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PubMed2004

Fluid resuscitation improves intestinal blood flow and reduces the mucosal damage associated with strangulation obstruction in pigs.

BACKGROUND: Strangulation obstruction of the small bowel is associated with local and systemic circulatory changes, local loss of fluid, and damage of the strangulated bowel segment. We wanted to examine to which extent these changes can be prevented by intravenous fluid administration. MATERIALS AND METHODS: In anesthetized pigs, strangulation obstruction was induced by increasing the pressure in a baby pressure gasket placed around a loop of ileum until venous pressure in the loop reached 50 mm Hg. During the strangulation period (180 min), a group of eight animals (Fluid(min) group) received 10 ml. kg(-1). hour(-1) Ringer acetate solution intravenously, whereas another eight animals (Fluid(max) group) received 55 ml. kg(-1). hour(-1) Ringer acetate solution intravenously. Blood flow to the strangulated bowel was measured by transit time flowmetry and colored microspheres. After completed experiments, whole wall samples of the strangulated loop were selected for microscopy. RESULTS: In the Fluid(min) group, the heart rate increased, the arterial pressure decreased markedly, and the urine output decreased toward zero. In the Fluid(max) group, the heart rate and arterial pressure remained fairly constant and the urine output increased. Blood flow to the strangulated bowel decreased in both groups, but significantly more in the Fluid(min) group. The intestinal blood flow was highly dependent on the arterial blood pressure. The strangulated mucosa showed markedly more damage in the Fluid(min) group than the Fluid(max) group. The degree of mucosal damage correlated linearly with the mucosal blood flow. CONCLUSION: The administration of large amounts of fluid to animals with strangulation obstruction normalized the arterial pressure and improved the intestinal blood flow thus minimizing damage to the intestinal mucosa.

Animals↗
PubMed1999

Endotoxin and cytokine release in strangulation obstruction and in partial occlusion of the mesenteric artery in pigs.

BACKGROUND: The study was performed to determine if endotoxin or the cytokines interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor (TNF) are liberated from strangulated or partially ischemic small bowel. METHODS: Strangulation obstruction was induced by elevating pressure in a gasket placed around a loop of ileum until venous pressure reached 50 mm Hg. Low arterial flow in a loop of ileum was produced by arterial clamping reducing blood flow by 70%. A proximal bowel loop was used for control. Arterial blood flow was measured by transit time flowmetry. Blood samples were collected before and after 30, 90 and 180 min of strangulation or clamping. Plasma levels of endotoxin and cytokines (TNF, IL-1 and IL-6) were measured by limulus amebocyte lysate test and bioassays, respectively. RESULTS: Strangulation obstruction caused more extensive mucosal damage than arterial clamping. Strangulation was followed by markedly increased venous concentration and release of IL-6 in the strangulated loop. Partial arterial occlusion did not cause increased release of IL-6. Strangulation or partial clamping did not influence the concentration of endotoxin, IL-1 or TNF in intestinal venous blood. CONCLUSIONS: Strangulation obstruction causes increased release of IL-6 to intestinal venous blood. IL-6 levels did not increase after 70% reduction of arterial blood flow. The early IL-6 increase was not detected in systemic blood. Strangulation did not cause early changes in plasma levels of endotoxin, TNF or IL-1.

Animals↗
PubMed2003

Strangulated external hernias in Kumasi.

BACKGROUND: In our hospital, Komfo Anokye, Kumasi theatre records show that more than 65 per cent of hernia repairs are performed for strangulation. The low level of elective repair may be linked to poverty, ignorance and fear, factors commonly found in a rapidly expanding young city like Kumasi with ever increasing population. This paper highlights the morbidity and mortality associated with surgery for strangulated external hernias. METHOD: The details of consecutive adult patients admitted to our emergency ward with a diagnosis of strangulated hernia were recorded. In addition the mode of presentation, hernia type, treatment and the outcome were recorded for each case. RESULTS: Out of 120 strangulated external hernias 76 were indirect, 6 recurrent and 4 direct a total of 86 (71.7%) inguinal hernias. Strangulated femoral hernias were diagnosed in 12 (10 percent)) of the cases. These were all females. Other hernias included 13 (10.8%) para-umbilical and 9 (7.5%) of incisional hernias. Strangulation occurred in more men (80) than women (40) and 75% of these patients were aged 50 years or below. The most common physical sign for the diagnosis of strangulation was a tender lump at a previous hernia site. One hundred and seventeen patients were operated upon with an over all bowel resection rate of 24.1%. The over-all mortality was 11.8%. For the inguinal hernias, mortality was lower at 6.2% but higher for the incisional hernia at 33%. Apart from hernia type delayed operation after 72 hours increased the need for bowel resection. CONCLUSION: The significant and unacceptable morbidity and mortality associated with surgery for strangulated hernias may be avoided by advocating for mass elective repair of these hernias before strangulation occurred.

Adult↗
PubMed1998

Release of endothelin-1 in strangulation obstruction of the small bowel in pigs.

Evidence has been provided that increased portal vein pressure results in increased release of endothelin-1 (ET-1). Strangulation obstruction is associated with increased venous pressure, and we wanted to determine if it is associated with increased local release of ET-1 and elevated concentration of ET-1 in systemic blood. Strangulation obstruction was induced by elevating pressure in a gasket placed around a loop of ileum until venous pressure reached 50 mm Hg. Ischemia in a bowel loop was induced by arterial clamping, reducing blood flow by 70%. Blood samples were collected before and after 30, 90, and 180 min of strangulation or ischemia. ET-1 was determined by radioimmunoassay following acidification and extraction on C18 columns. In strangulated loop the blood flow decreased by 70%. ET-1 concentration remained around 5 pg/ml in arterial blood, increased fourfold in strangulated venous blood, and remained unchanged in venous blood from control bowel. The release of ET-1 from the strangulated loop to blood increased twofold. Ischemia resulted in reduced release of ET-1. It is concluded that strangulation obstruction causes increased release of ET-1 to venous blood in the strangulated loop, but not increased ET-1 concentration in systemic blood. The increased ET-1 release was probably due to increased venous pressure, not to low blood flow.

Animals↗
PubMed1983

Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability.

Early recognition of intestinal strangulation in patients with small bowel obstruction is essential to allow safe nonoperative management of selected patients. We prospectively evaluated preoperative diagnostic parameters as well as the preoperative judgement of the senior attending surgeon for the determination of the presence or absence of intestinal strangulation in 51 consecutive patients who were about to undergo laparotomy for complete mechanical small bowel obstruction. Strangulation was present in 21 (42 percent) of the 51 patients. No preoperative clinical parameter, including the presence of continuous abdominal pain, fever, peritoneal signs, leukocytosis, or acidosis, or a combination thereof proved to be sensitive, specific, and predictive for strangulation. Moreover, the senior surgeon's experienced clinical judgement detected strangulation in only 10 of 21 patients with strangulation preoperatively (sensitivity, 48 percent). Indeed, only 1 of these 10 patients had an early, reversible lesion, whereas 9 had advanced, irreversible infarction. Only 25 of 36 preoperative assessments of simple obstruction proved correct (predictive value of an assessment of no strangulation, 69 percent). Overall, the preoperative assessment was correct in only 35 of the 51 patients (efficiency, 70 percent). These data show that in patients with complete mechanical small bowel obstruction, the preoperative diagnosis of strangulation cannot be made or excluded reliably by any known clinical parameter, combination of parameters, or by experienced clinical judgement. Nonoperative management of complete intestinal obstruction is therefore undertaken at a calculated risk (31 +/- 51 percent in the present series) of delaying definitive treatment of intestinal ischemia.

Adolescent↗
PubMed1997

The quantitative alteration of the DNA content in strangulation marks is an artefact.

UNLABELLED: It is frequently difficult to prove the vitality in cases of fatal hanging. Using impulse cytophotometry, Müller et al. (Krim. Forens. Wiss. 44, 1981) reported on possibly vital alterations of the DNA content in five strangulation marks (hypodiploidy). The objective of the present study was to perform a re-evaluation by means of current methods of quantitative DNA analysis. The investigation included 24 cases of hanging (typical, n = 11; atypical, n = 13). DNA was extracted by use of phenol/chloroform and quantitated photometrically in relation to the tissue weight. In addition, skin specimens were examined histologically and their water content was determined. The mean DNA content of strangulation marks was 3.2 micrograms DNA/mg tissue, that one of uninjured skin (control) 1.4 microgram DNA/mg tissue. The ratio of DNA content between strangulation grooves and control skin varied from 1.2 to 5.2 (average: 2.4) implicating apparently elevated DNA levels in strangulation marks. Histology revealed typical changes with absence of leukocyte infiltration suggesting mechanical compression of DNA containing layers. The additional determination of the water content emerged-in dependence on the macroscopic appearance, dried or non-dried-reduced values for strangulation marks (average: 42% vs. 66%). Statistical analysis demonstrated a significant correlation between elevated DNA content and reduced water content of strangulation marks. CONCLUSION: the markedly elevated DNA content of strangulation marks is interpreted as an artefact due to drying of the skin with a reduction of the water content (and weight) in the course of mechanical cutaneous alterations (compression). Therefore, quantitative changes in the local DNA content of the groove have no importance as a sign of vitality in fatal strangulations.

Artifacts↗
PubMed2001

Clinical study of strangulation obstruction of the small bowel.

Early diagnosis of strangulation obstruction is very important for surgeons because delayed diagnosis often leads to severe complications. Thirty patients underwent an operation because of small bowel obstruction between April, 1993 and December, 1999. In the present study, we examined the differences in clinical findings between simple obstruction and strangulation obstruction. In addition, we examined the manifestation of systemic inflammatory response syndrome (SIRS) and whether it is useful for early diagnosis of strangulation obstruction, and whether it is correlated with the severity of ischemia due to strangulation. Tenderness was examined in all patients and signs such as abdominal irritation were detected more often in patients with strangulation obstruction than in the patients with simple obstruction. According to SIRS, the large number of the patients with strangulation obstruction showed SIRS before operation and the manifestation of SIRS correlated well with the length of the necrosis in the strangulated small bowel. We recognized the importance of anamnesis and clinical findings in examinations of small bowel obstruction, furthermore, it was suggested that SIRS should be the warning sign for strangulation obstruction.

Abdomen↗
PubMed2000

[Prognosis of strangulated inguinal hernia in the adult: influence of intestinal necrosis. Apropos of 34 cases].

The aim of this study was to determine the outcome for patients treated for strangulated inguinal hernia with intestinal resection for gangrenous. Between May 1997 and November 1998, 124 patients were admitted to our hospital for acute intestinal obstruction; 34 of them were treated for strangulated inguinal hernia and 17 underwent an intestinal resection. The outcome for the 34 patients with strangulated hernias were analysed retrospectively. Strangulated inguinal hernia occurred in young patients (80 per cent of our patients were aged under 45 years) and strangulation had evolved over an average of 2.5 days. The clinical picture was simple strangulated hernia in 10 cases, with intestinal obstruction syndrome in 15 cases, peritonitis in 3 cases, phlegmonous hernia in 4 cases, and fistulae in one case. Fifty per cent of patients had intestinal resection with poor means of resuscitation. This resection concerned 80 per cent of patients with strangulation lasting over 72 hours. Surgical repair of hernia was performed in 24 cases at the same time. There were numerous complications, notably: wound sepsis (16 cases), post-operative peritonitis (3 cases) and multiple system failure (12 cases). The mortality rate was 40 per cent and concerned 86 per cent of patients with small bowel necrosis and 89 per cent of those admitted after 96 hours of strangulation.

Adolescent↗
PubMed1989

The causes and value of hyperphosphatemia in experimental strangulation obstruction.

In model experiments with mongrel dogs, intestinal strangulation obstruction was induced by occluding the superior mesenteric veins, and a rise in the inorganic phosphate value of the blood was observed. The high inorganic phosphate values of the fluid exuding from the strangulated bowel suggest that intestinal factors associated with the strangulated bowel may be partly responsible for this elevated phosphatemia. However, hyperphosphatemia was also found in a model experiment in which the route through which the fluid was absorbed into the blood from the peritoneal cavity was interrupted by keeping the strangulated bowel in an intestinal bag. After this, in the model experiments in which a systemic blood pressure depression curve with a percentage reduction similar to that of the decreasing arterial blood pressure resulting from strangulation was produced (by exsanguination, and even by exsanguination with adequate perfusion of the gut), plasma inorganic phosphate values also increased. Therefore it is undeniable that systemic factors other than the above-mentioned local factors are related to the rise in plasma inorganic phosphate values in experimental strangulation obstruction. Because it is not possible to assert that phosphatemia is specific to intestinal strangulation, the importance of a rise in inorganic phosphate values in the early diagnosis of intestinal strangulation cannot be considered very great.

Animals↗
PubMed1987

Intestinal obstruction with strangulation of the small bowel.

The records of 128 patients operated on for adhesive complete mechanical obstruction of the small intestine were retrospectively reviewed. The gut proved to be strangulated in 53 cases, irreversibly in 16 and reversibly in 37, while 75 patients had simple obstruction (12, 29 and 59%). Continuous abdominal pain was more common in strangulation than in simple obstruction and leukocytosis was most common in irreversible strangulation (both differences significant). But no preoperative clinical parameter was specific for strangulation obstruction. Preoperative hospital stay greater than 25 hours was significantly more common in irreversible strangulation obstruction than in the other groups. Strangulation was preoperatively recognized in only 25% of the cases. The overall mortality rate was 5.5%, but with no statistical intergroup difference, possibly because so few patients died. The study showed that strangulation usually is unrecognized preoperatively, and that early operation is essential for obstruction due to intestinal strangulation. Early surgery is therefore indicated in most cases clinically diagnosed as intestinal obstruction.

Adolescent↗
PubMed1987

Small bowel obstruction: computer-assisted prediction of strangulation at presentation.

A multivariate computer analysis has been performed on the presenting data of patients with simple small bowel obstruction that settled with conservative treatment (n = 120) and of patients with viable strangulation small bowel obstruction (n = 38) and non-viable strangulation small bowel obstruction (n = 39) found at operation. Initially only 66 per cent of patients with viable strangulation and 46 per cent of those with non-viable strangulation had been treated by immediate surgery after resuscitation. The remainder had been treated conservatively for a median of 3.8 and 2.2 days respectively before undergoing surgery. The computer predicted on the basis of presenting symptoms and signs that 82 per cent of patients with viable strangulation and 97 per cent of those with non-viable strangulation had or would develop strangulation and should have undergone immediate surgery. We advocate that the computer can assist in the management of patients with small bowel obstruction.

Constriction, Pathologic↗
PubMed1989

Timing of strangulation in adult hernias.

This retrospective study aimed to determine why the incidence of strangulated hernias in adults remains high. Seventy-nine patients presented with clinical evidence of hernia strangulation which required urgent surgery during the period 1979-87. Forty-six patients (58 per cent) had noted a hernia present for at least 1 month before strangulation: 18 (23 per cent) had not reported it to their family doctor, 19 (24 per cent) were known by family practitioners or non-surgical medical personnel to have a hernia but had not been referred for surgical opinion, and nine (11 per cent) had been previously assessed surgically with a view to elective repair. Of these nine, five were considered unfit, three were on waiting lists for operation and one had refused surgery. Thirty-two patients (40 per cent) presented primarily with strangulation within days of developing a hernia. The duration of hernia before strangulation in one patient was unknown. Although an unavoidable number of patients will continue to present with strangulation within days of developing a hernia, the overall incidence could be significantly reduced by greater public awareness of the risks of hernia strangulation and by a policy of immediate patient referral and prompt elective repair.

Adult↗
PubMed2003

Usefulness of known computed tomography and clinical criteria for diagnosing strangulation in small-bowel obstruction: analysis of true and false interpretation groups in computed tomography.

Computed tomography (CT) criteria have proven useful, but not sufficient, for diagnosis of bowel strangulation. The purpose of the present study was to evaluate the use of clinical criteria in the interpretation of CT scans as a means of improving the diagnostic accuracy of CT, especially in patients whose CT scans are equivocal for distinguishing simple obstruction from strangulated obstruction. We analyzed the CT scans of 136 patients with simple (n=70) or strangulated (n=66) small-bowel obstruction. Three radiologists interpreted the CT scans independently for the presence of intestinal strangulation. According to their interpretation, 136 patients were divided into two groups, i.e., a false and a true interpretation group. The diagnostic value of known CT and four clinical criteria (tenderness, tachycardia, fever, and leukocytosis) were compared in the two groups. The diagnostic accuracy of CT criteria for distinguishing simple obstructions from strangulated small-bowel obstructions ranged between 73% and 80%. Of the 136 patients, 31 belonged to the false group and 105 to the true group. The CT criteria that were highly specific in both groups included severe mesenteric haziness, serrated beak, and poor bowel wall enhancement. Among the clinical criteria, both tachycardia and leukocytosis were highly specific in both groups. The number of positive clinical criteria was helpful in making a diagnosis; none or one clinical criterion indicated a simple obstruction, whereas three or four criteria indicated a strangulated obstruction; when this result was applied retrospectively to the false group, the CT diagnostic accuracy improved in 19 of the 31 patients. The use of clinical criteria when CT findings are equivocal, may overcome the inherent limitations of CT for diagnosing strangulated small-bowel obstruction.

False Negative Reactions↗
PubMed2005

The value of plasma cytokine measurement for the detection of strangulation in patients with bowel obstruction: a prospective, pilot study.

PURPOSE: The aim of this prospective blinded study was to examine whether measurement of plasma cytokines is a predictor of strangulation in patients with bowel obstruction. METHODS: Seventy-seven consecutive patients diagnosed with bowel obstruction were included. Blood samples were obtained at enrollment in all patients and at surgery (immediately before operation) if patients required surgery. RESULTS: Forty-three patients were managed conservatively (group 1) and 34 patients required surgery, of whom 20 had no bowel strangulation (group 2) and 14 had bowel strangulation (group 3). The mean plasma interleukin (IL)-6 levels at enrollment were significantly higher in group 3 (107.8 pg/ml) than in groups 1 (11.3 pg/ml, P < 0.0001 vs. group 3) and 2 (23.6 pg/ml, P < 0.0001 vs. group 3). The sensitivity and specificity of plasma IL-6 level (> or = 40 pg/ml) in predicting strangulation were 86 percent (95 percent confidence interval, 60-97 percent) and 86 percent (95 percent confidence interval, 80-88 percent), respectively. The plasma IL-6 levels at surgery significantly increased compared to those at enrollment (from 107.8 pg/ml to 205.8 pg/ml, P = 0.0003) in group 3, however, they did not increase significantly in group 2. Among other clinical and laboratory parameters, plasma lactic acid levels (> or = 15 mg/dl) at enrollment were significantly associated with strangulation. In the multivariate analysis, both plasma IL-6 (</> or = 40 pg/ml) and lactic acid (</> or =15 mg/dl) levels at enrollment were significant predictive factors for strangulation. IL-1beta and tumor necrosis factor-alpha were not detected in the plasma of most patients during the study. CONCLUSION: Plasma IL-6 measurement might be an additional diagnostic tool that can predict strangulation in patients with bowel obstruction.

Analysis of Variance↗
PubMed2004

Experimental studies to estimate the intestinal viability in a rat strangulated ileus model using a dielectric parameter.

This study aimed at establishment of adequate evaluation of intestinal viability before release of the strangulated intestine by measuring electrical properties. In rats a 20-cm segment of the distal ileum and mesentery was strangulated. The intestine was strangulated for 0, 2, 15, 45, 90, and 120 min. The conductance and capacitance obtained by impedance analyzer were used to calculate tan(delta)m in the strangulated intestine. ATP was measured as well. In another experiment, after various periods of strangulation, tan(delta)m was measured just before release of the strangulation. Rats were divided into Group A (survived for 7 days) and Group D (died within 7 days). There was a positive correlation between tan(delta)m and ATP levels (P < 0.01). And tan(delta)m was significantly greater in Group A than in Group D (P < 0.05). There were no deaths at a tan(delta)m value of 2.36 or more and no survivors at a tan(delta)m of less than 2.20 except for one rat. These results suggested that tan(delta)m may be a useful index of the viability of the strangulated intestine before reperfusion.

Adenosine Triphosphate↗
PubMed2001

Age distributions of horses with strangulation of the small intestine by a lipoma or in the epiploic foramen: 46 cases (1994-2000).

OBJECTIVE: To test the hypothesis that strangulation of the small intestine by a lipoma or in the epiploic foramen is more common in older horses. DESIGN: Retrospective study. ANIMALS: 46 horses. PROCEDURE: Ages of horses with strangulation of the small intestine by a lipoma (n = 29) or in the epiploic foramen (17) were compared with ages of 79 horses with miscellaneous small intestinal lesions. Effects of increasing age on risk of the diseases of interest were examined by use of logistic regression and a 1-sided trend test for binomial proportions. RESULTS: Mean age of the horses with strangulation in the epiploic foramen (9.6 years) was the same as that for the horses with miscellaneous small intestinal lesions (7.7), but mean age of the horses with strangulation by a lipoma (19.2) was significantly greater than that for the other groups. The proportion of horses with lipoma increased significantly with increasing age, but the proportion with strangulation in the epiploic foramen did not. CONCLUSIONS AND CLINICAL RELEVANCE: Results refute the current suggestion that increasing age predisposes horses for strangulation of the small intestine in the epiploic foramen but support the suggestion that the risk of strangulation of the small intestine by a lipoma increases with age.

Age Distribution↗
PubMedDate not supplied

Strangulated ventral hernia model in rats.

This study was performed to describe a new model of strangulation obstruction mimicking the situations relevant to abdominal hernias. The strangulation obstruction was induced either by intra-abdominal ligation of an ileal segment 2 cm in length (n = 20) or by a pursestring suture around a fascial defect with a strangulated intestinal loop placed subcutaneously (n = 20). Ten animals served as sham operated controls (n = 10). All animals were euthanized at 12 h postoperatively; strangulated ileum segments were collected for histopathological examination. Microscopic injury scores were similar in both strangulation groups, which were significantly different from the control group (p <.001). The model described here seems to be appropriate for use in further experimental studies concerning strangulation obstruction injury and its consequences, with the added advantage of visualization of the strangulated intestinal loop beneath the skin.

Animals↗
PubMed1988

Early mucosal healing and chronic changes in pony jejunum after various types of strangulation obstruction.

Strangulation obstruction was induced in anesthetized ponies for periods of 2 and 3 hours by clamping 45-cm segments of jejunum and their veins only (venous strangulation obstruction, VSO) and arteries and veins (arterial and venous strangulation obstruction, AVSO). These types of strangulation obstruction were studied in 4 segments in each of 4 ponies allowed to survive 12 hours (group 1) and in a single segment in each of 10 ponies allowed to survive 42 days (group 2) after the strangulation period ended. On visual inspection, segments subjected to VSO had hemorrhage and edema in the bowel wall and mesentery and were dark purple after all time intervals. They improved slowly after clamps were removed, but remained hemorrhagic and edematous. Segments subjected to AVSO were purple and had mild edema and scattered petechiae in the bowel wall and mesentery. They improved rapidly and closely resembled normal bowel after 5 minutes of reperfusion. On light and scanning electron microscopy, the mucosa of intestine subjected to VSO and AVSO had necrotic, denuded villi 1 hour after the strangulation periods ended. Twelve hours after removal of occlusion devices in group-1 ponies, 4 (25%) segments were unchanged, 4 (25%) had deteriorated, and 8 (50%) had stunted villus remnants partly or completely lined with regenerating epithelium. Separation and detachment of villus tip mucosal cells were seen in 3 of 4 control segments, 1 and 12 hours after the strangulation periods ended.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, General↗