Search Results (101)

A 57-year-old man presented with fever and progressive odynophagia three days after a suspected fish bone impaction. Laboratory tests revealed leukocytosis (17,400/µL) and an elevated C-reactive protein level (8.93 mg/dL). Initial chest radiography was unremarkable, ruling out pneumomediastinum. Contrast-enhanced computed tomography (CT) of the neck revealed focal thickening of the cervical esophageal wall, along with a low-attenuation collection and mild fat stranding surrounding the esophagus. Also, extraluminal air was absent. These findings supported the diagnosis of intramural abscess rather than free perforation. Upper endoscopy revealed a submucosal bulging lesion with a pinpoint mucosal defect that was actively draining pus, consistent with a contained intramural collection. Water-soluble contrast esophagogram confirmed smooth passage without extravasation, obstruction, or the double-lumen sign. The patient received bowel rest, intravenous piperacillin/tazobactam, and close observation. Symptoms and inflammatory markers improved, and follow-up CT confirmed the resolution of the intramural collection. Esophageal intramural abscesses develop when an infection spreads within the submucosa after a mucosal breach. In East Asia, this often occurs due to fish bone impaction. Early CT enables the differentiation of esophageal intramural abscess from perforation or dissection and guides the selection of conservative, rather than interventional, management. Full article

Cecal volvulus is a rare cause of acute abdominal pain, resulting from torsion of the cecum and ascending colon due to abnormal mobility caused by inadequate peritoneal fixation. Clinical presentation is often vague and nonspecific, which can delay diagnosis and treatment. Computed tomography (CT) is the imaging modality of choice, as it not only confirms the presence and location of the volvulus but also identifies serious complications such as ischemia or perforation. Abdominal radiographs may be inconclusive, especially when the twisted bowel loop is fluid-filled, aligned antero-posteriorly, or obscured by adjacent gas-filled loops. We present the case of a 65-year-old woman who arrived at the emergency department with sudden-onset abdominal pain. Abdominal CT revealed classic signs of cecal volvulus, including the rarely reported ‘embryo sign,’ which proved crucial for swift diagnosis and intervention. Recognizing both common and less common CT features, such as the embryo sign, is paramount for rapid diagnosis and appropriate management in emergency situations. Familiarity with the full radiologic spectrum of this condition can significantly improve patient outcomes. Full article

Background and Clinical Significance: Ingestion of foreign bodies may lead to perforation of the gastrointestinal tract in its various segments. This may be accompanied by infections of the mediastinum after esophageal perforations and peritonitis after perforations of the stomach and bowel. Case Presentation: A 64-year-old man was admitted to the hospital because of abdominal pain and fever. The laboratory testing showed increased indices of inflammation. A CT scan of the abdomen revealed perforation of the stomach pylorus wall from a foreign body. Additionally, there were imaging findings suggesting concealed peritonitis in the adjacent area of stomach perforation. A 3.9 cm foreign body was removed with gastroscopy. The investigation into the nature of the foreign body suggested that it was a fish otolith (a structure composed of calcium carbonate, also known as an ear bone). The patient adhered to a Mediterranean diet. He recalled ingesting parts of the head of a 2.5 kg sea bream about 40 days before his admission to the hospital. The patient received broad-spectrum antimicrobial treatment, specifically intravenous ampicillin/sulbactam (2 g/1 g) every 8 h. He had complete resolution of his infection, with full resolution of symptoms and normalization of all abnormal signs noted in the physical examination at outpatient follow-up. Conclusions: Ingestion of a fish otolith may lead to perforation of the gastrointestinal tract and subsequent intra-abdominal infection. Prompt diagnosis with abdominal imaging, especially a CT scan, removal of the foreign body by upper gastrointestinal endoscopy (if possible), and broad-spectrum antibiotics are necessary for the successful management of such cases. Full article

Background: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor prognosis, most frequently metastasizing to the liver, peritoneum, and lungs. Intestinal metastases are exceptionally rare and easily misinterpreted as primary small-bowel tumors, typically presenting with acute complications such as obstruction, perforation, or bleeding. Methods: We combined a detailed case description with a narrative literature review. PubMed/MEDLINE and Embase (2000–2025) were searched for case reports and case series describing intestinal metastases from PDAC with histopathological and immunohistochemical confirmation. Case presentation: We report a female patient presenting with acute intestinal obstruction caused by a synchronous ileal metastasis from PDAC. Imaging revealed an ileal stenosing lesion and a pancreatic body mass. An exploratory laparotomy identified a 3 cm transmural ileal tumor with additional serosal nodules. Histopathology confirmed a moderately differentiated adenocarcinoma. Immunohistochemistry supported pancreatic origin (CK7+, CA19-9+, faint CDX2), with mutant-type p53 positivity, ultra-low HER2/Neu expression, and a Ki-67 index of ~50%. The patient underwent segmental enterectomy with terminal ileostomy, followed by systemic therapy. Conclusions: This represents an exceptional and rare clinical finding rather than a presentation from which broad conclusions can be drawn. Histopathological and immunohistochemical analysis supported pancreatic origin and helped avoid misclassification as a primary intestinal neoplasm. It underscores the importance of careful clinicopathological correlation and multidisciplinary evaluation in atypical metastatic scenarios, while illustrating how surgery can provide symptom control and enable systemic therapy. Given its rarity, these observations should be interpreted with caution and regarded as descriptive rather than generalizable. Full article

Post-transplant lymphoproliferative disorder (PTLD) poses significant risks following organ transplantation, characterized by potential aggressiveness. This report aims to discuss a case of PTLD presenting as B-cell large-cell lymphoma (DLBCL) post kidney and pancreas transplantation. A 44-year-old female with type 1 diabetes underwent simultaneous cadaver kidney and pancreas transplantation. She presented with fever, night sweats, and weakness, revealing multiple lesions on CT, including in transplanted and native kidneys and pancreas. A biopsy of the transplant kidney confirmed PTLD, DLBCL subtype, with complex immunohistochemical findings. Chemotherapy (R-CHOP) was initiated but complicated by bowel perforation necessitating surgery and antibiotics, transplant renal vein thrombosis, pyelonephritis, and neutropenia. Despite the complications, the normal function of the transplanted kidney was maintained, which made it possible to implement the standard chemotherapy protocol. This case underscores the diagnostic challenges and therapeutic complexities of PTLD, specifically DLBCL, in transplant recipients. The co-infection of COVID-19 and aspergillosis in a multiple immunocompromised patient indicated a possible rapid course of the disease with global respiratory insufficiency and a fatal outcome despite all applied therapeutic modalities. Full article

Background: Multiple high-powered magnet ingestion is a surgical emergency due to inter-loop attraction leading to ischemia, necrosis, perforation, and fistula formation. While well documented in children, adult cases—particularly those complicated by entero-enteric fistula—remain rare, and management is largely extrapolated from pediatric guidelines. Objective: To present a rare case of adult entero-enteric fistula following multiple neodymium magnet ingestion, we review the literature and propose an adapted management algorithm for adults. Methods: A narrative PubMed review was performed to identify pediatric and adult cases of magnet ingestion complicated by gastrointestinal fistula. Search terms included magnet ingestion, entero-enteric fistula, neodymium, and adult. Reported case characteristics, diagnostic modalities, treatments, and outcomes were analyzed. Results: A 38-year-old male with schizophrenia presented with small bowel obstruction five days after ingesting multiple magnets. Abdominal radiography revealed clustered radiopaque bodies in the distal ileum. Emergency laparotomy identified an entero-enteric fistula caused by pressure necrosis from inter-loop magnetic attraction. Segmental enterectomy with side-to-side anastomosis was performed, with uneventful recovery. The literature review identified only a few adult cases, which showed similar pathophysiology but frequent diagnostic delays and higher complication rates compared with pediatric cases. Conclusions: This case adds to the scarce adult literature on magnet-induced entero-enteric fistula and supports the adaptation of pediatric-based protocols for adults, with attention paid to psychiatric comorbidity and delayed presentation. Early imaging, timely intervention, and multidisciplinary care are essential to prevent severe gastrointestinal injury. Full article

Background: Non-islet cell tumor hypoglycemia is increasingly reported with gastrointestinal stromal tumors (GIST), but population-level estimates of its clinical impact are limited. We evaluated associations between hypoglycemia and inpatient outcomes among GIST hospitalizations. Methods: We conducted a retrospective cross-sectional study of the National Inpatient Sample (NIS) 2018–2020. Adult GIST discharges were identified by ICD-10-CM codes and stratified by hypoglycemia. Primary outcomes were in-hospital mortality and resource utilization—length of stay (LOS) and total hospital charge. Secondary outcomes included malnutrition, sepsis, ascites, peritonitis, bowel perforation, intestinal obstruction, gastrointestinal bleeding, and iron deficiency anemia. Analyses used survey-weighted logistic regression for binary outcomes and generalized linear models for continuous outcomes. A propensity score-matched sensitivity analysis balanced sepsis and malnutrition. Results: Among 61,725 GIST hospitalizations, 0.72% had hypoglycemia. Mortality was 12.6% with hypoglycemia vs. 3.1% without; adjusted odds of death were higher (aOR 4.16, 95% CI 2.06–8.37; p < 0.001). Hypoglycemia was also associated with malnutrition (aOR 5.63, 3.37–9.40), sepsis (aOR 4.00, 2.24–7.14), ascites (aOR 3.43, 1.63–7.19), and peritonitis (aOR 2.91, 1.17–7.22). LOS was 4.61 days longer on average (not significant; p = 0.185), and total hospital charge was $5218 higher (β = 19,116.8; p = 0.95). In the matched cohort, the mortality association attenuated but persisted (aOR 1.38, 1.27–1.49; p < 0.001); peritonitis remained significant (aOR 1.10, 1.04–1.17), intestinal obstruction (aOR 4.91, 3.44–7.05) and iron deficiency anemia (aOR 3.54, 1.62–7.74) became significant, while ascites and gastrointestinal bleeding were not significant. Conclusions: Hypoglycemia in GIST, although uncommon, marks a higher-risk inpatient trajectory with increased mortality and several complications; these signals largely persist after balancing severity proxies. Resource-use differences were directionally higher but not statistically significant. Recognition of hypoglycemia may aid risk stratification and inpatient management in GIST. Full article

Background/Objectives: Pneumatosis cystoides intestinalis (PCI) is a rare condition in children characterized by gas-filled cysts in the intestinal wall. The presence of pneumoperitoneum poses significant diagnostic and therapeutic challenges, often mimicking gastrointestinal perforation. This systematic review aims to summarize the existing evidence on PCI-associated pneumoperitoneum in children. Methods: A systematic literature search was conducted in PubMed/Medline for articles published from January 1972 to March 2025. Studies involving patients ≤16 years old with PCI-related pneumoperitoneum and providing information on clinical presentation, diagnosis, treatment, and outcomes were included. Data extraction and study selection were independently performed by two reviewers in accordance with PRISMA guidelines. Results: Out of 209 articles initially identified, 23 studies comprising 95 pediatric cases (age range: 4 months–14 years) were included. The majority had underlying conditions such as malignancies, autoimmune disorders, or gastrointestinal motility issues and were often treated with corticosteroids and/or immunosuppressants. Most cases were incidentally diagnosed through radiographic imaging. Conservative treatment (bowel rest, antibiotics, parenteral nutrition) was applied in 85% of cases, while surgical intervention occurred in 11%. Only three cases had confirmed intestinal perforation. All patients experienced resolution of PCI; however, 20 died due to unrelated underlying diseases. Conclusion: Despite the case heterogeneity of this review, PCI-related pneumoperitoneum in children is an uncommon but clinically important entity, particularly in immunocompromised patients, that may lead to misdiagnosis and unnecessary surgery. Conservative management is effective in most cases, and clinical findings should guide treatment decisions. Increased awareness among pediatricians and surgeons is crucial to avoid overtreatment. Full article

Background/Objectives: Intra-abdominal infections (IAIs) constitute significant clinical challenges that can rapidly progress to life-threatening conditions if not promptly diagnosed and treated. Traditional pathogen identification methodologies, predominantly culture-based, frequently necessitate extended turnaround times (TATs) and exhibit limitations in detecting polymicrobial or anaerobic infections. Methods: We implemented Oxford Nanopore Technology (ONT) sequencing to analyze the microbiota in patients with IAIs at Taichung Veterans General Hospital. The study cohort comprised sixteen patients with IAIs. Following specimen collection, DNA extraction was performed, and then full-length 16S rRNA and ITS region amplification and subsequent ONT sequencing were conducted. Results: Conventional clinical culture-based methodologies detected pathogens in 13 patients. Among the 14 successfully sequenced specimens, ONT sequencing elucidated a diverse spectrum of bacteria and fungi, with read counts ranging from 375 to 19,716. Polymicrobial and anaerobe-enriched communities were predominantly observed in lower gastrointestinal tract infections, specifically colonic or small bowel perforations, whereas upper gastrointestinal perforations, including those of the stomach or duodenum, were frequently dominated by Streptococcus, Granulicatella, or Candida species. The sequencing identified pathogens concordant with culture results, including Escherichia coli, Enterococcus, and Candida albicans. In addition, anaerobic or low-abundance taxa were exclusively identifiable through sequencing methodologies. Conclusions: ONT sequencing facilitated results within up to 24 h and successfully detected pathogens in culture-negative cases. These findings underscore the utility of ONT sequencing as an expeditious and comprehensive diagnostic modality for IAIs. Full article

Background/Objectives: Infants with high-output enterostomies often require prolonged parenteral nutrition (PN), increasing risks of infections, liver dysfunction, and impaired growth. Mucous fistula refeeding (MFR) is proposed to enhance intestinal adaptation, weight gain, and distal bowel maturation. This systematic review and meta-analysis assessed its effectiveness, safety, and technical aspects. Methods: Following PRISMA guidelines, studies reporting MFR-related outcomes were included without data or language restrictions. Data sources included PubMed, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Library, and UpToDate. Bias risk was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Meta-analysis employed random- and fixed-effects models, with outcomes reported as odds ratios (ORs) and 95% confidence interval (CI). Primary outcomes assessed were weight gain, PN duration, and complications and statistical comparisons were made between MFR and non-MFR groups. Results: Seventeen studies involving 631 infants were included; 482 received MFR and 149 did not. MFR started at 31 postoperative days and lasted for 50 days on average, using varied reinfusion methods, catheter types, and fixation strategies. MFR significantly improved weight gain (4.7 vs. 24.2 g/day, p < 0.05) and reduced PN duration (60.3 vs. 95 days, p < 0.05). Hospital and NICU stays were also shorter (160 vs. 263 days, p < 0.05; 122 vs. 200 days, p < 0.05). Cholestasis risk was lower (OR 0.151, 95% CI 0.071–0.319, p < 0.0001), while effects on bilirubin levels were inconsistent. Complications included sepsis (3.5%), intestinal perforation (0.83%), hemorrhage (0.62%), with one MFR-related death (0.22%). Conclusions: Despite MFR benefits neonatal care, its practices remain heterogeneous. Standardized protocols are required to ensure MFR safety and efficacy. Full article

Background: Robotic deep inferior epigastric artery perforator (DIEP) flap surgery is a technique used for autologous breast reconstruction to maintain the integrity of the rectus abdominis muscle while also utilizing robotic assistance for flap harvest. This study assesses postoperative outcomes of patients undergoing robotic DIEP flap reconstruction through the measurement of postoperative pain, narcotics use, and antiemetic usage. Methods: A retrospective analysis was performed for patients undergoing robotic DIEP flap breast reconstruction between March 2024 and March 2025. Postoperative pain scores (1–10 scale), narcotics usage (measured in oral morphine equivalents), antiemetic usage, and complications were recorded. Patient outcomes were compared to a control group of 40 patients who had undergone abdominal-based free flap breast reconstruction. Results: Overall, 14 patients underwent robotic DIEP flap breast reconstruction, representing 24 breasts. The average patient age was 56.5 (range: 30–73). Ten patients underwent bilateral breast reconstruction, and four underwent unilateral breast reconstruction. The average length of stay postoperatively was 4.86 days (±1.23 days), and the return of bowel function occurred in 1.29 days (±0.47 days). No patients experienced an unplanned return to the OR or flap failure. Average pain scores on postoperative day 1 (POD1), 2 (POD2), and 3 (POD3) were 4.0 (±0.6), 3.4 (±0.6), and 2.93 (±0.5), respectively. Average antiemetic usage totalled 1.25 doses (±0.25). Average daily OME use was 27.7 (±5.0) for POD1, 25.96 (±6.3) for POD2, and 21.23 (±7.11) for POD3. This averaged to a total hospital OME use of 74.9 (±15.7) per patient. Patients undergoing robotic DIEP flap reconstruction required a significantly lower narcotics dosage, as well as a lower antiemetic dosage, during the first three days postoperatively compared to the control abdominal free flap group. Average pain scores in the robotic DIEP flap reconstruction patient group were also significantly decreased, specifically in POD2 and POD3. Conclusions: The robotic DIEP flap offers advantages in autologous breast reconstruction compared to other abdominal free flap reconstructive methods. In this limited retrospective study, the use of the robotic DIEP flap lowers chances of flap failure and complications, while also improving narcotics use, antiemetic use, and postoperative pain. Full article

Background and Clinical Significance: Acquired myenteric hypoganglionosis is a rare dysmotility disorder that can present in childhood and adulthood, characterized by a reduced number of ganglion cells within Auerbach’s plexus. Due to the rarity of the pathology, few case reports of acquired myenteric hypoganglionosis in adolescents have been described. This case report explores the presentation, risk factors, and surgical complications associated with the ultimate diagnosis of myenteric hypoganglionosis. Case Presentation: We present a case of a 12-year-old male with a history of constipation and achalasia, presenting with constipation and abdominal distention, who underwent a colonoscopy, which was converted to an exploratory laparotomy with loop ileostomy creation due to persistent significant abdominal distention. This was complicated by colonic perforation, most likely secondary to stercoral colitis, requiring takeback to the operating room on postoperative day 11 for an exploratory laparotomy with bowel resection and mucous fistula creation. The patient was then referred to Boston Children’s Hospital for motility studies, which revealed poor colonic motility and plans to reassess motility in 1 year. Conclusions: Although rare, it is important to have high clinical suspicion for acquired myenteric hypoganglionosis in children, especially males, with severe constipation. Full article

Background and Clinical Significance: Pylephlebitis is a suppurative thrombophlebitis of porto-mesenteric veins. It is a rare complication of intraabdominal infection or inflammation. Case Presentation: A 46-year-old female patient presented to the Emergency Department (ED) with a three-day history of subfebrile body temperature (37.5 °C) and dull pain in the right lower abdominal quadrant propagating to the left lower quadrant, with frequent bowel movements and liquid stool consistency. Inflammatory markers were elevated. Following transabdominal ultrasound, possible diagnoses were inflammatory changes of the appendix or sigmoid colon. She was given oral antibiotics and discharged home with a surgical follow-up the next morning. The next day, due to the worsening of the symptoms, surgery was performed with no additional imaging studies. Intraoperative findings were diverticulitis of the sigmoid colon with perforation and peritoneal inflammation, and primary anastomosis with a diverting ileosotomy was performed. The patient was discharged from the hospital after seven days with completed antibiotic treatment. Twelve days later, the patient presented to the ED with a two-day fever (38 °C), elevated inflammatory markers and imaging findings consistent with pylephlebitis: complete left portal vein thrombosis, partial thrombosis of the segmental branch of the right portal vein and thrombosis of the inferior mesenteric vein. The administration of anticoagulants and antibiotics started and after nine days she was discharged home. Conclusions: Timely treatment is a necessity in patients with diverticulitis to prevent complications. Furthermore, clinicians and radiologists should be familiar with vascular complications of diverticulitis because their detection and the following treatment can prevent more extensive disease. Full article

Background/Objectives: Small bowel tumors (SBTs) encompass a diverse range of tumor types, with benign tumors being the most prevalent. However, the incidence of malignant SBTs is increasing, particularly small bowel adenocarcinoma; this poses a diagnostic challenge for clinicians and radiologists due to the varied and nonspecific clinical and radiological presentations associated with SBTs. In fact, SBTs can present differently in emergencies, often mimicking inflammatory diseases or manifesting as complications such as intussusception, small bowel obstruction (SBO), intestinal ischemia, perforation, gastrointestinal bleeding, or metastatic disease. These tumors can remain asymptomatic for extended periods. Methods: We present a pictorial review on the role of imaging in evaluating SBTs, focusing on the emergency setting where diagnosis can be incidental. We also include some representative cases that may be useful for radiologists and residents in clinical practice. Results: Despite these challenges, contrast-enhanced computed tomography (CECT) is usually the best modality to use in emergencies for evaluating SBTs, and in some cases, a diagnosis can be made incidentally. However, when possible, multimodal imaging through cross-sectional imaging remains crucial for the non-invasive diagnosis of SBTs in stable patients, as endoscopic procedures may also be impractical. A complementary CT study with distension using negative oral contrast media, such as water, polyethylene glycol, or mannitol solutions, can improve the characterization of SBTs and rule out multiple SBT locations, particularly in small bowel neuroendocrine tumor (NET) and gastrointestinal tumor (GIST) localization. Positive water-soluble iodine-based oral contrast, such as Gastrografin (GGF), can be used to evaluate and monitor the intestinal lumen during the nonsurgical management of small bowel obstruction (SBO) or in suspected cases of small bowel perforations or the presence of fistulas. Magnetic resonance enterography (MRE) can aid in improving the characterization of SBTs through a multiplanar and multisequence study. Positron emission tomography combined with CT is generally an essential modality in evaluating metastatic disease and staging and assessing tumor prognosis, but it has limitations for indolent lymphoma and small NETs. Conclusions: Therefore, the integration of multiple imaging modalities can improve patient management and provide a preoperative risk assessment with prognostic and predictive indicators. In the future, radiomics could potentially serve as a “virtual biopsy” for SBTs, allowing for better diagnosis and more personalized management in precision medicine. Full article

Background: Vascular Ehlers–Danlos syndrome (vEDS) is a rare connective tissue disorder characterized by collagen type III deficiency, predisposing to spontaneous arterial, uterine, and intestinal ruptures. While intestinal complications are recognized in vEDS, intestinal failure (IF) secondary to these complications is a rare and potentially life-threatening occurrence. This study aimed to describe the clinical presentation, surgical management, and outcomes of pediatric patients with IF secondary to vEDS and to provide a comprehensive review of the limited existing literature on this challenging clinical scenario. Methods: This study comprises a case series of pediatric patients with IF due to vEDS complications and a comprehensive literature review. Clinical data were collected from medical records, including age at diagnosis, surgical history, complications, nutritional status, and long-term outcomes. A literature review was performed to identify studies reporting gastrointestinal complications, surgical outcomes in pediatric vEDS patients, and cases of intestinal failure. Results: Two pediatric patients with vEDS and IF were included. Both patients experienced intestinal perforations and surgical complications and required long-term parenteral nutrition (PN). One patient required PN for 18 months before achieving enteral autonomy, while the other remains dependent. The literature review included four articles and revealed a high risk of complications, including anastomotic leaks, fistulae, and recurrent perforations, in patients with vEDS undergoing intestinal surgery. Delayed diagnosis of vEDS was common. Conclusions: Intestinal complications in pediatric patients with vEDS can lead to severe short bowel syndrome and long-term PN dependence. Early diagnosis and a multidisciplinary approach are crucial for optimizing patient care and minimizing complications. Full article