Minimally Invasive Elective Surgery as a Treatment of Bowel Invagination in a Peutz-Jeghers Syndrome Case

We present a case of a 24-year-old woman with Peutz-Jeghers syndrome, recurrent colic abdominal pain, and lower gastrointestinal bleed for the last 5 years. Colonoscopy showed hamartomas without any dysplasia. In the enteral magnetic resonance imaging, a distal jejunum and ileum invagination, secondary to hamartomas was detected. The patient was referred to the Surgery Department and despite few symptoms, elective surgery was proposed. By laparoscopic surgery approach, the entire bowel was carefully revised, 3 intussusceptions and bowel volvulus were found, 2 in jejunum and 1 in ileum, causing incomplete obstruction and intestinal dilatation, with a diameter of 6 cm. These intussusception areas were marked with a silk filament, after achieving devolvulation and disinvagination. A 5-cm laparotomy was done, to externalize the entire bowel, to explore it manually, to verify the absence of other lesions, and locate silk points. By longitudinal enterotomies on the antimesenteric intestinal border where silk filaments were located, the polyps were removed through their stalk, and the enterotomies were transversely closed. Postoperative evolution was favorable, starting oral tolerance on the fourth day and being discharged from the hospital on the seventh day. Eight months later, the patient was asymptomatic with a better quality of life.

Isolated Ascending Colon Varix: An Unusual Cause of Lower Gastrointestinal Bleed

Ectopic varices, defined as dilated portosystemic veins located at unusual sites other than the gastroesophageal junction and fundus, have been reported in cases of cirrhosis with underlying portal hypertension. The common sites usually are the rectum and duodenum. Isolated colon varix is therefore a rare phenomenon and such varix presenting with lower gastrointestinal bleed as the first manifestation is still uncommon. A high index of clinical suspicion, timely imaging with full-length colonoscopy, and subsequent endoscopic therapy can effectively manage this rare entity.

522 Audit of Acute Lower Gastrointestinal Bleed Management in a District General Hospital

Introduction Acute Lower Gastrointestinal Bleed (ALGIB) is a common emergency surgical referral. This project aims to audit current practice at a district general hospital against new British Society of Gastroenterology guidelines, which gives recommendations regarding assessment (Oakland score), investigation and management. Method A retrospective study was undertaken over one year (2019) of patients presenting to A&E or referred via GP with ALGIB. Patients were identified through the coding department. An online proforma was used for data collection, which was analysed with SPSS. Results 76 appropriate patients identified. Median length of hospital stay was 1 day. 10 patients (13.2%) scored ≤8 (probability of safe discharge 95%), 19 (11.8%) patients scored ≤9 (probability of safe discharge 93%) and 57 patients (75%) scored ≥10. 19 patients discharged the same day, of which 3 (15.8%) scored ≤8 and 8 (42.1%) scored ≤9. 23 patients admitted overnight, of which 5 (21.7%) scored ≤8 and 6 (26.1%) scored ≤9. Of 66 patients classified as ‘major’, 41 (62.1%) did not have a colonoscopy. Conclusions Introduction of a scoring mechanism and disseminating guidelines will enable GPs and A&E doctors to safely discharge ALGIB patients with appropriate outpatient investigations and reduce surgical admissions. There is currently poor compliance with inpatient investigations.

Traumatic Arterio-Enteric Fistula—A Report of 2 Cases With Review of Literature

Background: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. Case Description: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. Conclusion: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.

Rare cause of acute abdomen–cocaine-induced small intestinal perforation with coexisting lower gastrointestinal bleed: an unusual presentation

Cocaine, an alkaloid, is an addictive drug and its abuse as a recreational drug is on the increasing side with its associated complications. Gastrointestinal complications, after cocaine abuse, are less known and need to be addressed since the abuse is on the rise and the existing evidence is scarce. We report a case of a 22-year-old male patient who presented with abdominal pain following a cocaine injection. On examination, signs of peritonitis were noted and laparotomy revealed a 2×1 cm perforation in the distal ileum. The unhealthy intestinal segment was resected and taken out as a double-barrel ileostomy. The patient had an episode of severe lower gastrointestinal bleeding on postoperative day 6. CT and colonoscopy revealed signs of ischaemic bowel and tissue biopsy showed oedematous, inflamed and haemorrhagic bowel mucosa. The patient was managed conservatively and is doing well under follow-up in a de-addiction centre.

Pleomorphic leiomyosarcoma of colonic mesentery: an unusual cause of lower GI bleed - case report and literature review

Mesenteric masses are infrequent lesions ranging from benign cyst to aggressive malignancies and often present as diagnostic and therapeutic challenge. The mesentery is a frequent recipient of metastasis from the gastrointestinal tract, pancreas, and biliary cancers. Primary mesenteric tumours are relatively rare, mostly mesenchymal in origin and benign in nature. Examples include gastrointestinal stromal tumours and smooth muscle tumours. Pleomorphic leiomyosarcoma of mesocolon is extremely rare with a reported incidence of 1:350,000. So accurate preoperative diagnosis of mesenteric soft tissue tumours is generally difficult. It accounts for less than 1% of the malignant tumours found in colon. Leiomyosarcoma is a malignant tumour arising from smooth cell lineage. These tumours occur most commonly in middle aged individuals. We describe a case of pleomorphic leiomyosarcoma arising from the colonic mesentery in a 27-year-old male patient, with massive lower gastrointestinal bleed (LGI bleed) causing drop in haemoglobin level from 9 mg/dl to 6 mg/dl. Ultrasonography and CECT abdomen suggestive of (17.5×11.6×10.6) cm mass in left side upper abdomen in splenic hilar region. Left hemicolectomy with excision of mass with splenectomy and distal pancreatectomy done. The diagnosis was based on histopathological evaluation using immunohistochemistry (IHC). Histopathological report suggestive of pleomorphic leiomyosarcoma with SMA and vimentin positivity on immunohistochemistry but CD 34 and CD 117 were negative, differentiating it from GIST.