Jejunal Diverticulosis Causing Small Intestinal Volvulus and Closed Loop Obstruction.

BACKGROUND Jejunal diverticulosis are false diverticula of the small bowel that form from outpouching of the mucosa and submucosa. They are pulsion diverticula that are often asymptomatic and can be found incidentally during surgery. In some instances, jejunal diverticula could result in intestinal obstruction. Small intestinal volvulus is an uncommon cause of small bowel obstruction that results in a closed loop obstruction and is an indication for emergent surgical intervention. CASE REPORT We report a case of an 84-year-old man who presented to the Emergency Department with abdominal pain and generalized weakness. A preoperative computerized tomographic scan demonstrated a closed loop small bowel obstruction with mesenteric swirling. The patient was taken for a diagnostic laparoscopy, which revealed extensive proximal jejunal diverticulosis and a volvulus of the involved jejunum. An exploratory laparotomy was warranted for safe detorsion of the small bowel and resection of the diseased segment. The small bowel was successfully detorsed, with resection of the involved jejunum. Intestinal continuity was established by a primary side-to-side anastomosis. CONCLUSIONS Jejunal diverticula have been reported in the literature as a cause of small bowel obstructions, and very few reports exist of concurrent small bowel volvulus. In very rare instances, both of these conditions can coexist. There should be prompt surgical intervention in all cases of closed loop small bowel obstructions to prevent intestinal ischemia, perforation, and sepsis.

Importance of Prenatal Diagnosis of Ileal Atresia in Gestational Diabetes Cases.

BACKGROUND Maldevelopment of the fetal bowel can result in the rare condition of intestinal atresia, which results in congenital bowel obstruction. This report describes a case of prenatal diagnosis of fetal ileal atresia at 22 weeks' gestation. CASE REPORT Here, we present a 24-year old woman who was 22 weeks into her first pregnancy when she underwent routine fetal ultrasound. She was diagnosed with gestational diabetes mellitus. Her body mass index was normal and she had normal weight gain. The ultrasonographic examination performed revealed a hyperechoic bowel and a small dilatation of the bowel. The couple was counselled for possible intestinal atresia and its postnatal implications. At 33 weeks of gestation, polyhydramnios appeared, and the intestinal distension was much more pronounced, with hyperechoic debris in the intestinal lumen (succus-entericus). After birth, surgery was performed and we concluded the patient had type II atresia, which was surgically treated. CONCLUSIONS This report has highlighted the importance of antenatal ultrasound in detecting fetal abnormalities, and has shown that rare conditions such as intestinal atresia can be accurately diagnosed and successfully managed. Surgical correction, if implemented promptly after stabilizing the general condition, can have a relatively good prognosis. Coexisting fetal ileal atresia and gestational diabetes mellitus are rare occurrences, which can make each condition even more difficult to treat.

Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience.

PURPOSE: Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop-Koop (BK) approach to JIA in improving outcomes. METHODS: A retrospective cohort study was performed on children with complex JIA (Type 2-4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05. RESULTS: A total of 122 neonates presented with JIA in 1/2018-12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018-2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41-0.98) with the increased use of BK. CONCLUSION: Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.

Pancake kidney and jejunal atresia: An uncommon dual anomaly detected prenatally-A case report.

Pancake kidney is a renal fusion anomaly with only a few reported prenatal diagnoses. Other structural anomalies beyond the urogenital system may also be associated. This study describes a dual anomaly case detected prenatally, comprising of pancake kidney and jejunal atresia. A postnatal abdominal ultrasound confirmed both kidneys were fused in the midline at the aortic bifurcation level, along with a type 3b jejunal atresia. Based on the available limited evidence about pancake kidney, renal functions appear to remain largely preserved and unaffected as in our case according to 6 months of follow-up. However, further investigation is needed to explore any potential association with chromosomal and structural abnormalities in selected cases.

Iatrogenic Small Intestinal Obstruction / Obstrucción iatrogénica del intestino delgado

An 83-year-old female, suffering from abdominal pain, nausea, and vomiting, was admitted to our hospital. Gas-liquid level and tumor was not seen on the abdominal computed tomography scan. Instead, two high density balloon which were 2.7cm(distal) and 3.3cm(proximal) in diameter separately were shown (Figure A) in small intestine. The balloons proved to be part of ileus tube and iohexol which was incorrectly injected into the balloons caused a blockage in the tube. During colonoscopy, we were surprised to find that the distal balloon had passed through the ileocecal valve and we punctured it easily (Figure B). However, affected by the broken distal balloon, we could not reach another one. Finally, we cut off the connector fixed to the face and instructed the patient to take some oral paraffin oil and exercise appropriately. The next day, the balloons were discharged with the symptoms alleviated. It is rare for iatrogenic foreign body to cause ileal obstruction).(AU)

Diagnostic value of the microcolon using ultrasonography in small bowel atresia.

BACKGROUND: Microcolon helps diagnose small bowel atresia (SBA) using contrast enema. However, there are no ultrasonography (US) microcolon criteria for diagnosing SBA. Therefore, this study aimed to evaluate colon accuracy and other characteristics for diagnosing SBA by US, using surgical or clinical information as the reference standard. METHODS: US was performed on 46 neonates aged ≤ 7 days old. In the study group (n = 15), neonates with SBA were confirmed following surgery. In the study group without SBA (n = 15), neonates with other gastrointestinal problems besides SBA were confirmed by surgical or clinical follow-up. Sixteen neonates without gastrointestinal problems were classified as the control group. The colonic diameter was measured, and colonic gas was sought and observed. Statistical analysis was performed to compare US parameters between the study group and other two groups. The optimal cut-off value of the colonic diameter for SBA diagnosis was obtained using receiver operating characteristic analysis. RESULTS: Colonic diameters (0.5 cm) in the study group (interquartile ranges [IQR], 0.5-0.6 cm) was significantly smaller than that in the group without SBA (0.9 cm; IQR, 0.8-1.2 cm) (P < 0.001) and in the control group (1.2 cm; IQR, 0.8-1.35 cm) (P < 0.001). Optimum cut-off value for diagnosing SBA was 0.65 cm (sensitivity, 90.3%; specificity, 86.7%; accuracy, 89.1%) for the colonic diameter. Combining microcolon and gas-negativity showed the best performance in SBA diagnosis using US, with increased accuracy (91.3%). CONCLUSION: A colon < 0.65 cm in diameter should be called a microcolon; combining US with gas-negativity is an essential diagnostic basis for SBA.

Small-bowel atresias: a case series with review of the disease and imaging findings.

Small-bowel atresias are among the most common causes of intestinal obstruction in newborns, and they often require urgent surgical treatment. Imaging techniques play a very important role in their diagnosis, which is often suspected on prenatal obstetric ultrasound and confirmed on postnatal plain-film X-rays. Abdominal ultrasound's lack of ionizing radiation, wide availability, low cost, and high resolution is making this technique increasingly important in confirming atresias and in detecting possible complications in newborns. This review analyzes a series of cases seen at our center. It summarizes the different types of small-bowel atresias, focusing on the clinical presentation, imaging findings on different modalities, presence of associated disease, management, clinical course, and outcomes.

Intestinal Atresias.

Intestinal atresia is a form of congenital bowel obstruction that requires operative repair in the early neonatal period. Duodenal atresia and jejunoileal (JI) atresia are appropriately seen as distinct entities. Both can be suspected with fetal imaging, which can assist with prenatal counseling of families. Duodenal atresia is more commonly associated with comorbidities, whereas JI atresia is more often an isolated finding. Surgical repair is essential and is typically well tolerated. Although it may take time to achieve intestinal function postoperatively, these infants are usually able to tolerate full feeds after resolution of the ileus. Excellent short- and long-term outcomes for isolated duodenal atresia and JI atresia are expected.

[Ileal Atresia Due to Intrauterine Intussusception]. / Intrauterine Invagination als Ursache einer Dünndarmatresie.

Intussusception commonly affects children in the first year of life but it may rarely also appear in utero. We report a newborn with delayed passing of meconium, repeated vomiting, and abdominal distension in the first week of life. After radiological diagnosis of a small bowel obstruction, the newborn underwent an exploratory laparotomy where an ileal atresia proximal to an intussusception was found. After resection of the affected bowel, an end-to-end anastomosis was possible. The postoperative period was uneventful. This case shows that intrauterine intussusception can be a rare cause for ileal atresia. Fast diagnosis and effective interdisciplinary team work are essential for a satisfying outcome.

Atresias de intestino delgado. Revisión de la patología y hallazgos radiológicos asociados a distintos casos / Small-bowel atresias: a case series with review of the disease and imaging findings

Las atresias de intestino delgado son una de las causas más frecuentes de obstrucción intestinal en el neonato y habitualmente requieren tratamiento quirúrgico urgente. Las técnicas de imagen conforman una parte muy importante del diagnóstico, aportando la ecografía obstétrica prenatal la sospecha inicial y siendo la radiografía simple de abdomen la prueba que confirma el diagnóstico tras el nacimiento. La ecografía abdominal en el recién nacido está cobrando cada vez mayor importancia, debido a su inocuidad, disponibilidad, bajo coste y alta capacidad de resolución, tanto para la confirmación del diagnóstico como para la detección de las posibles complicaciones asociadas. En este artículo analizamos una serie de casos vistos en nuestro centro y elaboramos un resumen de los diferentes tipos de atresias de intestino delgado, haciendo hincapié en la clínica, los hallazgos radiológicos obtenidos en las diferentes modalidades de imagen, la existencia de patología asociada, su manejo y su evolución.(AU)

Small-bowel atresias are among the most common causes of intestinal obstruction in newborns, and they often require urgent surgical treatment. Imaging techniques play a very important role in their diagnosis, which is often suspected on prenatal obstetric ultrasound and confirmed on postnatal plain-film X-rays. Abdominal ultrasound's lack of ionizing radiation, wide availability, low cost, and high resolution is making this technique increasingly important in confirming atresias and in detecting possible complications in newborns. This review analyzes a series of cases seen at our center. It summarizes the different types of small-bowel atresias, focusing on the clinical presentation, imaging findings on different modalities, presence of associated disease, management, clinical course, and outcomes.(AU)

Association between small-bowel mucosal damage and related diseases: Observational study in celiac patients / Asociación entre lesiones en la mucosa del intestino delgado y otras enfermedades: Estudio observacional en pacientes celiacos

Celiac disease is a systemic, chronic and autoimmune disorder that affects genetically susceptible individuals. Due to the increasing incidence of this pathology and the precision of new detection methods, celiac disease diagnosis has improved dramatically in recent years. Hereby, a study was performed to evaluate celiac disease’s prevalence, attending to associated diseases as well as clinical determinants. A convenience sample of 254 patients diagnosed between 2007 and 2017 in the South of Spain was selected: 212 were confirmed for celiac disease, 18 remained with suspected celiac disease and 24 were considered silent patients. Multivariate logistic regression models were applied to patients’ data. 95.3% of the subjects obtained a positive result in the genetic-molecular diagnosis, with prevalence of female patients’ group (58.7%). Moreover, females were associated with diarrhea and abdominal pain to a greater extent (54.3% and 66.2%, respectively). Youngsters had accused villi atrophy and larger concentrations of anti-tTG antibodies compared to adults, but had more adhesion to treatment and recovered better than the older group. Deficit in Fe and multimorbidity were also factors associated with villi atrophy. The multivariate analysis adjusted for sex and age showed a direct association between intestinal lesion and Fe deficit, the presence of vomiting and the number of diseases associated with celiac disease. Novel results of the present study refer to the association between the level of intestinal injury and the multimorbidity associated with celiac disease. (AU)

La enfermedad celíaca es un trastorno sistémico, crónico y autoinmune que afecta a individuos genéticamente susceptibles. Debido al incremento en la incidencia de esta patología y la precisión de los nuevos métodos de detección, el diagnóstico de la enfermedad celíaca ha mejorado drásticamente en los últimos años. De esta manera, se ha realizado un estudio para evaluar la prevalencia de la enfermedad celíaca, atendiendo tanto a las enfermedades asociadas como a los determinantes clínicos. Se seleccionó una muestra de conveniencia de 254 pacientes diagnosticados entre 2007 y 2017 en el sur de España: 212 fueron confirmados de enfermedad celíaca, 18 permanecieron con sospecha de enfermedad celíaca y 24 fueron considerados pacientes silentes. Se aplicaron modelos de regresión logística multivariante a los datos de los pacientes. El 95,3% de los sujetos obtuvo un resultado positivo en el diagnóstico genético-molecular, con predominio del grupo de pacientes del sexo femenino (58,7%). Además, las mujeres se asociaron en mayor medida con diarrea y dolor abdominal (54,3% y 66,2%, respectivamente). Los jóvenes se asociaron a una mayor atrofia de las vellosidades y concentraciones de anticuerpos-tTG superiors en comparación con los adultos, pero mostraron una mayor adherencia al tratamiento y se recuperaron mejor que el grupo de mayor edad. El déficit de Fe y la multimorbilidad también fueron factores asociados con la atrofia de las vellosidades. El análisis multivariante ajustado por sexo y edad mostró una asociación directa entre la lesión intestinal y el déficit de Fe, la presencia de vómitos y el número de enfermedades asociadas a la enfermedad celíaca. Los nuevos resultados del presente estudio se refieren a la asociación entre el nivel de lesión intestinal y la multimorbilidad asociada a la enfermedad celíaca. (AU)

¿Está asociada la malrotación intestinal sintomática en el paciente adulto con el sobrecrecimiento bacteriano de intestino delgado? / Is there an association between adult symptomatic intestinal malrotation and small intestinal bacterial overgrowth?

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[A man with swollen abdomen, abdominal pain and nausea]. / Een man met een bolle buik, buikpijn en misselijkheid.

A 45-year-old man presented with acute intestinal obstruction, due to congenital peritoneal encapsulation. This rare malformation leads to an accessory peritoneal sac around all or part of the small bowel. Torsion of this sac can lead to acute bowel obstruction and therefore ischaemia. In this case, detorsion and adhesiolysis resulted in a positive outcome.

Diagnostic laparoscopy to exclude malrotation following inconclusive upper gastrointestinal contrast study in infants.

PURPOSE: We report the use of diagnostic laparoscopy as an alternative to laparotomy in the investigation of infants with clinical features concerning for malrotation and inconclusive upper gastrointestinal contrast study. METHOD: Case note review of all infants in whom laparoscopy was performed during 2016-2020 to investigate for possible malrotation. RESULTS: Eight infants were identified. All presented with acute clinical features of malrotation (bilious vomit) without evidence of an alternate explanatory diagnosis. All underwent upper gastrointestinal contrast study, with three also undergoing abdominal ultrasound. The radiological examinations could not exclude malrotation and all proceeded to laparoscopy. At laparoscopy, the small intestine was run to exclude the presence of midgut volvulus. In six cases, normal rotation was confirmed and no abnormal pathology was found. Two proceeded to laparotomy and underwent correction of malrotation. All infants recovered without complication. CONCLUSION: Laparoscopy is an excellent modality for further investigation of infants presenting acutely in whom intestinal malrotation cannot be formally excluded radiologically. The positive identification of the DJ flexure and cecum in correct anatomical sites, both fixed to the posterior abdominal wall, provides adequate reassurance of low risk of volvulus and avoids a full laparotomy. We recommend diagnostic laparoscopy in cases of inconclusive upper gastrointestinal contrast study.

Multiple Small Bowel Diverticula Were an Unexpected Finding During Laparoscopic Enterectomy for Crohn's Disease.

INTRODUCTION: Small bowel diverticulosis (SBD) is a rare entity. Although it is usually an asymptomatic condition, clinical manifestations may vary from non-specific clinical signs to severe and complicated disease. The coexistence of SBD and Crohn's disease (CD) is rarely reported in the current literature. AIM: We present a rare case of concomitant Crohn's disease (CD) and SBD in a male patient, where multiple jejunal diverticula were an incidental intraoperative finding. Preoperative evaluation with magnetic resonance enterography (MRE) failed to recognize the coexistence of these two entities. Surgeons should be aware of the possibility of this rare situation. CASE REPORT: A 52-year-old Caucasian male diagnosed with CD was referred to our department for surgical intervention due to an ileal stricture. The patient reported no past medical history, except for a few episodes of bloody diarrhoea during a three-year period. The index colonoscopy revealed luminal narrowing in the ileum at approximately 70 cm proximal to the ileocaecal valve, and biopsies revealed findings compatible with CD. Clinical examination and laboratory tests were unremarkable one day before surgery. The patient underwent laparoscopic segmental resection of the affected part of the ileum. Intraoperatively, multiple non-inflamed diverticula along the jejunum extending from the Treitz ligament to the proximal ileum were recognized. Our patient had an uncomplicated post-operative course and was discharged on the fifth post-operative day. Pathological examination revealed features compatible with CD in the active phase. The patient was referred to his gastroenterological team for further consultation regarding the appropriate post-operative management. CONCLUSION: Concomitant CD and SBD is a rare condition, and the differential diagnosis may be challenging due to overlapping symptoms.

Diagnostic performance and role of the contrast enema for low intestinal obstruction in neonates.

PURPOSE: We aim to evaluate the diagnostic performance and relationship between clinical characteristics, imaging findings, and final diagnosis for the neonatal contrast enema (CE). METHODS: Retrospective 10-year review of all neonatal CEs including imaging findings, clinical information, indication, and final diagnosis from discharge summaries, surgical reports, and pathology (reference standard). Two blinded pediatric radiologists reinterpreted 366 CEs for obstruction, microcolon, rectosigmoid index (RSI), serrations, meconium, ileal cut-off, transition zone, diagnosis, and level of confidence. CE diagnostic performance was calculated versus reference standard. RESULTS: Diagnoses included Hirschsprung disease (HD) (15.8%), small left colon syndrome (14.8%), small intestinal atresia/colonic atresia (SIA/CA) (12.6%), meconium ileus (MI) (4.4%), and normal (48.9%). CE had a moderate specificity (87.7%) and low sensitivity (65.5%) for HD; abnormal RSI and serrations showed high specificities (90.3%, 97.4%) but low sensitivities (46.6%, 17.2%). CE showed high specificity (97.4%) and low sensitivity (56.3%) for MI blinded to cystic fibrosis status. Microcolon was specific (96.6%) but not sensitive (68.8%) for MI. CE showed highest PPV (73.1%) (specificity 95.6%, sensitivity 82.6%) for SIA/CA. Microcolon with an abrupt cut-off was specific (99.1%) but not sensitive (41.3%) for atresias. CONCLUSION: Neonatal CE demonstrates high specificities and low to moderate sensitivities across all diagnoses, with lowest performance in HD. CLINICAL TRIAL REGISTRATION: None.