROUND: Intestinal ischemia has been described in case reports of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (coronavirus disease 19, COVID-19). AIM: To define the clinical and histological, characteristics, as well as the outcome of ischemic gastrointestinal manifestations of SARS-CoV-2 infection. METHODS: A structured retrospective collection was promoted among three tertiary referral centres during the first wave of the pandemic in northern Italy. Clinical, radiological, endoscopic and histological data of patients hospitalized for COVID-19 between March 1st and May 30th were reviewed. The diagnosis was established by consecutive analysis of all abdominal computed tomography (CT) scans performed. RESULTS: Among 2929 patients, 21 (0.7%) showed gastrointestinal ischemic manifestations either as presenting symptom or during hospitalization. Abdominal CT showed bowel distention in 6 patients while signs of colitis/enteritis in 12. Three patients presented thrombosis of main abdominal veins. Endoscopy, when feasible, confirmed the diagnosis (6 patients). Surgical resection was necessary in 4/21 patients. Histological tissue examination showed distinctive features of endothelial inflammation in the small bowel and colon. Median hospital stay was 9 d with a mortality rate of 39%. CONCLUSION: Gastrointestinal ischemia represents a rare manifestation of COVID-19. A high index of suspicion should lead to investigate this complication by CT scan, in the attempt to reduce its high mortality rate. Histology shows atypical feature of ischemia with important endotheliitis, probably linked to thrombotic microangiopathies.

Dual Pathology: A Rare Association in Surgical Acute Abdomen.

Among the causes of acute surgical abdomen intestinal perforation and mesenteric ischemia are some of the leading causes of morbidity and mortality. Gastric perforation has a mortality rate of 20-30% and mesenteric ischemia has a mortality of 60%. The presence of both pathologies in the same patient at the same time is a rare association and very few cases have been reported till now. This association has been described in cases of polyarteritis nodosa. Here we are presenting our case in which no such vascular pathology was identified. We have tried to hypothesize the reason behind this rare association.

Internal Hernia as a Cause of Acute Abdomen in a Pediatric Patient.

An acute abdomen is a complex case with multiple possible etiologies and requires the help of many different disciplines. We present the case of a two-year-old female who presented to the emergency department in acute distress, pale in complexion, and continuously guarding her abdomen. Physical examination revealed a distended, rigid abdomen with tenderness to palpation of the abdomen in all four quadrants. A computed tomography scan illustrated markedly dilated loops of small bowel but unclear etiology of obstruction with no evidence of perforation. Stat diagnostic laparotomy showed a strangulated internal hernia secondary to a congenital mesenteric defect. The mesenteric defect was repaired laparoscopically, and 25 cm of necrotic bowel was resected with an end-to-end anastomosis. Internal hernias secondary to mesenteric defects are the most common forms of internal hernias in pediatric patients and present with a 100% mortality rate if left untreated. This case illustrates the importance of a high index of suspicion, thorough physical examination, prompt diagnosis, and treatment in preventing a fatal outcome in these patients.

Trans-Serosal Multimodal Optical Coherence Tomography for Visualization of Microstructure and Blood Circulation of the Small Intestine Wall.

The aim of the study was to evaluate the performance of trans-serosal multimodal OCT (MM OCT) in in vivo detecting of changes in microstructure and blood circulation of the small intestine wall caused by arteriovenous ischemia resulted from intestine strangulation. MATERIALS AND METHODS: In experiments on Wistar rats (n=22), we examined the small intestine wall in vivo using MM OCT; the access to the intestine was reached through laparotomy. The microvasculature and microstructure of the wall were studied before and after acute arteriovenous ischemia created by ligation of a small bowel segment. The results were then added with data obtained from histological and intravital microscopic examination. RESULTS: Trans-serous MM OCT allowed us to visualize the bowel wall to its entire thickness, distinguish between the serous-muscular and mucous-submucosal layers, and detect the villi and functioning blood vessels. The structures were best seen after a fat emulsion had been administered into the bowel lumen. In OCT images made in the optical coherent angiography (OCA) mode, large paired vessels (arteries and veins) and micro-vessels with a diameter of >15 µm could be seen. Most of the blood vessels were imaged in the depth range of 80-300 µm from the surface. Capillaries with a diameter of 7-10 µm were not seen, but they produced an overall bright background. In the OCA images reconstructed from a volume of 2.4×2.4×1.8 mm, the total length of the vascular bed before ischemia was 18.3 [16.6; 19.8] mm.Strangulation of the intestinal loop was associated with changes in the CP OCT picture: the villi-associated vertical pattern and shadows of blood vessels disappeared and the depth of tissue visualization in the cross-channel decreased. The optical equivalents of the serous-muscular layer were preserved; after 180±12 min of ischemia, their proportion in the intestinal wall thickness increased from 25 [18; 32] to 42 [31; 55]% (p=0.031). At that time-point, OCA images of the strangulated bowel loop looked all similar: a uniform dark background with isolated fragmentary large vessels and no signs of blood flow in the microvascular network. CONCLUSION: Trans-serous MM OCT provides for in vivo visualization of microstructures critical for surgical gastroenterology: the intestinal wall layers including villi and blood vessels of each layer, as confirmed by histological analysis. Destructive processes in the intestinal wall resulting from bowel ligation bring about optical changes, which can be detected using real-time MM OCT.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery.

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process. Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.

Disappearing portal venous gas in acute pancreatitis and small bowel ischemia.

We report an usual case of hepatic portal venous gas (HPVG) in the setting of acute pancreatitis and small bowel ischemia. Interestingly, the HPVG disappeared within 2 hours of the original computed tomography scan, despite the patient having small bowel ischemia. The patient had a complicated clinical course, dying 62 days postadmission. This case highlights that HPVG in setting of acute pancreatitis and small bowel ischemia has a very high morbidity and mortality, requiring early detection and aggressive surgical management.

Paroxysmal Nocturnal Hemoglobinuria Presenting as Recurrent Jejunitis / 대한내과학회지

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematopoietic stem cell disorder characterized by chronic complement-mediated intravascular hemolysis, nocturnal hemoglobinuria, predisposition to thrombosis and secondary bone marrow failure. Small bowel ischemia is a complication of PNH but has not been reported to date in a Korean adult. We report here a case of PNH presenting as recurrent jejunitis. Despite the uncommon etiology, PNH should be considered in the differential diagnosis of patients with unexplained recurrent jejunitis.

In vivo analysis of intestinal permeability following hemorrhagic shock.

AIM: To determine the time course of intestinal permeability changes to proteolytically-derived bowel peptides in experimental hemorrhagic shock. METHODS: We injected fluorescently-conjugated casein protein into the small bowel of anesthetized Wistar rats prior to induction of experimental hemorrhagic shock. These molecules, which fluoresce when proteolytically cleaved, were used as markers for the ability of proteolytically cleaved intestinal products to access the central circulation. Blood was serially sampled to quantify the relative change in concentration of proteolytically-cleaved particles in the systemic circulation. To provide spatial resolution of their location, particles in the mesenteric microvasculature were imaged using in vivo intravital fluorescent microscopy. The experiments were then repeated using an alternate measurement technique, fluorescein isothiocyanate (FITC)-labeled dextrans 20, to semi-quantitatively verify the ability of bowel-derived low-molecular weight molecules (< 20 kD) to access the central circulation. RESULTS: Results demonstrate a significant increase in systemic permeability to gut-derived peptides within 20 min after induction of hemorrhage (1.11 ± 0.19 vs 0.86 ± 0.07, P < 0.05) compared to control animals. Reperfusion resulted in a second, sustained increase in systemic permeability to gut-derived peptides in hemorrhaged animals compared to controls (1.2 ± 0.18 vs 0.97 ± 0.1, P < 0.05). Intravital microscopy of the mesentery also showed marked accumulation of fluorescent particles in the microcirculation of hemorrhaged animals compared to controls. These results were replicated using FITC dextrans 20 [10.85 ± 6.52 vs 3.38 ± 1.11 fluorescent intensity units (× 10(5), P < 0.05, hemorrhagic shock vs controls)], confirming that small bowel ischemia in response to experimental hemorrhagic shock results in marked and early increases in gut membrane permeability. CONCLUSION: Increased small bowel permeability in hemorrhagic shock may allow for systemic absorption of otherwise retained proteolytically-generated peptides, with consequent hemodynamic instability and remote organ failure.

Cytomegalovirus enteritis with ischemia in an immunocompetent patient: A rare case report.

INTRODUCTION: Cytomegalovirus (CMV) is predominantly an opportunistic infection in the immunocompromised patients. Though, there are few cases of CMV colitis being reported in the immunocompetent individuals, CMV enteritis is exceedingly rare and enteritis leading into small bowel ischemia has never been reported yet. PRESENTATION OF CASE: A-78-year-old male patient presented with distal small obstruction for 4 days duration. Clinical examination revealed a distended abdomen and localised peritonism in right iliac fossa. An initial computed tomography (CT) scan revealed distended small bowel loops up to the thickened inflammed terminal illeum with no free fluid or gas and a normal appendix. No immunosuppressive risk factors such as human immunodeficiency virus, transplant procedures, or steroid therapy were present. Hematologic investigations showed leucocytosis with neutrophilia. Diagnostic laparoscopy confirmed a thickened terminal ileum causing small bowel obstruction. Laparoscopy converted to laparotomy and right hemicolectomy was performed. Histology showed isolated small bowel ischemia with ulcerative changes and cytomegalovirus inclusions. The patient was started on ganciclovir therapy and subsequently had an uneventful recovery and discharged after 16 days. DISCUSSION: Cytomegalovirus enteritis was initially not suspected in our patient. In this case CMV caused ischemia of the small bowel without evidence of colonic involvement. Even in elderly patients, the small bowel remains resilient to the ischemic changes because of the copious blood supply. CONCLUSION: We report possibly the first case of isolated small bowel ischaemia caused by cytomegalovirus in immunocompetent individuals, needed surgical resection.

Ischemic and injured bowel evaluation by Fluorescence imaging.

AIM: Although fluorescence has been proposed for estimation of bowel perfusion decades ago it is still not widely used. In emergency situations like mesenteric ischemia, fluorescence might give objective criteria to evaluate the perfusion and guide the decisions of surgeons. METHOD: The use of near-inrafrared angiography by PinPoint (Novadaq) in a serial of four emergency situations of acute mesenteric ischemia has been evaluated in a university hospital setting. RESULTS: The use of the near-infrared tool is in emergency situations easy to handle and little time-consuming. The angiography showed clearly the perfusion in regions that were not estimated as recoverable by the surgeons. In one of the cases a significant amount of bowel could be spared by use of the system. CONCLUSION: Although the assessment of the perfusion with the applied system is comprehensible, it would be desirable to evaluate a threshold level in order to further objectify it. While the surgeons who used the tool were subjectively assured by the expressiveness it would need a randomized and maybe experimental setting to evaluate objectively the amount of spared bowel length.