Search Results (215)

Background and Clinical Significance: Superior mesenteric artery syndrome (SMAS) is a rare and often underdiagnosed cause of proximal intestinal obstruction, resulting from compression of the third portion of the duodenum between the SMA and the aorta. It typically occurs in individuals with significant weight loss due to mesenteric fat depletion. CasePresentation: We report the case of a 14.5-year-old female presented with a 6-day history of intractable vomiting and epigastric pain, on a background of intermittent vomiting over the preceding six months associated with a 7 kg unintentional weight loss, culminating in inability to tolerate oral intake. Her clinical course was complicated by a transient episode of blurred vision, numbness, and incoherent speech, initially suspected to be a neurological event. Extensive gastrointestinal and neurological investigations were inconclusive. Elevated fecal calprotectin levels raised suspicion for inflammatory bowel disease, given her family history, though endoscopy and histopathology were unremarkable. Advanced imaging ultimately demonstrated a markedly reduced aortomesenteric angle (6°) and distance (4 mm), confirming the diagnosis of SMAS. The patient was initially managed conservatively with total parenteral nutrition (TPN), achieving partial weight gain of 5 kg after 8 weeks of TPN. Due to persistent duodenal compression, surgical intervention was required. At 7-month follow-up, the patient remained symptom-free with restored nutritional status and a good weight gain. Conclusions: This case highlights the importance of considering SMAS in adolescents with chronic upper gastrointestinal symptoms and significant weight loss. Early recognition and appropriate imaging are essential to diagnosis, and timely surgical management can lead to excellent outcomes when conservative treatment is insufficient. Full article

Glucagon-like peptide-1 (GLP-1) receptor agonists and sodium–glucose cotransporter-2 (SGLT2) inhibitors have reshaped pharmacological management of type 2 diabetes, but emerging safety signals suggest a possible association with intestinal obstruction. Because many candidates for these agents already harbor risk factors for ileus and bowel obstruction, clarifying agent- and dose-specific gastrointestinal safety is clinically important. We aimed to re-evaluate the risk of intestinal obstruction across individual GLP-1 receptor agonists and SGLT2 inhibitors, with particular attention to dose stratification. We systematically searched eight databases through 21 January 2025 to identify randomized controlled trials (RCTs) comparing GLP-1 receptor agonists or SGLT2 inhibitors with placebo or active comparators in adults. The primary outcome was incident intestinal obstruction (small or large bowel). A frequentist random-effects network meta-analysis estimated odds ratios (ORs) with 95% confidence intervals (CIs) across drugs and dose tiers; Bayesian models and surface under the cumulative ranking (SUCRA) metrics were used for sensitivity analyses and treatment ranking. Risk of bias and certainty of evidence were assessed with standard Cochrane and GRADE-adapted tools. Fifty RCTs (47 publications; 192,359 participants) met inclusion criteria. Overall, canagliflozin use was associated with a higher incidence of intestinal obstruction than control therapies (OR 2.56, 95% CI 1.01–6.49), corresponding to an absolute risk difference of 0.15% and a number needed to harm of 658. High-dose canagliflozin (300 mg/day) showed the clearest signal (OR 3.42, 95% CI 1.08–10.76). In contrast, liraglutide was associated with a lower risk of intestinal obstruction (OR 0.44, 95% CI 0.24–0.81), with an absolute risk reduction of 0.34% and a number needed to treat of 295. No other GLP-1 receptor agonist or SGLT2 inhibitor demonstrated a statistically significant increase in obstruction risk. Frequentist and Bayesian analyses yielded concordant estimates and rankings. From a randomized-trial perspective, intestinal obstruction risk is not elevated for most GLP-1 receptor agonists and SGLT2 inhibitors. A dose-dependent safety signal was observed only for high-dose canagliflozin, whereas liraglutide may confer a protective effect. These findings refine gastrointestinal safety profiles for modern antidiabetic agents and may inform perioperative bowel management, drug selection, and dose optimization in patients at risk for ileus or adhesive obstruction. Full article

Background/Objectives: Metabolic comorbidities and systemic inflammation are implicated in colon carcinogenesis, yet their relationship with acute obstructive presentation and early in-hospital course remains unclear. This study evaluated whether age, metabolic multimorbidity, and inflammatory–metabolic biomarkers are associated with obstruction severity and length of stay in a surgical colon cancer cohort. Methods: We analyzed 677 consecutive adults undergoing surgery for histologically confirmed colon cancer. Acute presentation was categorized as no obstruction, subocclusive syndrome, or frank obstruction. Predictors included age, comorbidity count (multimorbidity defined as ≥2), diabetes, hypertension, and preoperative biomarkers (C-reactive protein (CRP), lipids, glucose; neutrophil-to-lymphocyte ratio (NLR)/platelet-to-lymphocyte ratio (PLR)/C-reactive protein-to-albumin ratio (CAR)where available). Multivariable logistic and ordinal regression assessed obstructive presentation; linear regression assessed length of stay. Results: Subocclusion or obstruction occurred in 34.8% of patients. In multivariable logistic regression, age was independently associated with obstructive presentation (odds ratio (OR) 1.016 per year; 95% confidence interval (CI) 1.001–1.032), while comorbidity count and CRP were not. In an ordinal model, age increased the odds of more severe presentation (OR 1.018 per year), whereas diabetes was inversely associated (OR 0.573). Length of stay was independently associated only with presentation severity (β = −0.959 days per category). Correlations between inflammatory indices and length of stay were negligible. Conclusions: In this hospital-based surgical cohort, age showed a modest association with obstructive presentation, while metabolic multimorbidity and routine inflammatory markers provided limited discrimination for obstruction or early in-hospital resource use. Full article

Background: Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, is an acute but reversible form of left ventricular dysfunction, most commonly triggered by physical or emotional stress. Although well documented in cardiology practice, its occurrence following hepatobiliary surgery is rarely reported. Case presentation: We describe the case of a 67-year-old woman with a history of arterial hypertension and prior cholecystectomy who was admitted for elective hepatobiliary surgery due to choledocholithiasis complicated by a liver abscess. She underwent laparotomy with choledocholithotomy, hepaticojejunostomy, and abdominal drainage. The postoperative course was complicated by intra-abdominal bleeding, requiring reoperation, and subsequent intestinal leakage, necessitating a second re-laparotomy. On the tenth postoperative day after the second surgery, she developed chest discomfort and dyspnea upon minimal exertion. Electrocardiography revealed T-wave inversions in leads V3–V6, while echocardiography demonstrated a reduced ejection fraction of 45% with apical akinesis. Plasma levels of N-terminal pro-B-type natriuretic peptide (NT–proBNP) were elevated, whereas troponin remained within normal limits. Coronary angiography excluded obstructive coronary artery disease, and ventriculography confirmed apical ballooning consistent with Takotsubo cardiomyopathy. Conclusions: This case highlights Takotsubo cardiomyopathy as a rare but important postoperative complication of major hepatobiliary surgery. Awareness of this condition in surgical patients presenting with acute chest symptoms is essential, as timely recognition and differentiation from acute coronary syndrome directly influence management and prognosis. 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 Objectives: Gallstone ileus (GI) is a rare mechanical intestinal obstruction resulting from gallstone impaction through a bilioenteric fistula, accounting for 1–4% of mechanical intestinal obstructions. This study aimed to evaluate the clinical approach, surgical management, and outcomes in a cohort of surgically treated GI patients. Materials and Methods: A retrospective cohort analysis of 12 patients diagnosed with GI and treated surgically between January 2018 and December 2024 was conducted. Data collected included demographics, clinical presentation, imaging findings, surgical approach, and postoperative outcomes. Descriptive statistics were used due to small sample size. Results: All patients presented with abdominal pain and vomiting, with delayed admission (mean 3.83 ± 2.08 days). Rigler’s triad was identified on CT in 91.7% of cases. The distal ileum (66.7%) was the most common site of obstruction, with a mean stone size of 3.19 ± 0.6 cm. Surgical management included enterolithotomy alone (66.7%, n = 8) and one-stage procedures (33.3%, n = 4). Laparoscopic approaches were employed successfully in 41.7% of cases (n = 5) without the need for conversion. Postoperative complications occurred in 41.7% of patients, with 8.3% mortality (n = 1). One recurrence was observed during a median (IQR) follow-up period of 33.00 (7.00–66.00) months. Conclusions: GI management should be individualized based on patient risk factors. In our cohort, enterolithotomy alone was the most common approach for high-risk elderly patients, while one-stage procedures were performed in stable patients with residual gallstones. Laparoscopic approaches were utilized in selected hemodynamically stable patients with appropriate surgical expertise. Our experience suggests that minimally invasive techniques can be successfully achieved in this traditionally challenging condition with careful patient selection. Full article

In this study, the structural changes and reconstruction mechanism of sesame protein-derived amyloid fibrils under varied digestive parameters (pepsin concentration, digestive pH and ionic strength) during gastric digestion were investigated, and the effect of fibril reconstruction on the gastric digestion stability of β-carotene nanoparticles was also explored. The results demonstrated that amyloid fibrils underwent a three-stage dynamic process of enzymatic hydrolysis, regeneration and degradation during gastric digestion. The pepsin concentration of 2 mg/mL was found to promote the balance between fibril hydrolysis and regeneration. The fibrils displayed a pronounced regenerative capacity at pH values of 1.5 and 2.5, whereas at pH 3.5, which was proximal to the isoelectric point of protein, aggregation and precipitation were observed. Furthermore, it was found that 10 mM NaCl exerted minimal influence on fibril stability, whereas the higher concentrations of salt ions were shown to obstruct regeneration and promote aggregation. Analyses through SDS-PAGE, GPC, and MALDI-TOF-MS revealed a gradual reduction in the molecular weight of the fibrils during gastric digestion, with certain fragments reaggregating to form new fibril structures. The fibril-based delivery system formed a stable protective structure for β-carotene nanoparticles, which not only prevented their aggregation but also facilitated their release in the small intestine. Full article

Background and Clinical Significanc: Congenital duodenal diaphragm (CDD) is a rare congenital condition causing partial or complete obstruction of the duodenum, most frequently located in the second part of the duodenum. It is a rare but important cause of intestinal obstruction in infants and young children. Clinically, it often presents with persistent vomiting and failure to thrive. Diagnosis can be made through abdominal X-ray showing the characteristic “double bubble” sign, upper gastrointestinal (GI) series, or gastroscopy. Case Presentation: A 17-month-old female infant with known psychomotor retardation was admitted for evaluation of inadequate weight gain and intermittent postprandial vomiting, both present since birth. Laboratory investigations, including metabolic and electrolyte panels, were within normal limits. Given the persistent clinical symptoms, an upper gastrointestinal series was performed to assess for possible anatomical abnormalities. Imaging revealed a significant delay in the passage of contrast into the second portion of the duodenum, with marked prestenotic dilatation. Subsequent gastroscopy identified a duodenal diaphragm nearly occluding the duodenal lumen at the same site, impeding the passage of the endoscope. Associated findings included gastritis and the presence of food debris in the stomach and proximal duodenum, indicating impaired gastric emptying. The patient underwent successful surgical management via duodenotomy with resection of the septum. Postoperative recovery was uneventful. Conclusions: In infants or young children with persistent postprandial vomiting and inadequate weight gain, anatomical causes such as duodenal diaphragm/web should be considered in the differential diagnosis. Once identified, treatment should be initiated promptly, either endoscopically or surgically, depending on the severity and anatomical characteristics of the obstruction. Full article

Background: Behçet’s disease (BD) and granulomatosis with polyangiitis (GPA) are distinct vasculitides. PR3-ANCA is considered specific for GPA, yet rare BD cases demonstrate positivity, creating diagnostic dilemmas. Case Presentation: We describe a young man fulfilling criteria for BD, presenting with recurrent oral and genital ulcers, ocular inflammation, catastrophic jejunal perforations, pulmonary embolism, and myocardial infarction with non-obstructive coronary arteries. Despite strong PR3-ANCA positivity, the global phenotype was consistent with BD. Management required a complex, multimodal immunosuppressive regimen that included corticosteroids, cyclophosphamide, therapeutic plasma exchange, and rituximab. Conclusions: PR3-ANCA positivity may represent a severe BD phenotype rather than true GPA overlap, underscoring the need for individualized treatment strategies. Full article

Introduction: Colonic lipomas (CLs) are benign neoplasms originating from adipose tissue within the gastrointestinal tract. They are often asymptomatic, but in certain cases, patients may present with gastrointestinal bleeding or symptoms related to intestinal obstruction. We report the cases of 18 patients undergoing both surgical and endoscopic resection of colonic lipomas. Given the variability in symptoms, lesion size, and patient demographics, the management of CLs represents a clinical scenario where treatment must be tailored to the individual, aligning with the principles of personalized medicine. This study aims to clarify the clinical and morphological factors guiding treatment selection for colonic lipomas, emphasizing a personalized approach to management. Materials and Methods: We retrospectively reviewed a prospectively collected database of 18 patients with histological diagnosis of colon lipoma after both endoscopic and surgical resection at the Campus Bio-Medico University Hospital, Rome, from 2016 to the first months of 2025. Results: The average patient age was 66 years, and the average maximum size of lipoma was 2.87 cm. The anatomical location of lipomas is very varied, ranging from the ileocecal valve to the distal sigma, and most procedures were endoscopic. Conclusions: Despite the fact that no established guidelines about the management of the CLs are reported in literature, the different approaches are related to symptomatology. Our findings try to clarify and demonstrate how the therapeutic decision, whether endoscopic or surgical, is personalized based on the patients and their clinical condition, illustrating how CL management reflects the broader framework of personalized medicine. Our work confirms that the patients most prone to intussusception phenomena are young women with large colonic lipomas. Full article

Background and Clinical Significance: Adult small intestinal intussusception is rare and, in this population, is usually secondary to a pathological lead point, such as benign or malignant masses. The symptoms are non-specific, and patients frequently present with intermittent abdominal pain, diarrhea, nausea, vomiting, and, in rare cases, bleeding. There are currently no specific guidelines. Surgery remains the gold standard treatment. Case Presentation: We report the case of a 55-year-old female affected by Shone’s syndrome, presenting to the emergency department with melena, severe anemia, diffuse abdominal pain, weakness, and palpitations. Diagnostic tests showed active bleeding in the small intestine and a subocclusive condition. Urgent surgery was performed, revealing an intussusception. Conclusions: A multidisciplinary approach is essential for its management. Surgical resection is the only option in these cases, as it allows histological examination to rule out malignancy. 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

Background/Objectives: Since ¹⁷⁷Lu-DOTATATE was approved for patients with somatostatin receptor (SSTR)-positive gastroenteropancreatic neuroendocrine tumors (NETs), tumor flare reactions including increased pain and small bowel obstruction (SBO) have been reported. Retrospective reviews report some success in using corticosteroids for treatment and prophylaxis of tumor flare reactions from ¹⁷⁷Lu-DOTATATE. Given that corticosteroids are used in practice to help prevent tumor flare reactions based on limited evidence, we aimed to assess if this practice was efficacious in our patient population. Methods: In this retrospective and single-institution study, we identified adult patients with NETs who were treated with ¹⁷⁷Lu-DOTATATE between 1 October 2019 and 31 December 2024; these patients received corticosteroids as prophylaxis for flare reactions due to high burden of disease, significant peritoneal or mesenteric disease, or disease involvement of critical structures as determined by the treating provider. Variables including demographics, diagnosis, treatment history, steroid dosing, and outcomes were collected within a RedCAP database. Results: Forty-six patients were identified as having received corticosteroid prophylaxis to prevent a tumor flare reaction due to ¹⁷⁷Lu-DOTATATE. Patients had a median age of 66, and 50% were female. The primary disease site was the small intestine (72%) followed by the pancreas (9%). The majority of patients had World Health Organization (WHO) grade 1 (41%) or WHO grade 2 (35%) diseases. Most patients (83%) received corticosteroids prior to the initiation of ¹⁷⁷Lu-DOTATATE, while 17% of patients received corticosteroids due to having a previous tumor flare after ¹⁷⁷Lu-DOTATATE administration. Despite corticosteroid prophylaxis, 28% of patients still experienced a tumor flare event, with three patients experiencing multiple tumor flare events. Small bowel obstructions occurred in 7% of patients and increased abdominal pain in 22% of patients. Adverse events (AEs) due to corticosteroids occurred in 28% of patients. Conclusions: Short-course corticosteroid prophylaxis to prevent tumor flare reactions in high-risk patients with neuroendocrine tumors treated with ¹⁷⁷Lu-DOTATATE did not appear to decrease the incidence of tumor flare reactions compared to previously reported numbers. Randomized, placebo-controlled trials looking at the use of corticosteroids to prevent tumor flare reactions in patients treated with ¹⁷⁷Lu-DOTATATE are needed to fully elucidate the safety and efficacy of corticosteroids used in this setting and to determine the impact on treatment outcomes. Full article

Objective: This study aims to determine how intestinal obstruction influences the tumor immune microenvironment (TIME) and its impact on prognosis in colorectal cancer (CRC). Methods: Immune cell densities (CD4⁺, CD8⁺, CD20⁺, CD68⁺) within central tumor (CT) and invasive margin (IM) compartments were quantitatively analyzed using immunohistochemistry (IHC) and QuPath digital pathology in surgical resection samples from 328 patients (164 obstructed colon cancer [OCRC] vs. 164 non-obstructed [NOCRC], cohorts matched by propensity scoring). Findings on tumor-infiltrating immune cell spatial distribution were integrated with peripheral blood immune cell counts and clinicopathological characteristics to characterize the obstructed colon cancer immune microenvironment. Associations with disease-free survival (DFS) and overall survival (OS) were evaluated. Results: OCRC exhibited higher lymphocytic infiltration, particularly in the CT compartment, compared to NOCRC, with significantly elevated CT-CD8⁺ T cell density in T4-stage OCRC (p < 0.005). Obstruction enhanced immune cell correlations across compartments, especially in T4 tumors, and the CD68⁺/CD8⁺ ratio effectively discriminated obstruction status (CT area under the curve (AUC): T4 = 0.879). Peripheral lymphocytopenia was pronounced in obstructive cases (p = 0.003). Critically, T4 OCRC showed a complete loss of all correlations between tumor-infiltrating immune cells and peripheral parameters. Despite increased infiltration, high CD8⁺ density in OCRC correlated with worse prognosis, indicating a paradoxical role influenced by obstruction context. CD68⁺ macrophages in the invasive margin consistently predicted improved survival (Disease-free survival [DFS]: Hazard ratio [HR] = 0.59, p = 0.008). Conclusions: Intestinal obstruction in CRC, particularly in T4-stage tumors, may represent an immunologically active state that alters local immune infiltration and systemic–local immune crosstalk. These findings suggest that obstruction status could refine prognostic stratification and inform therapeutic strategies, although validation in larger cohorts is warranted. Full article

Background/Objectives: Acute appendicitis is the most common non-obstetric surgical emergency during pregnancy. Diagnosing appendicitis in the third trimester remains especially challenging due to physiological changes that obscure clinical presentation and limit the utility of imaging modalities. These challenges can lead to diagnostic delays, increasing the risk of severe complications for both mother and fetus. Case presentation: We present a complex case of a 36-year-old pregnant woman at 29 + 4 weeks of gestation who developed acute appendicitis with an atypical clinical course. Her initial symptoms were nonspecific and misattributed to gastrointestinal discomfort related to pregnancy. Her condition progressively worsened, leading to an emergency laparoscopic appendectomy. Intraoperative findings confirmed a perforated, necrotic appendix. Postoperatively, she experienced multiple complications, including ileus, wound dehiscence, and complete eventration of the abdominal wall. These required two additional laparotomies and the application of vacuum-assisted closure (VAC) therapy for effective wound management. Despite the severity of maternal complications and the risk of preterm delivery, a multidisciplinary team provided coordinated care. The patient was delivered vaginally at 34 + 4 weeks using vacuum assistance. The neonate, who developed sepsis, was treated in the neonatal intensive care unit and discharged after 24 days. Both mother and child ultimately recovered. Conclusions: This case highlights the diagnostic complexity of appendicitis in late pregnancy and the potential for severe postoperative complications. Prompt surgical intervention, high clinical suspicion, and a multidisciplinary approach are crucial. Moreover, this report adds to the limited literature on the use of VAC therapy for abdominal eventration in pregnancy, demonstrating its feasibility and safety in selected cases. Full article