Small bowel emergency surgery: literature's review
World Journal of Emergency Surgery
Small bowel emergency surgery: literature's review
Carlo Vallicelli 0 3
Federico Coccolini 0 3
Fausto Catena 0 3
Luca Ansaloni 2
Giulia Montori 0 3
Salomone Di Saverio 1
Antonio D Pinna 0 3
0 General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital , Bologna , Italy
1 Emergency and Trauma Surgery Dept., Maggiore Hospital , Bologna , Italy
2 General and Emergency Surgery Dept., Ospedali Riuniti Hospital , Bergamo , Italy
3 General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital , Bologna , Italy
Emergency surgery of the small bowel represents a challenge for the surgeon, in the third millennium as well. There is a wide number of pathologies which involve the small bowel. The present review, by analyzing the recent and past literature, resumes the more commons. The aim of the present review is to provide the main indications to face the principal pathologies an emergency surgeon has to face with during his daily activity.
The small intestine is a complex organ with several
functions. In fact it is capable of digestion, absorption
and secretion, endocrine function and protects the
internal environment against noxious ingested substances
and against luminal bacteria and their toxins. The
potential surface area available for digestion and
absorption is amplified 600-times by circular mucosa folds,
villus mucosal architecture and the microvillus surface of
epithelium. Although specific properties are
characteristic of specific segments of small bowel, like bile acid
absorption in distal ileum, maximal resections are
feasible without a significant morbidity because of the
compensatory adaptation of remaining intestine. The small
bowel measures about 120 cm in length from pylorus to
ileocecal valve. The jejunum begins at ligament of
Treitz. Jejunum and ileum are suspended by a mobile
mesentery covered by a visceral peritoneal lining that
extends onto the external surface of the bowel to form
the serosa. Jejunum and ileum receive their blood from
the superior mesenteric artery (SMA). Although
mesenteric arcades form a rich collateral network, occlusion of
a major branch of the SMA may result in segmental
intestinal infarction. Venous drain is via the superior
mesenteric vein, which then joins the splenic vein
behind the neck of the pancreas to form the portal vein.
Peyer’s patches are lymphoid aggregates present on the
antimesenteric border of distal ileum. Smaller follicles
are present through all small bowel. Lymphatic drainage
of intestine is abundant. Regional lymph nodes follow
the vascular arcades and then drein toward the cysterna
chyli. Jejunal and ileal wall consists of serosa,
muscolaris, submucosa and, innermost, mucosa [
Mechanical small bowel obstruction
Acute mechanical obstruction of the intestine is a
common surgical emergency and a major cause of admission
to emergency surgery departments. Small bowel
obstruction occurs when there is an obstacle to the flow
of luminal contents caused by an extrinsic or intrinsic
encroachment on the lumen [
]. Adynamic ileus
presents the same symptoms of mechanical obstruction but
the underlying problem is disordered motility. One of
the keys to management of intestinal obstruction is
early diagnosis. Particularly, accurate early recognition
of strangulation is crucial because this emergency causes
bowel ischemia, necrosis and perforation. In neonates
most common causes are atresia, midgut volvulus and
meconium ileus, in infants groin hernia, intussusception
and Meckel’s diverticulum, whereas in young adults and
adults adhesions and groin hernia [
]. In small bowel
obstruction the normal mechanisms of intestinal
absorption are compromised, so an excess of fluid loss occurs.
Initially vomiting, bowel wall edema and transudation
into the peritoneal cavity are present, whereas in the
later stages venous pressure increases with consequent
bleeding into the lumen and aggravation of hypovolemia
]. Diagnosis is usually clinical. Main symptoms are
abdominal pain, absence of flatus or stool, nausea or
vomiting, dehydration, and abdominal distension if the
obstruction is not in proximal jejunum [
the kind of pain suggests the level of the small bowel
obstruction. Proximal obstruction tend to present with
more frequent cramps whereas distal obstructions cause
less severe cramps with longer duration between
episodes. Laboratory tests show an elevated hematocrit
because of intravascular volume loss. A significant
leukocytosis could indicate a strangulation or perforation.
Plain X-rays of the abdomen reveal dilatation of the
small bowel and air-fluid levels [
]. CT scan, eventually
with oral contrast, shows the dilatation of proximal
bowel and the collapse of distal bowel [
ultrasounds may be useful [
]. The key of management of
small bowel obstruction is the identification of intestinal
strangulation, because mortality increases from 2 to 10
folds in such cases. Therefore an immediate surgical
repair with an eventual bowel resection is mandatory.
However, the clinical diagnosis of small bowel
strangulation is extremely difficult and CT scan becomes very
useful, usually on the basis of either bowel wall
thickening, mesenteric edema, asymmetrical enhancement with
contrast, pneumatosis, or portal venous gas. Mortality
for small bowel obstruction has decreased during the
past 50 to 60 years from 25% to 5% [
therapy aims at correction of depletion of intravascular
fluids and electrolyte abnormalities. The patient should
be given nothing by mouth and nasogastric tube should
be inserted in patients with emesis. In patients with
adhesive small intestine obstruction, water-soluble
contrast medium (Gastrografin®) with a follow-through
study has not only a diagnostic but also a therapeutic
role, because it is safe and reduces the operative rate
and the time to resolution of obstruction, as well as the
hospital stay [
]. Surgical intervention is instead
mandatory for patients with a complete small bowel
obstruction with signs or symptoms indicative of
strangulation, perforation or those patients with simple
obstruction that has not resolved within 24 to 48 hours
of non operative treatment [
]. The surgical approach
includes adhesiolysis and resection of non viable
intestine. The extension of intestinal resection depends on
the purple or black discoloration of ischemic or necrotic
bowel. Viable intestine also has mesenteric arterial
pulsation and normal motility. When ischemic damage
is more limited, is sufficient adhesiolysis followed by a
10-15 minutes period of observation to allow for
possible improvement in the gross appearance of the
The role of laparoscopy in small bowel obstruction
has still to be defined. Certainly, laparoscopy represents
a diagnostic act and sometimes has a therapeutic role
]. The major indication is small bowel obstruction
due to unique band adhesion without signs of ischemia
and necrosis. In laparoscopic procedures the first trocar
has to be positioned using Hasson’s technique for open
laparoscopy to avoid accidental bowel perforations
related to bowel distension and adhesions with the
abdominal wall. After that, two 5 mm trocars must be
introduced under vision to explore the peritoneal cavity
and find the bowel segment obstructed by the band
adhesion. If ischemic or necrotic bowel is present
conversion to open surgery may be necessary. An
atraumatic grasp can be used to isolate the band adhesion,
which is coagulated by bipolar coagulator and then
sectioned with scissors. So the obstructed bowel segment is
liberated. The rate of laparotomic conversions ranges
widely from 0% to 52%, depending on patient selection
and surgical skills [
]. The principle reason is a
difficult exposition and treatment of band adhesions due
to a reduced operating field caused by small bowel
dilatation, multiple band adhesions, and sometimes the
presence of posterior band adhesion which are more
difficult to treat laparoscopically. The predictive factors
for successful laparoscopic adhesiolysis are a number of
previous laparotomies lower than 3, a non-median
previous laparotomy, appendectomy as previous surgical
treatment causing adherences, a unique band adhesion,
an early laparoscopic management (possibly within
24 hours), no signs of peritonitis and the experience of
the surgeon [
]. Relative contraindication are 3 or
more previous laparotomies and multiple adherences.
Finally, absolute contraindications to laparoscopic
adhesiolysis are an abdominal film showing a remarkable
dilatation (more than 4 cm) of the small bowel, signs of
peritonitis, severe cardiovascular or respiratory
co-morbidities and haemostatic disease, and hemodynamic
instability. Laparotomic conversion is often related to a
higher morbidity rate, so when the predictive factors for
a successful laparoscopy are not present a primary
laparotomic access becomes necessary . In any case,
early conversion is recommended to reduce
postoperative morbidity [
]. Many studies in literature suggest
that laparoscopic adhesiolysis in small bowel obstruction
is convenient if performed by skilled surgeons in
correctly selected patients, resulting in a shorter hospital
stay with a early flatus and a early realimentation and in
a lower postoperative morbidity. Nonetheless
laparoscopic surgery requires a longer operating time and
recurrent obstruction remains the major postoperative
risk in the management of these patients.
Acute surgical emergencies in patients with
inflammatory bowel disease are infrequent but may be dangerous
for life. Crohn’s disease is an important cause of small
bowel acute surgery [
]. Ileal localization,
particularly terminal ileum, is the most frequent in Crohn’s
disease, despite its pan-intestinal nature. Skip lesions
interest full-thickness the bowel wall and are able to
induce a wide spectrum of acute surgical emergencies.
Small bowel is the main site of bleeding in Crohn’s
disease. The bleeding is often from a localized source,
caused by erosion of a blood vessel within multiple deep
ulcerations that extend into bowel wall. Severe
hemorrhage is rare and requires surgery [
]. Other surgical
indications include a bleeding who doesn’t slow after 4
to 6 units of blood and recurrent hemorrhage [
Because of segmental disease, the best approach is to
localize the source of bleeding preoperatively. The
patient is stabilized and a nasogastric tube is inserted.
Gastroscopy, angiography and the use of labeled red
cells scan help localizing the hemorrhage. If the site of
bleeding is identified in small bowel, resection and
primary anastomosis is the gold standard surgical
treatment. Perforation is another surgical emergency in
patients with Crohn’s disease [
]. It occurs in 1% to 3%
of cases. The transmural nature of Crohn’s disease
creates inflammatory adhesions between bowel and local
structures, so the perforation is often sealed. If
perforation is suspected, the patient must be resuscitated and
prepared to surgery. Jejunal and ileal perforations
require resection and primary anastomosis if possible
]. Otherwise resection with intestinal
diversion is necessary. More than 25% of patients undergoing
surgery for Crohn’s disease will have either an
intraabdominal mass or abscess, and 40% of these have an
associated fistula . An intra-abdominal mass may be
the consequence of distended loops of proximal bowel
caused by distant strictures, thinning of diseased loops,
phlegmon with associated fistulae, or an abscess cavity
]. The cause of abdominal abscesses is the
transmural ulceration of the diseased bowel, which creates
secondary adhesions to adjacent structures resulting in
intraperitoneal, retroperitoneal or rarely intramesenteric
abscesses. Progresses in interventional radiological
techniques have increased, facilitating an improvement in
patient’s general conditions before the eventual surgical
repair. If general conditions are favorable, in selected
cases of perforation of the jejunum or ileum without
abscess and early intervention, primary reconstruction is
possible. However, having to do with intestinal
perforation and abscessed small bowel, resection with fecal
diversion is the gold standard surgical strategy. Intestinal
obstruction is the main complication requiring surgical
intervention in Crohn’s disease, affecting 35% to 54% of
]. Because of transmural nature of
disease process, obstruction can be the consequence of an
acute and active inflammation superimposing on a
stenotic portion of the bowel. Fibrosis and scarring with
stricture formation, and mass effect of an adjacent
abscess or phlegmon are common events in Crohn’s
disease. Although it is rare, a complete or near complete
intestinal obstruction not responsive to medical therapy
requires a surgical treatment [
]. The treatment
may be a resection or a strictureplasty depending on
localization of the disease [
]. Strictureplasty is a
safe and efficacy procedure for small bowel Crohn’s
disease in the long term [
]. Strictureplasty should be
reserved only for fibrotic stricture with inactive disease
and only if resection is inappropriate [
has been for a long time the mainstay treatment of
Crohn’s disease associated with small bowel strictures.
However, recurrence rates are high and most of patients
need multiple resections. So, the concern of short-bowel
syndrome led to the use of bowel-sparing procedures.
Principle indications for strictureplasty are multiple
strictures over large length of bowel, previous resections,
short bowel syndrome and strictures associated with
phlegmon or fistula [
include preoperative malnutrition (albumin < 2 g/dL),
perforation, multiple strictures over short length of
bowel, stricture short distant from area of resection and
bleeding from planned strictureplasty site [
Several strictureplasty techniques have been described
and the choice depends on the length of the stricture
. Short strictures are treated with Heineke-Mikulicz
strictureplasty. A longitudinal enterotomy is realized
over the stricture on the antimesenteric border of the
bowel and extended 1 to 2 cm onto either side of
normal bowel. The enterotomy can be realized using bistury
or cautery. Then, the enterotomy is closed transversally
with a interrupted, sieromuscolar, absorbable suture.
The closure should be performed in one or two layers
and must be tension-free. The Finney strictureplasty is
used for strictures of intermediate length. First of all, a
stay suture is localized in the midpoint of the stricture.
The enterotomy is performed throught the stricture,
again extending 1 to 2 cm onto normal bowel. Then
strictured segment is folded onto itself to realize a “U”
and another stay suture is localized in the normal side
of bowel to keep the “U” in place. The posterior edges
are sutured in a continuous way using an absorbable
suture. In the end, the anterior edges are closed with a
interrupted non absorbable suture. In 1996, Michelassi
introduced the side-to-side isoperistaltic strictureplasty
for long strictures, usually greater than 20 to 25 cm, and
multiple strictures over a limited area [
]. In this
technique, the sctrictured bowel is lifted up and his
mesentery is divided at the midpoint. Then the diseased bowel
is divided between atraumatic bowel clamps at the
midpoint of the stricture. The proximal end of the cut
bowel is brought over the distal end in a side-to-side
way. The two loops are approached with a single-layer,
interrupted, non absorbable suture. Then enterotomy is
realized longitudinally for the length of the stricture.
The ends of bowel are spatulated to avoid blind ends.
Next, a inner layer of running, full-thickness, absorbable
suture is placed and continued anteriorly. This anterior
layer is then followed by a layer of interrupted, non
absorbable, sieromuscolar suture. Markedly thickened
bowel loops, thickened and friable mesentery,
inflammatory phlegoms, fistula, abscesses and adhesions from
previous surgery represent a surgical challenge to the
laparoscopic approach. Many studies in literature
suggest that laparoscopic approach is feasible and safe in
terminal ileal Crohn’s disease, because it offers
advantages in terms of pulmonary function, length of hospital
stay, duration of postoperative ileus, cosmesis,
postoperative small bowel obstruction, and early
postoperative complications. Furthermore laparoscopy reduces the
hospitalization costs and improves patient satisfaction
Small bowel neoplasms
Tumors of the small bowel are a very rare entity,
accounting for only 1% of all gastrointestinal neoplasms
and 0,3% of all tumors [
]. The most common
modes of presentation are intestinal obstruction and
occult gastrointestinal hemorrhage. Occasionally, the
presentation involves the development of a palpable but
otherwise asymptomatic mass, whereas perforation and
gross bleeding are rare. Small bowel tumors are usually
located in the proximal small bowel, with the exception
of adenocarcinoma in the contest of ileal Crohn’s
disease and NETs [
Adenomas are the most common benign tumors of
jejunum and ileum. Their histological subtype are either
tubular adenomas with low malignant potential or
villous adenomas with high malignant potential. Lipomas
are more frequent in the ileum, have no malignant
potential and do not require a surgical excision unless
Malignant neoplasm present similarly to benign
lesions. Diagnosis is often delayed conducing to
advanced tumors, for whom surgical resection is rarely
]. Adenocarcinomas represent 50% of
all small bowel malignancies . Most lesions are
located in the proximal bowel, except in the setting of
Crohn’s disease in which most are ileal [
Resection is the best treatment but overall the prognosis is
poor due to late presentation in most patients (15% to
35% 5-year survival) [
]. Lymphomas represent 10%
to 20% of small bowel malignant tumors. The ileum is
the most common site of involvement because of the
greatest amount of gut-associated lymphoid tissue .
Primary small-bowel lymphoma is the most common
extranodal form of lymphoma. Most are non-Hodgkin’s
lymphomas and predominantly B-cells in origin [
Patients commonly present with fatigue, weight loss
and abdominal pain, whereas perforation, bleeding,
obstruction or intussusceptions are less frequent.
Treatment in such emergent cases is surgical and consists in
resection along with a wedge of mesentery. Adjuvant
therapy is recommended for patients with positive
margins. Survival for completely resected intestinal
lymphomas is about 50% .
Gastrointestinal stromal tumors (GISTs) can arise
anywhere in the gastrointestinal tract: 50-70% in the
stomach, 20-40% in the small bowel, 5-15% in the colon
and rectum, 5% in the esophagus and the omentum,
and rarely in the mesentery or retroperitoneum
]. They account for approximately 0,1% to 3%
of all gastrointestinal neoplasms. GISTs are more
common between the ages of 40 and 70, without sex
difference. GISTs are thought to arise from the intestinal
cells of Cajal, which are intestinal pacemaker cells that
regulate peristalsis. Bleeding occurs in almost 50% of
GISTs. Approximately 35% of patients present with
abdominal mass causing or not symptoms, and 20% of
patients have abdominal pain. When tumors arise from
the small bowel slow bleeding and mild obstructive
symptoms can go undiagnosed for a long. GISTs usually
do not metastatize beyond the gastrointestinal tract and
the liver [
]. Prognosis varies and depends on the
site of GIST, origin, mitotic index, and size. Small
intestine GISTs are more aggressive and have a worst
]. When GIST presents as an emergency,
surgery is the mainstay. In cases where is feasible and
the risk-benefit balance is favourable, the goal is to
completely resect the primary tumor, surrounding normal
tissue, and adjacent organs if they are affected with
GIST. Because of their fragility, surgeon must handle
GIST with great care to avoid tumor rupture. GISTs
are resistant to chemotherapy and radiotherapy .
However targeted chemotherapy has dramatically
increased the outcome of GISTs treatment, either of
Gastroenteropancreatic neuroendocrine tumors
(GEPNET) are a heterogeneous group of uncommon
malignancies occurring in the gastrointestinal system. The
incidence of GEP-NET is 2 to 3 per 100,000 people per
]. Symptoms depend on the tumor cells of
origin and the effects of secreted substances. However,
patients may seek medical care when gastrointestinal
emergencies occur. Imaging studies help to make a
diagnosis and include ultrasounds, CT, RMI, PET, and
radiolabeled somatostatin receptor scintigraphy
(OctreoScan) . Small bowel NETs are the most
common and occur more frequently in ileum than in
jejunum. Unfortunately 60% of these neoplasms are
diagnosed when distant metastasis to lymph nodes and
liver have occurred. 5-years survival rate is 60%, but
drops to 30% if liver metastasis are present [
About 10% of patients with metastatic ileal NETs have
classic carcinoid syndrome. Occasionally, ileal NET
presents with a massive gastrointestinal bleeding, secondary
to sclerosis of vasa recta, due to hypersecretion of
serotonin. Sclerosis of arterial vessels may also provoke a
bowel ischemia. Otherwise, endo-luminal growth of the
cancer or mesenteric fibrosis create the condition for an
intestinal obstruction. In such cases surgical treatment
Intestinal involvement of metastatic cancer is
common, mostly in the form of peritoneal carcinomatosis.
Because of the continuous recirculation of peritoneal
fluid through all the abdomino-pelvic cavity, small
bowel is an elective site for peritoneal metastasis. All
abdominal tumors can lead to peritoneal carcinomatosis,
particularly colorectal cancer, ovarian cancer, gastric
cancer, and primitive peritoneal neoplasms. The
diagnosis of peritoneal secondary tumors as the cause of small
bowel obstruction is often difficult. Obstruction in these
circumstances never resolves by conservative treatment
and surgical intervention is almost always indicated.
Although peritoneal carcinomatosis has been for a long
considered a terminal condition, in the latest years a
new curative option consisting of extensive
cytoreductive surgery (CRS) and hyperthermic intraperitoneal
chemotherapy (HIPEC) has emerged for accurately
selected patients [
Meckel’s diverticulum and acquired jejunoileal
Meckel’s diverticulum is the most common congenital
malformation of the gastrointestinal tract, interesting 2%
to 4% of population [
]. It is a true diverticulum due
to the persistence of omphalo-mesenteric duct, which
connects in fetal life the yolk sac to the intestinal tract
and usually obliterates in the 5th to 7th week of life. It is
localized on anti-mesenteric border of the distal ileum,
usually 30-40 cm far from the ileo-cecal valve [
Meckel’s diverticulum is lined mainly by the typical ileal
mucosa as in the adjacent small bowel. However, in 20%
of cases ectopic gastric mucosa may be found. Globally
the incidence of complications ranges from 4% to 16%
]. Although there is no sex differences in the
incidence of Meckel’s diverticulum, its complications are
3-4 times more frequent in males. Meckel’s diverticulum
is the most common cause of bleeding in the pediatric
age group. The risk of complications decreases with
increasing age [
]. The most frequent complications
in adults are obstruction due to the intussusceptions or
adhesive band, ulceration, diverticulitis and perforation
]. Preoperative diagnosis of symptomatic
Meckel’s diverticulum is difficult, especially in patients with
symptoms other than bleeding. In doubtful cases,
laparoscopy is the preferred diagnostic modality.
However, technetium 99-m pertechnate scan is the most
common and accurate non-invasive investigation,
although it is specific to ectopic gastric mucosa, not to
Meckel’s diverticulum . In the presence of
symptoms, the treatment of choice is the surgical resection.
This can be achieved either by diverticulectomy or by
the segmental bowel resection and anastomosis,
especially when there is palpable ectopic tissue, intestinal
ischemia or perforation [
Acquired jejunoileal diverticulosis (JID) is a rare entity
often asymptomatic and treated conservatively.
However, JID can develop a number of complications
requiring acute surgical care [
]. The incidence of JID
increases with age, with the peak occurring in the sixth
and seventh decades of life. The etiology is unclear, but
the most commonly accepted is the one related to the
acquired mechanism. A motor dysfunction or
jejunoileal dyskinesia leads to an intraluminal pressures
increase. As a result, mucosa and submucosa herniate
through the weakest site of the muscolaris of the small
bowel, which is on the mesenteric border where paired
vasa recta penetrate the bowel wall [
]. So, these are
pseudodiverticula. About 55% to 80% of diverticula
occur in the jejunum, 15% to 38% in the ileum and 5%
to 7% in both [
]. Two-third of patients have
multiple diverticula and therefore a major risk of developing
]. Although the diagnosis of JID is
often accidentally, 10% to 19% of patients with JID
present with acute and emergent complications.
Diverticulitis occurs in 2% to 6% of patients and can progress to
gangrene with full-thickness necrosis and perforation,
which has a mortality rate as high as 40%. Perforation
presents either with localized or generalized peritonitis,
and the mainstay of treatment includes resection of the
affected segment and primary anastomosis. Obstruction
occurs in 2% to 4% of patients, due to adhesions,
intussusceptions, volvolus, extrinsic compression from a
fluid-filled diverticulum, enteroliths [
complications interest 3% to 8% of patients with JID.
The proximity of the neck of the diverticula to the
mesenteric vessel is responsible for bleeding resulting
from erosion and ulceration of the mucosa. In case of
massive hemorrhage, surgical resection of the affected
bowel and anastomosis is mandatory [
Acute mesenteric ischemia
Acute mesenteric ischemia (AMI) is an uncommon
event, according for less than 1 case in every 1000
hospital admissions. Females are affected with three times
the frequency of males and patients are usually between
the age of 60 and 70 with several comorbidities [
Arterial embolism is the major cause of AMI, according
for 40% to 50% of cases [
]. Most events are
thromboembolic and arise from a cardiac source [
Thromboemboli tend to lodge in proximal superior mesenteric
artery (SMA), just beyond the first jejunal branches, a
minority (15%) may lodge at the SMA origin, whereas
about 50% lodge distal to the middle colic artery
]. In this case, proximal intestine and ascending
colon are spared. Instead atheroembolic emboli tend to
be smaller and to lodge in the distal SMA, therefore
affecting bowel perfusion less often and in more
localized areas. Acute arterial thrombosis superimposed on
preexisting severe atherosclerotic disease accounts for
25% to 30% of all cases [
]. Bowel infarction is more
insidious because extensive collateral are able to
maintain viability until there is a final closure of critically
stenotic vessel or collateral. The infarction is more
confluent, without sparing of small bowel or right colon
circulation, because SMA is often interested at its origin.
Acute presentation on a history of cronic mesenteric
ischemia is usual. The small bowel is able to tolerate a
significant reduction in blood flow. However, when the
ischemia is prolonged, it leads to disruption of the
intestinal mucosa. Patients present abdominal pain.
SMA embolism has the more rapid clinical decline due
to the lack of collateral vessels. The advent of
high-quality computed tomography angiography has supplanted
angiography to make the diagnosis of AMI [
However angiography still plays an important role not
only in the diagnosis but also in the treatment .
Diagnostic laparoscopy is not widely accepted because it
may miss areas of nonviable bowel. After initial
resuscitation and stabilization of the patient, surgery is
required for all patients who have evidence of
threatened bowel. Surgeon should proceed with
revascularization before resecting any intestine unless faced with an
area of frank necrosis or perforation or peritoneal
soilage. In such cases resection of the affected bowel
without reanastomosis and containment of the spillage
should be rapidly achieved before revascularization. In
few patients with massive bowel necrosis
revascularization can be avoided.
Pneumatosis intestinalis is the presence of gas within
the abdominal wall of the bowel. Benign pneumatosis
is an incidental finding without any underlying
pathology. Conversely, when pneumatosis intestinalis is the
result of primary intestinal pathology, urgent surgery is
mandatory. The intramural gas can result from
necrosis caused by ischemia, infarction, neutropenic colitis,
volvulus, and necrotizing enterocolitis. Benign
pneumatosis instead is related to a pulmonary source in
patients with COPD, asthma, or cystic fibrosis. The
intrathoracic air can dissect via the retroperitoneum
and into the intestinal wall. It is generally accepted
that patients with pneumatosis intestinalis associated
with either bowel obstruction or ischemia usually
require urgent surgery [
]. The presence of air within
the bowel wall itself does not mandate resection,
because the air may have tracked from another site
within the bowel, such a segment of ischemia or
necrosis. In such a case, only the ischemic bowel
segment must be resected [
Small bowel ulceration is usually the result of ingested
medications like enteric-coated potassium chloride,
nonsteroidal anti-inflammatory drugs, and corticosteroids
]. Clinical presentation is usually an intermittent
small bowel obstruction. Preoperative localization of
these lesions is difficult, and is frequently necessary the
palpation of the small bowel at laparotomy or an
intraoperative endoscopy. The treatment of small bowel
ulceration is surgical resection. Suture repair after the
perforation of small bowel ulceration presents a high
rate of complications. Recurrence after resection is rare.
The accidental or intentional ingestion of foreign
bodies is not rarely observed in emergency departments.
Although intestinal perforation is rare, the development
of abdominal pain with tenderness and leukocytosis
strongly suggests a perforation. In case of perforation,
surgical resection is required, because antibiotic
treatment is associated with chronic infection or stricture
VC, CoFe: Contributed both as first author, participating in study conception,
in analysis and interpretation of data, in manuscript draft and revision and in
giving the final approval.
AL, CF, MG, SDS, PAD: Participate in manuscript draft and revision and in
giving the final approval.
The authors declare that they have no competing interests.
1. Norton JA , Bollinger RR , Chang AE , et al: Surgery. Basic science and clinical evidence . Springer-Verlag New York, Inc.; 2001 .
2. Wangenstein O : Intestinal obstructions . Springfield, Thomas,; 1955 .
3. Harlow C , Stears R , Zeligman B , Archer P : Diagnosis of bowel obstruction on plain abdominal radiograph: significance of airfluid levels at different heights in the same loop of the bowel . AJR 1993 , 161 : 291 - 295 .
4. Frager D , Medwid S , Baer J , Molinelli B , Friedman M : CT of small bowel obstruction: value in establishing the diagnosis and determining the degree and cause . AJR 1994 , 162 : 37 - 41 .
5. Balthazar E : CT of small bowel obstruction . AJR 1994 , 162 : 225 - 261 .
6. Ko Y , Lim J , Lee D , Lim J : Small bowel obstruction: sonographic evaluation . Radiology 1993 , 188 : 649 - 653 .
7. Ogata M , Mateer J , Condon R : Prospective evaluation of abdominal sonography for the diagnosis of bowel obstruction . Am Surg 1996 , 223 : 237 - 241 .
8. Ihedioha U , Alani A , Modak P , Chong P , O'dwyer PJ : Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction . Hernia 2006 , 10 : 338 - 340 .
9. Cheadle WG , Garr EE , Richardson JD : The importance of early diagnosis in small bowel obstruction . Am Surg 1988 , 54 : 565 - 569 .
10. Chiedozi LC , Aboh IO , Piserchia NE : Mechanical bowel obstruction. Review of 316 cases in Benin city . Am J Surg 1980 , 139 : 389 - 393 .
11. Lawal OO , Olayinka OS , Bankole JO : Spectrum of causes of intestinal obstruction in adult Nigerian patients . S Afr J Surg 2005 , 43 : 34 - 36 .
12. Bizer LS , Liebling RW , Delany HM , Gliedman ML : Small bowel obstruction: the role of nonoperative treatment in simple intestinal obstruction and predictive criteria for strangulation obstruction . Surgery 1981 , 89 : 407 - 413 .
13. Williams SB , Greenspon J , Young HA , Orkin BA : Small bowel obstruction: conservative vs surgical management . Dis Col Rectum 2005 , 48 : 1140 - 1146 .
14. Mohamed AY , al-Ghaithi A , Langevin JM , Nassar AH : Causes and management of intestinal obstruction in a Saudi Arabian hospital . J R Coll Surg Edimb 1997 , 42 : 21 - 23 .
15. McEntee G , Pender D , Mulvin D , McCullogh M , Naeeder S , Farah S , Badurdeen MS , Ferraro V , Cham C , Gillham N : Current spectrum of intestinal obstruction . Br J Surg 1987 , 74 : 976 - 980 .
16. Kirshstein B , Roy-Shapira A , Lantsberg L , Avinoach E , Mizrahi S : Laparosocpic management of acute small bowel obstruction . Surg Endosc 2005 , 19 : 464 - 467 .
17. Roscher R , Frank R , Baumann A , Berger HG : Resulta of surgical treatment of mechanical ileus of the small intestine . Chirurg 1991 , 62 : 614 - 619 .
18. Akcackaya A , Alimoglu O , Hevenek T , Bas G , Sahin M : Mechanical intestinal obstruction caused by abdominal wall hernias . Ulus Trauma Derg 2000 , 6 : 260 - 265 .
19. Uludag M , Agkun I , Yetkin G , Kebudi A , Isgor A , Sener A : Factors affecting morbidity and mortality in mechanical intestinal obstruction . Ulus Trauma Derg 2004 , 10 : 177 - 184 .
20. Biondo S , Pares D , Fargo R , Marti-Rague J , Kreisler E , De Oca J , Jaurrieta E : Large bowel obstruction: predictive factors for postoperative mortality . Dis Col Rectum 2004 , 47 : 1889 - 1897 .
21. Di Saverio S , Catena F , Ansaloni L , et al: Water-soluble contrast medium (gastrografin) value in adhesive small intestine obstruction (ASIO): a prospective, randomized, controlled clinical trial . Word J Surg 2008 , 32 ( 10 ): 2293 - 2304 .
22. Branco BC , Barmparas G , Schnüriger B , Inaba K , Chan LS , Demetriades D : Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction . Br J Surg 2010 , 97 ( 4 ): 470 - 8 .
23. Abbas S , Bisset IP , Parry BR : Oral water soluble contrast for the management of adhesive small bowel obstruction . Cochrane database of systematic reviews 2007 , , 3 : CD004651 .
24. Farinella E , Cirocchi R , La Mura F , et al: Feasability of laparoscopy for small bowel obstruction . Word J Emerg Surg 2009 , 4 : 3 .
25. Dindo D , Schafer M , Muller MK , Clavien PA , Hahnloser D : Laparoscopy for small bowel obstruction: the reason for conversion matters . Surg Endosc 2009 .
26. Suter M , Zermatten P , Halkic N , Martinet O , Bettschart V : Laparoscopic management of mechanical small bowel obstruction: are there predictors of success or failure? Surg Endosc 2000 , 14 ( 5 ): 478 - 83 .
27. Ghosheh B , Salameh JR : Laparoscopic approach to acute small bowel obstruction: review of 1061 cases . Surg Endosc 2007 , 21 ( 11 ): 1945 - 9 .
28. Zerey M , Sechrist CW , Kercher KW , Sing RF , Matthews BD , Heniford BT : Laparoscopic management of adhesive small bowel obstruction . Am Surg 2007 , 73 ( 8 ): 773 - 8 .
29. Wang Q , Hu ZQ , Wang WJ , Zhang J , Wang Y , Ruan CP : Laparoscopic management of recurrent adhesive small-bowel obstruction: Long-term follow-up . Surg Today 2009 , 39 ( 6 ): 493 - 9 .
30. Crohn B , Ginsburg L , Openheimer G : Regional ileitis: a pathologic and clinical entity . JAMA 1932 , 99 : 1232 .
31. Hwang JM , Varma MG : Surgery in inflammatory bowel disease . World J Gastroenterol 2008 , 14 ( 17 ): 1678 - 1690 .
32. Leowardi C , Heuschen G , Kienle P , Heuschen U : Surgical treatment of severe inflammatory bowel disease . Dig Dis 2003 , 21 : 54 - 62 .
33. Berg DF , Bahadursingh AM , Kaminski DL , et al: Acute surgical emergencies in inflammatory bowel disease . Am J Surg 2002 , 184 ( 1 ): 45 - 51 .
34. Jobanputra S , Weiss EG : Strictureplasty. Clin Colon Rect Surg 2007 , 20 ( 4 ): 294 - 302 .
35. Jawhari A , Kamm M , Ong C , Forbes A , Bartram C , Hawley P : Intrabdominal and pelvic abscess in Crohn's disease: the results of non-invasive and surgical management . Br J Surg 1998 , 85 : 367 - 391 .
36. Stone W , Veidenheimer MC , Corman Ml , et al: The dilemma of Crohn's disease: long term follow-up of Crohn's disease of the small intestine . Dis Col Rectum 1977 , 20 : 372 - 76 .
37. Platell C , Mackay J , Collopy B , et al: Crohn's disease: a colon and rectal department experience . ANZ surg 1995 , 65 : 570 - 5 .
38. Michelassi F , Balestracci T , Chappel R , Block GE : Primary and recurrent Crohn's disease . Eperience with 1379 patients. Ann Surg 1991 , 214 : 230 - 238 , discussion 238- 240 .
39. Hurst RD , Molinari M , Chung TP , Rubin M , Michelassi F : Prospective study of the features, indications and surgical treatment in 513 consecutive patients affected by Crohn's disease . Surgery 1997 , 122 : 661 - 667 , discussion 667- 668 .
40. Yamamoto T , Brain IM , Allan RN , Keighley RB : An audit of stictureplasty for small bowel Crohn's disease . Dis Col Rectum 1999 , 42 : 797 - 803 .
41. Resegotti A , Astegiano M , et al: Strictureplasty in Crohn's disease. Indications and results . Minerva Chir 2000 , 55 : 313 - 17 .
42. Gardiner KR , Disari BV : Operative management of small bowel Crohn's disease . Surg Clin North Am 2007 , 87 : 587 - 610 .
43. Michielassi F : Side to side isoperistaltic strictureplasty for multiple Crohn's strictures . Dis Colon Rectum 1996 , 39 : 345 - 349 .
44. Rosenthal RJ , Bashankaev B , Wexner SD : Laparoscopic management of inflammatory bowel disease . Dig Dis 2009 , 27 : 560 - 564 .
45. Wu J , Birnbaum E , Kodner I , Fry R , Read T , Fleshman J : Laparoscopic assisted ileocolic resection in patients with Crohn's disease: are abscesses , phlegmons or recurrent disease contradictions? Surgery 1997 , 122 : 682 - 688 .
46. Bemelman WA , Slors JF , Dunker MS , van Hogezand RA , van Deventer SJ , Ringers J , Griffioen G , Gouma DJ : Laparoscopic-assisted vs open ileocolic resection for Crohn's disease. A comparative study . Surg Endosc 2000 , 14 : 721 - 725 .
47. Tabet J , Hong D , Kim CW , Wong J , Goodacre R , Anvari M : Laparocopic vs open bowel resection for Crohn's disease . Can J Gastroenterol 2001 , 15 : 237 - 242 .
48. Barclay TH , Schapira DV : Malignant tumors of the small intestine . Cancer 1983 , 51 : 878 - 881 .
49. DiSario JA , Burt RW , Vargas H , McWhorter WP : Small bowel cancer: epidemiological and clinical characteristics from a population-based registry . Am J Gastroeterol 1994 , 89 : 699 - 701 .
50. Kala Z , Kysela P : Meluzinova H Small bowel tumors in the elderly 65+ years: 10 years of experience . Z Gerontol Geriat 2008 , 41 : 403 - 407 .
51. Kindblom LG , Remotti HE , Aldenborg F , et al: Gastrointestinal pace maker cell tumor (GIPACT): gastrointestinal stromal tumors show phenotypic chearacteristic of the intestinal cells of Cajal . Am J Pathol 1998 , 142 : 1249 - 1269 .
52. Catena F , Ansaloni L , Gazzotti F , et al: Small bowel tumors in emergency surgery: specificity of clinical presentation . ANZ J Surg 2005 , 75 ( 11 ): 997 - 999 .
53. Mussi C , Capriotti R , Scaini A , Angelini C , Crippa S , Uggeri F , Sartori P : Management of small bowel tumors: personal experience and new diagnostic tools . Int Surg 2005 , 90 : 209 - 214 .
54. Ciccarelli O , Welch JP , Kent GG : Primary malignant tumors of the small bowel . The Hartford Hospital experience 1969-1987. Am J Surg 1987 , 153 : 350 - 354 .
55. Ashley SW , Wells SA Jr: Tumors of the small intestine . Sen Oncol 1988 , 15 : 116 - 128 .
56. Norberg KA , Emas S : Primary tumors of the small intestine . Am J Surg 1981 , 142 : 569 - 573 .
57. Cunningham JD , Aleali R , Aleali M : Brower ST Aufses AH . Malignant small bowel neoplasms: histopathologic determinants of recurrence and survival . Ann Surg 1997 , 225 : 300 - 306 .
58. Ouriel K , Adams JT : Adenocarcinoma of the small intestine . Am J Surg 1984 , 147 : 66 - 71 .
59. Turowsky GA , Basson MD : Primary malignant lymphoma of the intestine . Am J Surg 1995 , 169 : 433 - 441 .
60. Radaszkiewicz T , Dragosics B , Bauer P : Gastrointestinal malignant lymphomas of the mucosa-associated lymphoid tissue: factors relevant to prognosis . Gastroenterology 1992 , 102 : 1628 - 1638 .
61. Hansen PB , Vogt KC , Skov RL , Pedersen-Bjergaard U , Jacobsen M , Ralfkiaer E : Primary gastrointestinal non-Hodgkin's lymphoma in adults: a population based clinical and histopathologic study . J Intern Med 1998 , 244 : 71 - 78 .
62. Gisbertz IA , Schouten HC , Bot FJ , Arends JW : Cell turnover parameters in small and large cell varieties of primary intestinal non-Hodgkin's lymphoma . Cancer 1998 , 83 : 158 - 165 .
63. Lee HJ , Park S , Kim DK , Kim YH : Surgical resection of esophageal gastrointestinal stromal tumors . Ann Thorac Surg 2009 , 87 : 1569 - 72 .
64. Abraham SC , Krasinskas AM , Hofstetter WL , Swisher SG , Wu TT : “ Seedling” mesenchymal tumors (gastrointestinal stomal tumors and leiomyomas) are common incidental tumors of the esophagogastric junction . Am J Surg Pathol 2007 , 31 : 1629 - 35 .
65. Ji F , Wang ZW , Wang LJ , Ning JW , Xu GQ : Clinicopathological characteristics of gastrointestinal mesenchymal tumors and diagnostic value of endoscopic ultrasonography . J Gastroenterol Hepatol 2008 , 23 ( 2 ): e318 - 24 .
66. Miettinen M , Lasota J : Gastrointestinal stromal tumors: review of morphology, molecular pathology, prognosis and differential diagnosis . Arch Pathol Lab Med 2006 , 130 : 1466 - 78 .
67. Miettinen M , Sarlomo-Rikala M , Sobin LH , Lasota J : Esophageal stromal tumors: a clinicopathologic, immunohistochemical, and molecular genetic study of 17 cases and comparison with esophageal leyomiomas and leyomiosarcomas . Am J Surg Pathol 2000 , 24 : 211 - 22 .
68. De Matteo RP , Lewis JJ , Leung D , Mudan SS , Woodruff JM , Brennan MF : Two tundre gastrointestinal stromal tumors: recurrence patterns and prognostic factors for serviva . Ann Surg 2000 , 231 : 51 - 58 .
69. Miettinen M , Furlong M , Sarlomo-Rikala M , Burke A , Sobin LH , Lasota J : Gastrointestinal stromal tumors, intramural leiomyomas and leiomyosarcomas in the rectum and anus: a clinicopathological, immunihistochemical and molecular genetic study of 144 cases . Am J Surg Pathol 2001 , 25 : 1121 - 1133 .
70. Biasco G , Velo D : Agriman I et al Gastrointestinal stromal tumors: report of an audit and review of the literature . European Journal of Cancer Prevention 2009 , 18 : 106 - 116 .
71. Huang HY , Li CF , Huang WW , Hu TH , Lin CN , Uen YH , et al: A modification of NIH consensus criteria to better distinguish the highly lethal subset of primary localized gastrointestinal stromal tumors: a subdivision of the original high-risk group on the basis of outcome . Surgery 2007 , 141 : 748 - 756 .
72. Appetecchia M , Baldelli R : Somatostatin analogues in the treatment of gastroenteropancreatic neuroendocrine tumours, current aspects and new perspectives . Journal of Experimental & Clinical Cancer Research 2010 , 29 : 19 .
73. Ramage JK , Davies AH , Ardill J , Bax N , Caplin M , Grossman A , Hawkins R , McNicol AM , Reed N , Sutton R , Thakker R , Aylwin S , Breen D , Britton K , Buchanan K , Corrie P , Gillams A , Lewington V , McCance D , Meeran K , Watkinson A : UKNETwork for Neuroendocrine Tumours: Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours . Gut 2005 , 54 ( Suppl 4 ): iv1 - 16 .
74. Plöckinger U , Rindi G , Arnold R , Eriksson B , Krenning EP , de Herder WW , Goede A , Caplin M , Oberg K , Reubi JC , Nilsson O , Delle Fave G , Ruszniewski P , Ahlman H , Wiedenmann B : European Neuroendocrine Tumour Society: Guidelines for the diagnosis and treatment of neuroendocrine gastrointestinal tumours. A consensus statement on behalf of the European Neuroendocrine Tumour Society (ENETS) . Neuroendocrinology 2004 , 80 ( 6 ): 394 - 424 .
75. Maggiori L , Elias D : Curative treatment of colorectal peritoneal carcinomatosis: current status and future trends . Eur J Surg Oncol 2010 , 36 ( 7 ): 599 - 603 .
76. Chua TC , Robertson G , Liauw W , Farrell R , Yan TD , Morris DL : Intraoperative hyperthermic intraperitoneal chemotherapy after cytoreductive surgery in ovarian cancer peritoneal carcinomatosis: systematic review of current results . J Cancer Res Clin Oncol 2009 , 135 ( 12 ): 1637 - 45 .
77. Glockzin G , Ghali N , Lang SA , Schlitt HJ : Piso P Results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal cancer . J Surg Oncol 2009 , 100 ( 4 ): 306 - 10 .
78. Verwaal VJ : Long-term results of cytoreduction and HIPEC followed by systemic chemotherapy . Cancer J 2009 , 15 ( 3 ): 212 - 5 .
79. Sagar J , Kumar V , Shah DK : J R Meckel 's diverticulum: a systematic review . Soc Med 2006 , 99 : 501 - 505 .
80. Vaos G , Misiakos EP : Congenital anomalies of gastrointestinal tract diagnosed in adulthood-diagnosis and management . J Gastrointest Surg 2010 , 14 : 916 - 925 .
81. Woods K , Williams E , Melvin W , et al: Acquired jejunoileal diverticulosis and its complications: a review of literature . Am Surg 2008 , 74 ( 9 ): 849 - 854 .
82. Tsiotos GG , Farnell MB , Ilstrup DM : Nonmeckelian jejunal or ileal diverticulosis: an analysis of 112 cases . Surgery 1994 , 116 : 726 - 32 .
83. Ross CB , Richards WO , Sharp KW , et al: Diverticular disease of the jejunum and its complication . Am Surg 1990 , 58 : 319 - 24 .
84. Liu CY , Chang W , Lin S , et al: Analysis of clinical manifestations of symptomatic acquired jejunoileal diverticular disease . World J Gastroenterol 2005 , 11 : 5557 - 60 .
85. deBree E , Grammatikakis J , Christodoulakis M , Tsiftsis D : The clinical significance of acquired jejunoileal diverticula . Am J Gastroeterol 1998 , 93 : 2523 - 8 .
86. Kawamura S , Muneyoshi N , Yamamoto T , et al: Massive bleeding from multiple jejunal diverticula associated with an angiodysplasia: report of a case . Surg Today 2000 , 30 : 750 - 3 .
87. Lock G : Acute intestinal ischaemia . Best Pract Res Clin Gastroeterol 2001 , 15 : 83 - 98 .
88. Acosta S , Ogren M , Sternby NH , Bergquist D , Bjorck M : Clinical implication of management of acute thromboembolic occlusion of the superior mesenteric artery . Autopsy findings in 213 patients. Ann Surg 2005 , 241 : 516 - 522 .
89. Boley SJ , Feinstein FR , Sammartano R , Brandt LJ , Sprayregen S : New concepts in the management of emboli of the superior mesenteric artery . Surg Gynecol Obstet 1981 , 153 : 561 - 569 .
90. Mansour MA : Management of acute mesenteric ischemia . Arch Surg 1999 , 134 : 328 - 330 .
91. Wyers MC : Acute mesenteric ischemia: diagnostic approach and surgical treatment . Semin Vasc Surg 2010 , 23 : 9 - 20 .
92. Herbert GS , Steele SR : Acute and chronic mesenteric ischemia . Surg Clin N Am 2007 , 87 : 1115 - 1134 .
93. Stout CL , Masserchmidt CA , Leake AE , Veale WN , Stokes GK , Panneton JM : Retrograde open mesenteric stenting for acute mesenteric ischemia is a viable alternative for emergent revascularization . Vasc Endovascular Surg 2010 , 44 ( 5 ): 368 - 371 .
94. Knechtle SJ , Davidoff AM , Rice RP : Penumatosis intestinalis surgical management and clinical outcome . Ann Surg 1990 , 212 : 160 - 165 .
95. Perlemuter G , Chaussade S , Soubrane O , et al: Multifocal stenosing ulcerations of the small intestine revealing vasculitis associated with C2 deficiency . Gastroenterology 1996 , 110 : 1628 - 1632 .