Strangulated small intestinal obstruction following upper gastrointestinal panendoscopy Errol J. Pollard, MO, OS* Roderick K. Roberts, MO, OS, MRACP John A. Nye, MO, OS, FRACP Gastroenterology Unit Royal Brisbane Hospital Brisbane, Australia Upper gastrointestinal fiberoptic panendoscopy is a safe and reliable means of diagnosing disease of the esophagus, stomach, and duodenum. Complications do, however, occur in less than 0.4% of procedures. ' ·2 They include aspiration, intramural hematomas, intestinal pseudo-obstruction, perforation, and impaction. 3 - 6 An unusual complication, strangulated small bowel obstruction, following an emergency panendoscopy is reported. CASE REPORT A 62-year-old man was referred because of passing melena stools for 48 hours. Duodenal ulcer had been demonstrated radiologically in the past. Ten years previously, right hemicolectomy had been performed for appendiceal abscess. Twelve months following this operation an episode of adhesive small intestinal obstruction had been corrected surgically. ·Reprint r-equests: Dr. E.J. Pollard, C/- Royal Brisbane Hospital, Herston Road, Herston, Brisbane, 4029, Qld., Australia.
Figure 1. Erect abdominal radiograph showing distended loops mainly of small bowel with the large loop extending toward the left upper quadrant. 166
STRANGULATED ILEAL LOOP
Figure 2. Diagram representing the findings at laparotomy. The adhesive band beneath which the ileal loop had been trapped is identified. On admission the patient was pain-free, his abdomen was non-tender, and on rectal examination melena stool was present. Emergency panendoscopy was undertaken 6 hours following admission. A deformed duodenal cap with a chronic anterior wall duodenal ulcer and surrounding superficial ulceration was present. There was no bleeding from the ulcer at the time of endoscopy. Six hours after endoscopy the patient complained of abdominal distension and pain. A plain radiograph of the abdomen showed distended loops of large and small bowel with no evidence of free intraperitoneal gas (Figure 1). Despite continuous nasogastric aspiration and intravenous fluids his condition failed to improve, and laparotomy was undertaken 18 hours after endoscopy. Copious blood-stained peritoneal fluid was present with markedly distended loops of small bowel. A gangrenous loop of jejunum was trapped by a fibrous band between sigmoid colon and duodenum (Figure 2). This fibrous band was divided and the gangrenous segment of jejunum resected. A duodenal ulcer could be palpated in the first part of duodenum. The patient made an uneventful recovery. DISCUSSION The indication for endoscopy in this patient was upper gastrointestinal bleeding. Six hours following the procedure a strangulated small intestinal obstruction developed. It is extremely unlikely that this complication was responsible for the initial presentation as the patient had been observed medically for 54 hours before endoscopy. Thus it seems likely that the endoscopy and the development of the acute abdomen were causally related. There are several mechanisms by which upper gastrointestinal endoscopy may lead to acute abdominal emergency. Gastric perforation is a rare event and is usually recognized by failure of the stomach to distend. Large volumes of free intraperitoneal gas are usually present, although the site of the GASTROINTESTINAL ENDOSCOPY
perforation (usually high posterior wall) is often difficult to find. This complication occurred more frequently with the older rigid and semirigid instruments than with the modern flexible endoscopes. 7 The syndrome of pseudo-acute abdomen has been recently described.- In this syndrome, distension and pain develop immediately following endoscopy and are relieved by nasogastric suction. This usually occurs in the patient with gastric outlet obstruction. The mechanism is believed to be entrapment of air insufflated under pressure in the stomach during the procedure. Adhesive intestinal obstruction is a common surgical entity.8 There are several possible mechanisms including entrapment of bowel loop by adhesive bands, torsion of an intestinal loop on a band, or herniation of an intestinal loop into an acquired sac. While the actual mechanism of obstruction in the present case is speculative, it would seem likely that distension of small bowel loop already lying beneath the adhesive band may have lead to entrapment and subsequent strangulation. Such a development following endoscopy must be unusual. However, many of the patients undergoing gastrointestinal
Vascular dysplasia of the cecum as a repeated source of hemorrhage Role of colonoscopy in diagnosis
Repeated, massive, painless, gastrointestinal bleeding from an obscure source has always posed a challenging or even frustrating problem for practicing physicians. Despite vigorous diagnostic efforts, including laparotomy and selective angiography, diagnosis may not always be successful. The experience can be frightening for the patient. We report our experience with a patient afflicted by intermittent lower intestinal bleeding who was subjected to laparotomy, partial resection of the colon, and then to angiographic studies in a search for the site of bleeding. Careful colonoscopic examination eventually pin-pointed the exact site and type of bleeding and led to definitive surgical management. CASE REPORT A 56-year-old married man came to us for the first time in September 1974 with a 4-year history offrequent, loose bowel movements containing maroon or bright-red blood. This bleeding was not accompanied by abdominal pain or cramps although during each episode of bleeding he experienced generalized weakness, frequent dizziness, and anginal chest pain. In October 1970 he suffered his first episode of painless rectal bleeding, requiring transfusion of 3 liters of blood. A diagnosis of sigmoid diverticulosis was made at that time by barium enema. He then remained asymptomatic for 1Y2 years. In January 1973 he suffered 2 episodes of brisk rectal bleeding requiring multiple blood transfusions. During February 1973, frequent episodes of painless bleeding recurred, often accompanied by anginal chest pains and generalized weakness. "Reprint requests to: Krishan D. Thanik, MD, The Isaac Gordon Center for Digestive Diseases, The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607. VOLUME 23, NO.3, 1977
endoscopy have had previous operations and, presumably, have intra-abdominal adhesions. It is perhaps surprising then that this complication occurs so infrequently, considering the large number of gastrointestinal endoscopies performed. Gastroscopy is a safe and accurate procedure, but inevitably as experience expands the number and nature of complications will grow. REFERENCES 1. MYERS MA, GHAHREMANI GG: Complications of fibreoptic endoscopies. Radiology 115:293, 1975 2. SCHILLER KFR, COTTON PB, SALMON PR: Hazards of digestive fibre-endoscopy: a survey of British experience. Gut 13: 1027 (Abstr), 1972 3. COWEN AE, ISBISTER WH, CAMPBELL CB: Gastrointestinal endoscopy: current status and recent advances. Aust NZ J Med 4:75, 1974 4. FUJITA R, KUMURA F: Arrythmias and ischaemic changes of the heart induced by gastric endoscopic procedures. Am J Gastro 64:44, 1975 5. LEONIDAS H. BERRY (Ed): Gastrointestinal Panendoscopy. Springfield, Charles C Thomas, 1975 6.0GG TW, DAVIDSON AI: Respiratory failure following gastroscopy. Anaesthesia 30:194, 1975 7. JONES AE, DOL R, FLETCHER C, ROGERS HW: The risks of gastroscopy, a survey of 49,000 examinations. Lancet 1:647, 1951 8. COLE and ZOLLINGER In Textbook of Surgery Ninth Ed., Meredith Corporation.
Krishan D. Thanik, MD* William Y. Chey, MD
John Abbott, MD The Isaac Gordon Center for Digestive Diseases Department of Medicine and Pathology The Genesee Hospital and The University of Rochester School of Medicine and Dentistry Rochester, New York
Diverticulosis was again thought to be the cause of bleeding, and a segmental sigmoid colectomy with end-to-end anastamosis was performed. Postoperatively the complications of draining fistula from leakage of anastomosis, septicemia, and continued rectal bleeding necessitated a transverse colostomy. When the fistula healed, he continued to pass blood intermittently through his colostomy for the next 6 months. In September 1973, after noticing a large amount of bright red blood in the colostomy bag, he was readmitted to a hospital. Colonoscopic examination through the colostomy opening was unremarkable except for some "patchy reddened areas" near the cecum. Barium enema revealed an intact sigmoid anastomosis with healing of the fistulous tract. Closure of colostomy with end-to-end colonic anastomosis was done. During the following 6 months, he had 7 more hospitalizations because of recurrent hemorrhage requiring multiple blood transfusions. Extensive work-up for the source of bleeding - including panendoscopy, colonoscopy (during a non-bleeding period), upper gastrointestinal radiography, barium enemas, and 1 angiogram during active bleeding-failed to reveal a definite source. At the time of his first admission to The Genesee Hospital in September 1974 he was having loose bowel movements with intermittent passage of red and maroon blood in moderate amounts. He complained of increased episodes of anginal chest pain but denied abdominal pain, nausea, vomiting, or hematemesis. His medications included digoxin, nitroglycerin, antacids, Lomotil, and acetaminophen for headaches. He denied any fami ly history of episodic intestinal bleeding. Physical examination was normal. In particular, there was no 167
Figure 1. Erect abdominal radiograph showing distended loops mainly of small bowel with the large loop extending toward the left upper quadrant. 166
STRANGULATED ILEAL LOOP
Figure 2. Diagram representing the findings at laparotomy. The adhesive band beneath which the ileal loop had been trapped is identified. On admission the patient was pain-free, his abdomen was non-tender, and on rectal examination melena stool was present. Emergency panendoscopy was undertaken 6 hours following admission. A deformed duodenal cap with a chronic anterior wall duodenal ulcer and surrounding superficial ulceration was present. There was no bleeding from the ulcer at the time of endoscopy. Six hours after endoscopy the patient complained of abdominal distension and pain. A plain radiograph of the abdomen showed distended loops of large and small bowel with no evidence of free intraperitoneal gas (Figure 1). Despite continuous nasogastric aspiration and intravenous fluids his condition failed to improve, and laparotomy was undertaken 18 hours after endoscopy. Copious blood-stained peritoneal fluid was present with markedly distended loops of small bowel. A gangrenous loop of jejunum was trapped by a fibrous band between sigmoid colon and duodenum (Figure 2). This fibrous band was divided and the gangrenous segment of jejunum resected. A duodenal ulcer could be palpated in the first part of duodenum. The patient made an uneventful recovery. DISCUSSION The indication for endoscopy in this patient was upper gastrointestinal bleeding. Six hours following the procedure a strangulated small intestinal obstruction developed. It is extremely unlikely that this complication was responsible for the initial presentation as the patient had been observed medically for 54 hours before endoscopy. Thus it seems likely that the endoscopy and the development of the acute abdomen were causally related. There are several mechanisms by which upper gastrointestinal endoscopy may lead to acute abdominal emergency. Gastric perforation is a rare event and is usually recognized by failure of the stomach to distend. Large volumes of free intraperitoneal gas are usually present, although the site of the GASTROINTESTINAL ENDOSCOPY
perforation (usually high posterior wall) is often difficult to find. This complication occurred more frequently with the older rigid and semirigid instruments than with the modern flexible endoscopes. 7 The syndrome of pseudo-acute abdomen has been recently described.- In this syndrome, distension and pain develop immediately following endoscopy and are relieved by nasogastric suction. This usually occurs in the patient with gastric outlet obstruction. The mechanism is believed to be entrapment of air insufflated under pressure in the stomach during the procedure. Adhesive intestinal obstruction is a common surgical entity.8 There are several possible mechanisms including entrapment of bowel loop by adhesive bands, torsion of an intestinal loop on a band, or herniation of an intestinal loop into an acquired sac. While the actual mechanism of obstruction in the present case is speculative, it would seem likely that distension of small bowel loop already lying beneath the adhesive band may have lead to entrapment and subsequent strangulation. Such a development following endoscopy must be unusual. However, many of the patients undergoing gastrointestinal
Vascular dysplasia of the cecum as a repeated source of hemorrhage Role of colonoscopy in diagnosis
Repeated, massive, painless, gastrointestinal bleeding from an obscure source has always posed a challenging or even frustrating problem for practicing physicians. Despite vigorous diagnostic efforts, including laparotomy and selective angiography, diagnosis may not always be successful. The experience can be frightening for the patient. We report our experience with a patient afflicted by intermittent lower intestinal bleeding who was subjected to laparotomy, partial resection of the colon, and then to angiographic studies in a search for the site of bleeding. Careful colonoscopic examination eventually pin-pointed the exact site and type of bleeding and led to definitive surgical management. CASE REPORT A 56-year-old married man came to us for the first time in September 1974 with a 4-year history offrequent, loose bowel movements containing maroon or bright-red blood. This bleeding was not accompanied by abdominal pain or cramps although during each episode of bleeding he experienced generalized weakness, frequent dizziness, and anginal chest pain. In October 1970 he suffered his first episode of painless rectal bleeding, requiring transfusion of 3 liters of blood. A diagnosis of sigmoid diverticulosis was made at that time by barium enema. He then remained asymptomatic for 1Y2 years. In January 1973 he suffered 2 episodes of brisk rectal bleeding requiring multiple blood transfusions. During February 1973, frequent episodes of painless bleeding recurred, often accompanied by anginal chest pains and generalized weakness. "Reprint requests to: Krishan D. Thanik, MD, The Isaac Gordon Center for Digestive Diseases, The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607. VOLUME 23, NO.3, 1977
endoscopy have had previous operations and, presumably, have intra-abdominal adhesions. It is perhaps surprising then that this complication occurs so infrequently, considering the large number of gastrointestinal endoscopies performed. Gastroscopy is a safe and accurate procedure, but inevitably as experience expands the number and nature of complications will grow. REFERENCES 1. MYERS MA, GHAHREMANI GG: Complications of fibreoptic endoscopies. Radiology 115:293, 1975 2. SCHILLER KFR, COTTON PB, SALMON PR: Hazards of digestive fibre-endoscopy: a survey of British experience. Gut 13: 1027 (Abstr), 1972 3. COWEN AE, ISBISTER WH, CAMPBELL CB: Gastrointestinal endoscopy: current status and recent advances. Aust NZ J Med 4:75, 1974 4. FUJITA R, KUMURA F: Arrythmias and ischaemic changes of the heart induced by gastric endoscopic procedures. Am J Gastro 64:44, 1975 5. LEONIDAS H. BERRY (Ed): Gastrointestinal Panendoscopy. Springfield, Charles C Thomas, 1975 6.0GG TW, DAVIDSON AI: Respiratory failure following gastroscopy. Anaesthesia 30:194, 1975 7. JONES AE, DOL R, FLETCHER C, ROGERS HW: The risks of gastroscopy, a survey of 49,000 examinations. Lancet 1:647, 1951 8. COLE and ZOLLINGER In Textbook of Surgery Ninth Ed., Meredith Corporation.
Krishan D. Thanik, MD* William Y. Chey, MD
John Abbott, MD The Isaac Gordon Center for Digestive Diseases Department of Medicine and Pathology The Genesee Hospital and The University of Rochester School of Medicine and Dentistry Rochester, New York
Diverticulosis was again thought to be the cause of bleeding, and a segmental sigmoid colectomy with end-to-end anastamosis was performed. Postoperatively the complications of draining fistula from leakage of anastomosis, septicemia, and continued rectal bleeding necessitated a transverse colostomy. When the fistula healed, he continued to pass blood intermittently through his colostomy for the next 6 months. In September 1973, after noticing a large amount of bright red blood in the colostomy bag, he was readmitted to a hospital. Colonoscopic examination through the colostomy opening was unremarkable except for some "patchy reddened areas" near the cecum. Barium enema revealed an intact sigmoid anastomosis with healing of the fistulous tract. Closure of colostomy with end-to-end colonic anastomosis was done. During the following 6 months, he had 7 more hospitalizations because of recurrent hemorrhage requiring multiple blood transfusions. Extensive work-up for the source of bleeding - including panendoscopy, colonoscopy (during a non-bleeding period), upper gastrointestinal radiography, barium enemas, and 1 angiogram during active bleeding-failed to reveal a definite source. At the time of his first admission to The Genesee Hospital in September 1974 he was having loose bowel movements with intermittent passage of red and maroon blood in moderate amounts. He complained of increased episodes of anginal chest pain but denied abdominal pain, nausea, vomiting, or hematemesis. His medications included digoxin, nitroglycerin, antacids, Lomotil, and acetaminophen for headaches. He denied any fami ly history of episodic intestinal bleeding. Physical examination was normal. In particular, there was no 167
