Factors influencing the prognosis in acute intestinal obstruction. II. Special obstructions.
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In the light of three cases of their own observation, of children with mesenteric cysts causing complete or incomplete intestinal obstruction, the authors review the existing literature on the subject, discuss the etiology, clinical aspects, and therapeutic methods for the correction of such pathology, and conclude by calling attention to mesenteric cysts as possible causes of intestinal transit disorders in the pediatric age group.
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Internal hernia is a rare condition. These hernias are classified in different categories, depending on the location of its orifice. It should be considered in cases of acute intestinal obstruction, particularly in the absence of an external hernia or in the absence of history of previous abdominal surgery. The authors report a unique case of obstruction of the small bowel, that was almost entirely wrapped in a separate peritoneal sac.
Internal hernias through the broad ligament are an extremely rare cause of intestinal obstruction. Clinical symptoms and imaging are often nonspecific, making preoperative diagnosis difficult. The authors report a case in which multidetector computed tomography proved useful in the preoperative diagnosis.
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In total, 62 cases with advanced gynecological malignancy were analyzed for the value of interventions for intestinal obstruction. 35 patients had an ileostomy, 7 patients had other palliative surgical intervention and 20 patients were managed conservatively. The median survival after surgical intervention was 7.7 months as against 1.3 months in conservatively treated patients. After surgery, all patients were affected by severe complications due to the primary disease. 22 (52.3%) of surgically treated patients received further therapy. 45 out of 62 patients (77.4%) died of progressive cancer and 14 (22.6%) of ileus. Surgical intervention had a positive effect on survival time, but only a marginal effect on life quality.
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Based on a routine ultrasonic screening program of patients suffering from acute abdominal disorders, the efficacy of ultrasonic diagnosis of intestinal obstruction was assessed prospectively in a series of 48 patients. In the entire series proven to suffer from ileus, all were correctly diagnosed prior to further procedures. In cases with marked gaseous distention, typical ultrasonic patterns were objectivated using a side position of the patients. The assessment of specific mucosal structures permitted the identification of the obstruction site in mechanical ileus. Sonographic observation in real time motion yielded a differential diagnosis of cases with persisting peristalsis and cases with complete paralysis. In 6 cases, causative diagnosis of ileus was achieved by sonography alone, in 12 cases by combination of clinical and sonographic findings.
In this report, we present a six-year-old male patient with partial intestinal obstruction due to refractory Non-Hodgkin's lymphoma (NHL) whose partial obstruction was successfully treated with Taxol(R) without any surgical intervention. Following an unsuccessful treatment attempt to treat his high-grade (stage 3) B-cell lymphoma with standard and second-line chemotherapy regimens he was started on radiotherapy and third line chemotherapy during which he was admitted with partial obstructive ileus as a result of tumor progression. Treatment was continued with Taxol(R) and resulted in total cure of the ileus with reduction of palpable tumor mass over 24 h without necessitating any surgery. Taxol(R) (200 mg/m (2)/week) was administered without any major side effects/toxicities for six courses. A control CT of the abdomen revealed a significant reduction in tumor size. After the next course, the patient developed severe thrombocytopenia that unfortunately did not resolve before the patient died as a result of further tumor growth and dissemination. Although there are studies that report response to Taxol(R) treatment in adult patients with refractory NHL, our review of the literature failed to demonstrate any report about the effectiveness of Taxol(R) in childhood NHL. In conclusion, our case may indicate that Taxol(R) can be effective and be administered safely in an outpatient setting in children with refractory NHL with the aim of prolonging the survival without sacrificing good quality of life. Studies on larger number of patients are needed to make a definitive conclusion about the value of Taxol(R) in refractory childhood NHL.
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Gastric lipoma is a rare benign tumor. The symptoms are correlated with the size and the dimensions of neoplasm. It can be the cause of bleeding, gastroduodenal intussusception and intestinal obstruction, as in case reported and surgically treated. The Authors make a literature review to define the better diagnostic and surgical approach.
The diagnosis of cystic fibrosis in utero is based on amniotic fluid analysis. False negative results of this method underline the importance of antenatal ultrasonography to detect intestinal obstruction in affected fetuses.
Seven adults and four children with phytobezoar obstruction to the small bowel were reported. All adult patients had undergone previous laparotomies, six of which were gastric operations. Phytobezoar obstruction was not suspected in any of the adult patients and surgery was necessary to relieve the obstruction. Abnormal gastric function may predispose phytobezoars, and surgeons should be aware of the possibility in patients with previous gastric surgery. The children had been previously healthy, but all had a history of eating an excessive amount of fruit or seeds before the onset of symptoms. The obstruction was found to be incomplete and could be relieved by conservative treatment, including the use of colonic washouts. In children with intestinal obstruction a good dietary history should lead to the correct diagnosis so that surgery may be avoided.
The morphologic changes of the small intestine after the mechanical obstruction were studied by light and electron microscopy. After the ligation of the upper small intestine, segments of jejunum, both proximal and distal to the site of obstruction, were removed at intervals varying from 45 min to 24 h. The essential changes were found in the epithelial cells of the tips of villi, and few morphologic differences were recognized between samples proximal and distal to the site of obstruction. The most remarkable changes in the mucosa were the pseudopodlike extension of the cytoplasm, vacuolar alteration of the villus epithelial cells, desquamation of these degenerated cells, and the dilatation of the epithelial intercellular spaces. A few epithelial cells showed hypertrophy of the smooth endoplasmic reticulum. In the submucosa, vascular stasis and edema were observed throughout the course. The mechanism of fluid loss into the intestinal lumen was discussed briefly.
From January 1985 to December 1989 in our Department 178 patients were operated for colorectal carcinomas. Fifty (28%) underwent emergency procedure for intestinal obstruction. The male-female ratio is about 1. The mean age is 79.6 (range 40-91), but 76% of patients is 60-85 years old. The rectum-sigmoid junction was the most affected (30%), followed by the rectum (18%) and the sigma (16%). Thirty-five (70%) patients underwent intestinal resection. The early postoperative death rate is 18% (9 cases). All the patients operated upon had Dukes stage B-C neoplasms.
At the birth of two children the amniotic fluid was green colored. The Apgar scores were good. Because of bilious vomiting and food retention, respectively, an open stomach tube was inserted, out of which bilious stomach contains were drained. The cause of green amniotic fluid was not meconium production or infection with Listeria monocytogenes, but mixing with green bile. At further investigation the children both proved to have a high intestinal obstruction distal of the papilla duodeni major.