Small Intestinal Perforation Secondary to Necrotizing Enteritis—An Under-Recognized Complication of Crohn’s Disease

Small bowel perforation is an uncommon but severe event in the natural history of Crohn’s disease with fewer than 100 cases reported. We review Crohn’s disease cases with necrotizing enteritis and share a case of a 26-year-old female who presented with a recurrent episode of small intestinal perforation. A PubMed literature review of case reports and series was conducted using keywords and combinations of “Crohn’s disease,” “small intestine perforation,” “small bowel perforation,” “free perforation,” “regional enteritis,” and “necrotizing enteritis.” Data extracted included demographic data, pre- or postoperative steroid administration, medical or surgical management, and case fatality. Nineteen reports from 1935 to 2021 qualified for inclusion. There were 43 patients: 20 males and 23 females with a mean age of 36 ± 15 years old. 75 total perforations were described: 56 ileal (74.6%), 15 jejunal (20.0%), 2 cecal (2.7%), and 1 small intestine non-specified (2.7%). 38 of 43 patients were managed surgically by primary repair (11), ostomy creation (21), or an anastomosis (11). Of 11 case fatalities, medical management alone was associated with higher mortality (5/5; 100% mortality) compared to those treated surgically (6/38; 15.8% mortality; P < .001). Patient sex, disease history, acute abdomen, and pre- or postoperative steroid use did not significantly correlate with mortality. Jejunal perforation was significantly ( P = .028) associated with event mortality while ileal was not ( P = .45). Although uncommon, necrotizing enteritis should be considered in Crohn’s patients who present with small intestinal perforation. These cases often require urgent surgical intervention and may progress to fulminant sepsis and fatality if not adequately treated.

Potentially harmful materials in the feces of wild ring-tailed coatis (Nasua nasua) and health implications

ABSTRACT: In ecological parks, the proximity to tourist activities facilitates the exploration of garbage by coatis, with possible serious consequences for the animals health . We described the contents of wild coatis feces from three ecological parks. After analyzing 62 samples, fragments of plants and animals were identified in all feces. In the feces of two parks, seeds were present between 36.4% and 48.6% of the samples. Arthropod fragments were identified in 100% of the samples from two parks, but only 87.3% in a third park. Scales, bones or bird feathers were present in some samples. Undigested material of industrial origin was detected in 34.3% to 54.5% of the samples, such as fragments of paper, string, plastic, aluminum, latex and glass. Results are in line with other studies on the diet of wild coatis, but the intake of foreign bodies, potentially harmful to health, is described for the first time. Clinical problems resulting from ingesting waste can be dental fractures, mucosal erosions, intestinal perforation, peritonitis, impaction, diarrhea, weight loss, intoxication and infections. Coatis in the three parks are at risk of health, and actions are needed to avoid clinical and potentially fatal problems. Four actions are recommended to avoid ingesting foreign bodies: increasing the environmental education of visitors; improving the storage of waste generated in parks; periodically monitor the health of coatis, in order to make interventions when possible; make a permanent program to study the ecology of species in the three parks.

Rapunzel Syndrome – A Case Report: Trichobezoar as a Cause of Gastric Outlet Obstruction and Intestinal Perforation

Rapunzel syndrome is described as a rare manifestation of gastric trichobezoar extending throughout the bowel and is associated with psychiatric disorders. Its incidence in Pakistan is very rare and is found characteristically in adolescent females. Large or complicated trichobezoars are best managed by surgery. Psychiatric follow-up is essential to diminish the frequency of recurrence. We report an unusual case of Rapunzel syndrome causing gastric outlet obstruction and intestinal perforation.

Gross pathology of herons and egrets (family Ardeidae) at a wildlife rehabilitation centre in Northern California

Gross necropsies were performed on all herons and egrets (family Ardeidae) that died or were euthanized at a wildlife rehabilitation centre in Fairfield, California, over a six-week period in the summer of 2018 (n = 145). Of the animals necropsied, 108 (74.5%) were euthanized and 37 (25.5%) died. Common reasons for euthanasia were trauma (n = 24), MBD (n = 39) and non-specific signs such as hypothermia and obtundation that persisted in the face of medical and supportive care (n = 32). MBD was found both in birds at admission (n = 9) and later in care (n = 34), despite calcium supplementation to correct calcium:phosphorus ratios of foods. Feeder fish were suspected to be deficient in vitamin D, and supplementation successfully reduced the development of this problem during the care later in the season. Nematodes of the genus Eustrongylides were found in the coelomic cavities of 43 (30%) birds. High burdens were often accompanied by coelomitis and abscessation involving internal organs. Visceral gout (n = 10) and intestinal perforation (n = 4) were both strongly associated with the administration of meloxicam. These findings suggest meloxicam should be used with caution in these species. Other less common findings included septic arthritis, intestinal perforation and hepatomegaly. This study describes common gross pathological findings of herons and egrets in a wildlife rehabilitation centre in California and demonstrates the utility of gross necropsies in determining cause of death when more advanced post-mortem diagnostics are unavailable

Association of intrapartum drugs to spontaneous intestinal perforation: A single center retrospective review

ABSTRACT Background: Spontaneous intestinal perforation (SIP) occurs commonly in extremely low gestational age newborns (ELGANs; < 30 weeks GA). Early, concurrent neonatal use of indomethacin (Neo_IN) and hydrocortisone (Neo_HC), is a known risk for SIP. Mothers in premature labor often receive indomethacin (Mat_IN) for tocolysis and steroids (Mat_S) for fetal maturation. Coincidentally, ELGANs may receive Neo_IN or Neo_HC within the first week of life. There is limited data on the effect of combined exposures to maternal and neonatal medications. We hypothesized that proximity exposure to these medications may increase the risk of SIP. Design: We reviewed the medical records of ELGANS from June 2014 to December 2019 at a single Level III NICU. We compared antenatal and postnatal indomethacin and steroid use between neonates with and without SIP. Chi-Square, Student’s t-test, Fisher’s Exact test, and Mann-Whitney U tests were used for analysis. Results: Among 417 ELGANs, SIP was diagnosed in 23; predominantly neonates <26 weeks GA (n = 21/126, 16.7%). Risk factors analysis focused on this GA cohort in which SIP was most prevalent. Mat_IN administration within two days of delivery increased SIP risk (OR 3.00, 95%Cl 1.25-7.94, p=0.036). Neo_HC was not independently associated with SIP (p=0.38). A higher proportion of SIP group had close temporal exposure of Mat_IN and Neo_HC compared to the non-SIP group, though not statistically significant (14% v. 7%, p=0.24). Conclusions: Peripartum Mat_IN was associated with increased risk for SIP in this small study sample. Larger studies are needed to further delineate SIP risk from the interaction of peripartum maternal medication with early postnatal therapies and disease pathophysiology.