Clinical Profile and Outcome of Sub Acute Intestinal Obstruction. A Descriptive Cross-Sectional Study

The direct inguinal hernia has a wider neck and thus usually doesn’t present as strangulation or incarceration in comparison to the indirect component. When direct inguinal hernias are untreated for a longer duration, they may get strangulated and incarcerated. Hence such long-standing direct hernias with features of intestinal obstruction and /or peritonism should be promptly seen and diagnosed to prevent massive and unwanted intestinal resection. We are reporting a case of 83-year-old male presented to Surgical Emergency Department of Dhulikhel Hospital, Kathmandu University hospital with complaints of swelling in the right inguinoscrotal region for 12 years and progressed to become irreducible and painful for 12 hours. Clinically he had an acute intestinal obstruction. Intra-operatively we found a direct hernia containing congested small bowel loops and toxic fluids. The toxic fluid was suctioned and after confirming viability, modified Bassini’s repair was done with reinforcement of the posterior wall.
 Even direct inguinal hernia of longer duration can cause acute or sub-acute intestinal obstruction with or without features of peritonism. This complication is more common in elderly patients.

Crohn’s disease is an uncommon disease. Most common presentation is abdominal pain, diarrhea and weight loss. It may present as subacute or even acute intestinal obstruction. Crohn’s disease is very rare in Bangladesh. Here we report a case of Crohn’s disease where the initial presentation was severe microcytic hypochromic anaemia. Who had repeated blood transfusion for one year. Initially cause was not detected. Later on he presented with subacute intestinal obstruction. After all diagnostic work up no definitive diagnosis could be found. So laparotomy was done in Bangabandhu Shiekh Mujib Medical University (BSMMU). Histopathology report was suggestive of Crohn’s disease and he was on mesalazine with significant clinical improvement. DOI: http://dx.doi.org/10.3329/bjmed.v21i2.13620 Bangladesh J Medicine 2010; 21: 101-104

To the Editor: A 23-year-old male patient presented with abdominal pain, fever, and 1 episode of melena. A clinical diagnosis of enteric fever was made, but his serology for enteric fever was negative. He was managed conservatively. He improved and was discharged from the hospital. He was admitted 15 days later with complaints of melena for 2 days and mild abdominal pain. His hemoglobin was 5.5 g% at the time of admission. He had no history of fever, diarrhea, or vomiting. He was a farmer by occupation. On examination, he had thin built and was a moderately nourished person with pallor. Vital signs were within normal limits. Abdomen was tender over umbilical and paraumbilical regions. A provisional diagnosis of subacute intestinal obstruction with gastrointestinal bleed was made. There was no eosinophilia in the peripheral blood. All other biochemical and serological tests were within normal limits. Stool was also negative for ova and cysts. Endoscopy did not suggest bleeding proximal to second part of duodenum. Ultrasonogram showed excessive small bowel peristaltic movement. Laparatomy was done under general anesthesia. The jejunum was congested. Proximal loops of the jejunum were dilated with thickening and congestion of the distal portion. The serosa of the affected jejunum was inflamed. Omentum was adherent to the jejunum at the point of stricture. Other organs were of normal appearance. The thickened portions of the jejunum were resected, and an end-to-end anastomosis was done. The adhesions were released, and a peritoneal lavage was done. Intraoperative and postoperative periods were uneventful. Gross examination revealed a cut-open segment of small bowel measuring 38 cm in length. Serosal surface showed congested vessels, and fat was seen adherent to the serosal surface away from the site of mesenteric attachment. This resembled the creeping fat of Crohn disease. Mucosal surface shows multiple circumferential ulcers resembling tuberculous ulcers of the small intestine (Fig. 1). In the ulcerated area, numerous polypoid nodules were seen. There was mucosal edema in other areas of the intestine. Resected margins were normal.FIGURE 1: Gross specimen of jejunum showing circumferential transverse ulcers with nodules in the ulcerated area. Thick arrow shows the ulcerated area. Thin arrow shows the regenerative nodule.Multiple histopathologic sections examined showed ulcers in the jejunum lined by granulation tissue. The granulation tissue showed giant cells with numerous eosinophils, with lymphocytes, plasma cells and neutrophils. The giant cells contain ingested material, probably the digested larvae. The polypoid areas showed regenerative epithelium. In an area adjacent to the ulcer, cut sections of Strongyloides stercoralis larvae were seen in the mucosal crypts. Stain for acid-fast bacilli was negative. A diagnosis of S. stercoralis infestation was made. Strongyloides stercoralis is an intestinal nematode of humans. It is endemic in tropical and subtropical areas.1 Most infected individuals are asymptomatic, but S. stercoralis infestation is capable of transforming into a fulminant fatal illness under certain conditions associated with a compromise of host immunity.2 Here, the patient was not in an immunocompromised state. Acute strongyloidiasis may present with epigastric pain, diarrhea, and vomiting. Peripheral eosinophilia is high at the beginning during larval migration. It may drop to normal when the parasites are established in the intestine as in the present case where peripheral eosinophilia was normal. Gastrointestinal bleeding,3 in any combination, has been frequently reported. Strongyloidiasis may present with small bowel obstruction.4,5 The present case presented with upper gastrointestinal bleed with subacute intestinal obstruction. Mucosal ulceration is most common in the small intestine and can occur at any level from the esophagus6 or stomach7 to the rectum. Larvae may be seen in these ulcers on biopsy.7-9 This case presented with multiple circumferential ulcers mimicking tuberculous ulcers. Stain for acid-fast bacilli was negative. A case of S. stercoralis and mesenteric tuberculous infection with acute abdominal pain in a human immunodeficiency virus-positive patient has been reported.10 Data show that it can also present as eosinophilic granulomatous enterocolitis.11 Here, there was a similar picture on microscopy. A case of S. stercoralis infestation in an immunocompetent patient presented with diarrhea, weight loss, and microcytic anemia. Colonoscopy in that case only showed aphthous ulcers.12 Usually, it is asymptomatic in immunocompetent hosts.1 Choudhry et al13 have reported that endoscopic findings in immunocompetent hosts showed ulcerations and small raised nodular lesions. In our extensive literature search, we have not found a case of S.stercoralis to present with multiple circumferential ulcers. Strongyloides stercoralis is usually asymptomatic in immunocompetent hosts. Here, we would like to report the first case of S. stercoralis presenting as a circumferential jejunal ulcer. Subacute intestinal obstruction in an immunocompetent person is also a rare presentation. Thus, clinicians should be aware of the possibility of S. stercoralis infection as a cause of subacute intestinal obstruction and prevent the lethal complications. Sampath P. Kumar, MS* Partho P. Barman, MD† Erli Amel Ivan, MD† Renu G'Boy Varghese, MD, DNB† Prasanna C. Sekar, MS* Ramji Rai, MD† Departments of *General Surgery and †Pathology, Pondicherry Institute of Medical Sciences Pondicherry, India [email protected]

Intussusception, invagination of a segment of the gut into an adjacent one, is a relatively common cause of the intestinal obstruction in children but a very rare and uncommon clinical entity in the adults accounting to 1% and near about 65% of these are caused by malignant lead point. The Lipomatous polyp accounts for 4% of all benign tumors of the gut. In most of the cases, these are seen particularly in large intestine, usually sub mucosal and around ileocecal valve. These are mostly and very often asymptomatic. Mrs. Rahima Begum aged 65 years, previously was a healthy Bangladeshi housewife, with the history of recurrent abdominal colic of moderate intensity for the last 6 months, associated with the appearance of mass in the right lower quadrant with features of sub-acute intestinal obstruction got admitted into the Ibn Sina Medical College Hospital, Kallyanpur, Dhaka, Bangladesh. The required and most relevant investigations revealed the Ileocolic intussusception and underwent the right hemicolectomy. Postoperative recovery of the patient was uneventful excepting the hypertension only. Histopathology investigations revealed lipomatous polyp arising from the Ileocecal junction. This study reports intussuception in the adult due to lipomatous polyp, a very rare case presenting with sub acute intestinal obstruction.
 Bangladesh Journal of Medical Science Vol.20(1) 2021 p.204-207

A 23-year-old man presented to the emergency department with a history of recurrent episodes of subacute intestinal obstruction. Palpation revealed a firm, non-tender, mobile, non-pulsatile mass of size 8–10 cm...

Background: Large bowel obstruction is rarely caused by adhesions. To our knowledge, the few cases reported in literature are secondary to previous abdomino-pelvic surgery, and are in female patients. Case Reports: We report two cases of large bowel obstruction due to adhesions in males with no previous abdominal surgery. The first case was a 73 years old male previously well, who presented with a one week history of abdominal colicky pain with nausea. Initially this patient was thought to have symptomatic gallstones as a result of an ultrasound scan report. Consequently, a decision to take the patient for laparoscopic cholecystectomy was reached. Due to difficulties in achieving penumoperitoneum, a laparotomy was done; the patient was found to have a fibrous band across transverse colon causing obstruction. The second case was a 61 years old male, known diabetic and hypertensive, who presented with epigastric pain, nausea, vomiting and constipation. Abdominal X-rays demonstrated large bowel obstruction. At laparotomy, this patient was found to have adhesions causing sigmoid colon obstruction. Conclusion: In this paper, we demonstrate the rarity of large bowel obstruction secondary to adhesions especially in a virgin abdomen, emphasize the importance of good radiological expertise, and highlight the need to consider adhesions as a very rare but possible cause of large bowel obstruction.

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of multiple gas containing thin walled cysts in the intestinal wall and mesentery. It is sometimes associated with chronic obstructive pulmonary disease, but has been described most often in patients with gastrointestinal disorders including duodenal and gastric ulceration, small bowel obstruction, regional enteritis and gastrointestinal malignancy. Its association in the patient described below with severe systemic sclerosis is of particular interest. There have been occasional previous reports of this association which should be considered in any patient with systemic sclerosis who develops abdominal symptoms suggestive of acute or sub-acute intestinal obstruction, not readily explicable by other causes.

Acute intestinal obstruction is a common surgical emergency, defined as a partial or complete interruption of the forward flow of intestinal contents. It is associated with significant morbidity and mortality, and timely diagnosis and management are essential. This study aimed to evaluate the causes, clinical presentation, management, and outcomes of patients admitted with intestinal obstruction to Al-Thawra Modern General Hospital, Sana'a, Yemen. A prospective descriptive study was conducted on 105 patients diagnosed with intestinal obstruction between January 1 and December 31, 2024. Patients younger than 10 years or with early postoperative obstruction were excluded. Data on demographics, clinical features, laboratory and radiological findings, management, complications, and outcomes were collected and analyzed using SPSS. Of the 105 patients, 74 (70.5%) were male, with a male-to-female ratio of 2.38:1 and mean age of 45.2 ± 19 years; the 31-60 years age group was most affected (35.2%). Mechanical obstruction accounted for 75 cases (71.5%), while 30 cases (28.5%) were due to intestinal ileus. Adhesions and malignancy were equally the most common causes (21% each), followed by secondary peritonitis (18.1%), hernia (11.4%), and volvulus (15.3%). The majority of patients presented within 3-7 days of symptom onset, although 81% of malignant obstructions occurred in patients aged 19-60 years and often presented after more than 14 days. Conservative management was successful in 13.3% of patients, while the remainder required surgical intervention according to etiology and intraoperative findings. Postoperative complications occurred in 19% of patients, and overall mortality was 14.3%, highest among patients with malignancy, mesenteric ischemia, and obstructed hernia. Mechanical obstruction is the predominant type of intestinal obstruction, with adhesions and malignancy as leading causes. Advanced age, comorbidities, ischemia, and recurrent neoplasm were associated with poor outcomes. Preventive strategies, including reduction of adhesions, elective hernia repair, early cancer screening, and timely surgical intervention, are essential to reduce morbidity and mortality associated with intestinal obstruction.

Objective To explore the necessities and clinical value of acute intestinal obstruction with computed tomography of whole abdomen in over 80 years old patients. Methods 50 patients with acute intestinal obstruction were diagnosed in department of emergency surgery and underwent the abdominal CT examinations.The clinical data, CT and surgery pathology of all patients were compared and analyzed. Results All cases were verified by surgical operation and pathological diagnosis, including colorectal cancer(n=21) and incarcerated abdominal external hernia(n=21), appendicitis(n=2), adhesive intestinal obstruction(n=2), intestinal volvulus (n=2), and intestinal intussusception(n=1) and stercoral intestinal obstruction(n=1), 12 cases were accompanied by bowel necrosis and perforation.12 patients were treated by laparoscope surgery, 38 cases by open laparotomy, 48 patients acquired good recovery, and 2 cases died from extensive bowel necrosis and multi-organ failure. Conclusion CT examination in whole abdomen could rapidly and accurately diagnose the cause of intestinal obstruction, evaluate complications and risks, so as to provide reasonable treatment choice and time, making patients acquired the effective effects as soon as possible, reducing the bad consequences. Key words: Intestinal obstruction; Tomography, X-ray computed; Aged, over 80 years old

Previous abdominal surgery (PAS) increases risk of small bowel obstruction (SBO) due to adhesions, and appendectomy (appy) is an independent risk factor for abdominal adhesion-related complications. Peritoneal inflammation, e.g., acute appendicitis (AA), causes formation of reactive ascitic fluid (rA) that activates peritoneum surface mesothelial cells (MCs) to form adhesions. Pathologic adhesions may arise if restoration of MC-regulated fibrinolysis and secretion of glycocalyx (GCX) are disrupted. Proteins affecting these processes may originate from peritoneal rA. This is a prospective observational IRB-approved study at three Level 1 trauma centers where rA is collected prior to surgical intervention for non-perforated AA or adhesiolysis for SBO. Samples from 48 appy and 15 SBO patients were used to treat human MCs and subjected to quantification of 85 inflammatory mediators. Results were compared between patients with surgically naïve abdomens (naïve) and patients with >1 PAS. Select rA caused MCs to form clusters of fibroblastic cells, extracellular matrix fibers (FIB), and secretion of GCX. PAS and naïve patient rA fluids were clustered into "fiber-GCX" (FIB-GCX) groups: highFIB-highGCX, highFIB-lowGCX, noFIB-highGCX, noFIB-lowGCX, and noFIB-noGCX. Between groups, 26 analytes were differentially abundant including innate immune response, wound healing, and mucosal defense proteins. Factors that contributed to the differences between groups were rA-induced highFIB and history of PAS. Overall, PAS patient rA showed a muted immune response compared to rA from naïve patients. Our data suggest that abdominal surgery may negatively impact future immune responses in the abdomen. Further, quantifying immunomodulators in peritoneal rA may lead to the development a personalized approach to post-surgical adhesion treatment and prevention.

Internal hernias are rare cause of intestinal obstruction. In adults important causes of internal hernia are previous abdominal surgery, trauma or peritoneal inflammation. Primary internal hernia in adults is extremely rare. Non-specific presentation, limited utility and expertise in imaging pose a challenge in pre-operative diagnosis. High index of suspicion and early intervention to prevent morbidity and mortality are necessary. We report a case of previously healthy 76-year-old male patient presenting with acute intestinal obstruction and who was later diagnosed with primary pericecal internal hernia on exploratory laparotomy. Hernial gate was located along right paracolic gutter around one foot from ileocecal junction.

Abstract. Introduction. The initial manifestations of intestinal insufficiency syndrome in acute intestinal obstruction are a pronounced inhibition of intestinal motor activity, which may be a reflex consequence of a previously developed pathological process. The surgical intervention performed against this background becomes another factor that increases the inhibition of intestinal motility. These disorders are based on a change in the “balance” of sympathetic and parasympathetic nervous influences and humoral factors. The aim of the study was to improve the treatment outcomes of patients with acute intestinal obstruction by developing and improving enteral therapeutic measures. Materials and methods. An analysis of the treatment results of 119 patients with acute mechanical intestinal obstruction of non-neoplastic genesis who were admitted to the surgical department during 2021-2024 was conducted. The age of the studied patients ranged from 18 to 80 years. Among them, 74 (62.2%) were men, and 45 (37.8%) were women. The control group consisted of 56 patients, the main group consisted of 63 patients. Results and discussion. In the main group, postoperative complications were observed in 8 (12.6%) patients. Mortality was 3.3% (2 patients died). Thus, the supplemented complex of traditional treatment measures with intra- and postoperative intestinal decompression, intestinal lavage and enterosorption is an important stage in intestinal insufficiency syndrome interrupting the pathogenetic chain of development in patients with acute intestinal obstruction. It contributes not only to the prevention of intestinal insufficiency syndrome, but also to the reduction of endogenous intoxication, the restoration of all intestinal functions, and also creates conditions for the early activation of patients and the reimbursement of energy costs and the body’s needs for plastic materials in a natural - enteral way. Conclusions. Timely and adequate implementation of enteral therapeutic measures: intra- and postoperative intestinal decompression, intestinal lavage, as well as enterosorption, which is an important stage of the comprehensive treatment of patients with acute intestinal obstruction and the prevention of intestinal insufficiency syndrome, contributes to the reduction of postoperative complications from 33.8% to 12.6% and mortality from 7.2% to 3.3%.

Background: Small bowel obstruction is defined as a mechanical or functional obstruction of the intestine preventing the normal transit of product of digestion. It can occur at any level distal to the duodenum and is considered to be a medical emergency. Acute intestinal obstruction has attracted wide attention and extensive research. As a consequence of experimental research, a considerable decline has been observed in the mortality of acute intestinal obstruction. The aim of this study was to observe the causes, evaluation and surgical management of small bowel obstruction among cases presenting with the same in the Department of General Surgery of Katihar Medical College. Methods: Eighty cases of small bowel obstruction were observed in this study. The cases were selected among patients visiting the outdoor clinic of General Surgery in Katihar Medical College. The selected cases belonged to different aetiology, age groups and sex. Results: Abdominal tenderness was the commonest finding during per abdomen examination. Adhesion was the commonest aetiology observed in this study followed by obstructed hernia. General trend of reporting to the hospital was observed to be on the third day of onset. Higher incidence of small bowel obstruction was observed in cases in sixth decade of life. There was predominance among the males and in cases belonging to lower socio-economic class. Conclusions: Mechanical obstruction of the small intestine due to extrinsic causes constituted a major part among the presenting cases in this study. The degree of distension has a direct relation with the duration of the symptom. Small bowel obstruction can be confirmed using a radiogram in erect posture. Mortality due to small bowel obstruction can be reduced if timely intervention is sought by the presenting cases. Early diagnosis, effective resuscitation and timely surgery are the main treatment options that should be considered.

Introduction: Acute abdomen is a very common problem in emergency department. Aims and Objectives: This study aims to find out the clinical and epidemiology profile of acute abdominal pain among patients attending emergency department of Santosh Medical College Ghaziabad. Materials and Methods: A tertiary care hospital based, cross-sectional study was conducted from January 2018- April 2019 2018, among patients presenting with acute abdominal pain to Santosh Medical College Ghaziabad, India. Data was entered on a standard data collection sheet after obtaining a written informed consent. Results: Out of 1200 patients admitted via the Emergency Department at the Hospital, 200 (16.6%) were admitted with atraumatic acute abdominal pain. Out of 200, 120(60%) were due to Surgical causes and 80 due to non-surgical causes. Most consistent symptom and sign were pain abdomen and abdominal tenderness respectively. Acute cholecystitis was the most common etiology of acute abdominal pain (35.8% cases), followed by, Renal Stones (30.5%), Acute Appendicitis (17.5%) and Intestinal Obstruction (16.67%) respectively. Conclusion: About 16.60% of all emergency admissions were due to acute abdominal pain and about 60.0% of all atraumatic acute abdominal pain was due to surgical cause. Acute cholecystitis was the most common cause of surgical abdominal pain. Keywords: Acute abdominal pain (AAP), Right hypochondrium (RHC), Epigastrium, Hypochondrium.

Background: Diabetes mellitus (DM) is a complex endocrinological disorder with altered metabolism of blood glucose. Diabetic ketoacidosis (DKA) is one of the life-threatening acute complications of DM that mainly occurs in type 1 diabetes patients, as well as in some patients with type 2 diabetes. The mortality rate associated with DKA depends on the experience of the treating hospital in dealing with this condition; thus, it is critical that patients detect DKA and get medical help as soon as possible. Aims and Objectives: To study risk factors for DKA, clinical and biochemical profile of DKA patients. Correlation between serum amylase level, serum bicarbonate level and mean duration of hospital stay. Materials and Methods: A cross-sectional analytical study was carried out on 100 DKA patients in the Department of Medicine, SGMH Rewa, Madhya Pradesh from January 2021 to June 2022. The data extracted included clinical presentation, precipitating factors, laboratory profile, complications, and hospitalization outcomes. Results: Of the 100 patients admitted for DKA; 70 had type 2 diabetes (70%) and 30 (30%) were type I diabetes. The average age at the time of presentation was 48.61±19.59 years. The commonest precipitating factor was infection (38%) followed by other factors (62%). The most common clinical features at the time of presentation were altered sensorium, fever, vomiting, polyuria, polydipsia, weakness, lethargy, myalgia, headache, anorexia, abdominal pain, and orthopnea. The values for RBS, HCO3, and pH were 525.0±62.4, 12.6±2.69, and 7.14±0.31, respectively. There was no significant difference in clinical and biochemical profile of patients with type 1 and type 2 diabetes. The mortality rate was 3% and factors found to be significant predictors were comorbid condition, severity of mental status, severity of dehydration, RBS at the time of presentation, and severe acidosis. Conclusion: The most common precipitating factors are infection and omission of insulin or irregular treatment. The most common clinical features at the time of presentation are nausea, vomiting, abdominal pain, headache, and dehydration. There is no significant difference in the clinical and biochemical profile of patients with type 1 and type 2 diabetes. The mortality rate in DKA is 3% and the most notable predictors of poor prognosis are; severity of altered sensorium, severity of comorbid condition, severe dehydration, severe acidosis, and identification and treatment of precipitating factors are more important. Patient education plays a crucial role in the prevention of DKA.