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Current Gastroenterology Reports Jun 2017This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. (Review)
Review
PURPOSE OF REVIEW
This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy.
RECENT FINDINGS
SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
Topics: Abdominal Pain; Diagnosis, Differential; Dilatation, Pathologic; Humans; Ileus; Intestinal Obstruction; Intestine, Small; Laparoscopy; Nausea; Physical Examination; Postoperative Complications; Vomiting
PubMed: 28439845
DOI: 10.1007/s11894-017-0566-9 -
Digestive Surgery 2020Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including...
BACKGROUND
Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis.
METHODS
We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients.
RESULTS
Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after "clinically successful" treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10-20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%.
CONCLUSIONS
The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.
Topics: Anastomosis, Roux-en-Y; Bile Ducts; Cholangitis; Cholecystectomy; Constriction, Pathologic; Dilatation; Humans; Iatrogenic Disease; Jejunum; Liver Cirrhosis, Biliary; Prognosis; Quality of Life; Recurrence; Reoperation; Retrospective Studies
PubMed: 30654363
DOI: 10.1159/000496432 -
Alimentary Pharmacology & Therapeutics Aug 2018Fibrotic stricture is a common complication of Crohn's disease (CD) affecting approximately half of all patients. No specific anti-fibrotic therapies are available;...
BACKGROUND
Fibrotic stricture is a common complication of Crohn's disease (CD) affecting approximately half of all patients. No specific anti-fibrotic therapies are available; however, several therapies are currently under evaluation. Drug development for the indication of stricturing CD is hampered by a lack of standardised definitions, diagnostic modalities, clinical trial eligibility criteria, endpoints and treatment targets in stricturing CD.
AIM
To standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Chron's disease.
METHODS
An interdisciplinary expert panel consisting of 15 gastroenterologists and radiologists was assembled. Using modified RAND/University of California Los Angeles appropriateness methodology, 109 candidate items derived from systematic review and expert opinion focusing on small intestinal strictures were anonymously rated as inappropriate, uncertain or appropriate. Survey results were discussed as a group before a second and third round of voting.
RESULTS
Fibrotic strictures are defined by the combination of luminal narrowing, wall thickening and pre-stenotic dilation. Definitions of anastomotic (at site of prior intestinal resection with anastomosis) and naïve small bowel strictures were similar; however, there was uncertainty regarding wall thickness in anastomotic strictures. Magnetic resonance imaging is considered the optimal technique to define fibrotic strictures and assess response to therapy. Symptomatic strictures are defined by abdominal distension, cramping, dietary restrictions, nausea, vomiting, abdominal pain and post-prandial abdominal pain. Need for intervention (endoscopic balloon dilation or surgery) within 24-48 weeks is considered the appropriate endpoint in pharmacological trials.
CONCLUSIONS
Consensus criteria for diagnosis and response to therapy in stricturing Crohn's disease should inform both clinical practice and trial design.
Topics: Catheterization; Clinical Trials as Topic; Colon; Consensus; Constriction, Pathologic; Crohn Disease; Dilatation; Endoscopy; Expert Testimony; Fibrosis; Humans; Intestinal Obstruction; Intestine, Small; Practice Guidelines as Topic; Reference Standards
PubMed: 29920726
DOI: 10.1111/apt.14853 -
European Journal of Radiology Feb 2019To systematically review the clinical manifestations, MRI appearance, and management of tumefactive Virchow-Robin spaces (VRs).
OBJECTIVE
To systematically review the clinical manifestations, MRI appearance, and management of tumefactive Virchow-Robin spaces (VRs).
METHODS
A systematic MEDLINE literature search was performed. Data were extracted per tumefactive VRs location (type 1: along lenticulostriate arteries entering the basal ganglia; type 2: along perforating medullary arteries; type 3: mesencephalothalamic region; and other locations).
RESULTS
Ninety-nine articles were included, comprising 164 patients. There were few reports on type 1 tumefactive VRs (n = 5 patients) and tumefactive VRs at other locations (n = 16 patients). In type 2 tumefactive VRs (n = 62 patients), clinical manifestations were reported in 12.9%, signal abnormalities of adjacent brain parenchyma were reported in 32.3%, and MRI follow-up of 23/24 asymptomatic tumefactive VRs showed no change (mean follow-up of 3.2 years). In type 3 tumefactive VRs (n = 80 patients), clinical manifestations were reported in 75.0%, signal abnormalities inside VRs or adjacent brain parenchyma were reported in 3.8%, and neurosurgical outcome (59 reported patients) was generally good. Type 3 tumefactive VRs may increase after neurosurgery (5/59 [8.5%] reported patients; 0.5-14 years follow-up) or spontaneously (2/5 [40%] reported patients; 2 and 9 years follow-up), requiring (repeated) neurosurgery.
CONCLUSION
In type 2 tumefactive VRs, clinical manifestations and signal abnormalities of adjacent brain parenchyma occur in a minority of cases, and follow-up of asymptomatic patients seems unnecessary. In type 3 tumefactive VRs, clinical manifestations are common, concomitant signal abnormalities occur infrequently, and neurosurgical outcome is generally good. Follow-up of type 3 tumefactive VRs is suggested. There are limited data on other types of tumefactive VRs.
Topics: Arteries; Dilatation, Pathologic; Glymphatic System; Humans; Magnetic Resonance Imaging; Reproducibility of Results
PubMed: 30691661
DOI: 10.1016/j.ejrad.2018.12.011 -
European Archives of... Nov 2023This study aimed to assess the changes in spirometry parameters or indices after relieving laryngotracheal stenosis (LTS) in adult patients. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This study aimed to assess the changes in spirometry parameters or indices after relieving laryngotracheal stenosis (LTS) in adult patients.
METHODS
A systematic review and meta-analysis of studies from PubMed, Scopus, Web of Science, Cochrane Library, and EBSCO databases was conducted for assessing changes in spirometry values after endoscopic balloon dilatation of LTS in adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Relevant data, such as changes in mean spirometry values between preoperative and postoperative interventions, and findings of receiver operating characteristic curve analyses for predicting the need for surgical intervention, were extracted.
RESULTS
Ten studies including 330 patients overall met the inclusion criteria. Significant improvements were observed from preoperative to postoperative mean values of different spirometry parameters and indices. The overall mean differences in peak expiratory flow (ΔPEF), expiratory disproportion index (ΔEDI), and peak inspiratory flow (ΔPIF) were 2.26 L/s (95% CI 2.14-2.38), 27.94 s (95% CI 26.36-29.52), and 1.21 L/s (95% CI 0.95-1.47), respectively. ΔPEF and ΔPIF values increased, while ΔEDI decreased. In predicting the need for surgical intervention, EDI had the highest sensitivity (88%), and forced expiratory volume per second/forced vital capacity had the highest specificity (85%).
CONCLUSION
Spirometry is a valuable tool for assessing patients with LTS. PEF, EDI, and PIF were the most commonly reported spirometry parameters that significantly improved after airway stenosis was relieved.
Topics: Adult; Humans; Constriction, Pathologic; Spirometry; Tracheal Stenosis; Respiratory Function Tests; ROC Curve; Laryngostenosis
PubMed: 37522909
DOI: 10.1007/s00405-023-08159-7 -
Journal of Clinical Gastroenterology 2015With the widespread use of abdominal imaging, an incidentally found dilated common bile duct (CBD) is a common radiographic finding. The significance of a dilated CBD as... (Review)
Review
BACKGROUND
With the widespread use of abdominal imaging, an incidentally found dilated common bile duct (CBD) is a common radiographic finding. The significance of a dilated CBD as a predictor of underlying disease and long-term outcome have not been well elucidated.
GOALS
A systematic review of studies on patients with dilated CBD was performed to identify etiologies and clinical factors that may predict which patients require further diagnostic testing and long-term outcomes. A PubMed search for relevant articles published between 2001 and 2014 was performed.
RESULTS
The search yielded a total of 882 articles, and after careful individual review for eligibility and relevancy, 9 peer-reviewed studies were included. A cause of the CBD dilation was found on average in 33% of cases and the most common causes were: CBD stone, chronic pancreatitis, and periampullary diverticulum. The overall CBD diameter was not associated with finding a causative lesion. Coexisting CBD and intrahepatic bile duct dilation, age, and jaundice were found to be indicators of pathologic lesions. Dilation of both the CBD and pancreatic duct was suggestive of pancreatic disease, especially pancreatic malignancy in the setting of obstructive jaundice. Follow-up was reported in 6 studies ranging from 6 to 85 months, and generally there was no change in the diagnosis.
CONCLUSIONS
Incidentally found biliary tract dilatation can be a manifestation of significant biliary tract disease including malignancy. Long-term outcome is not well defined and further prospective studies examining the most cost-effective approach to evaluation are needed.
Topics: Adult; Age Factors; Aged; Bile Ducts, Intrahepatic; Biliary Tract Diseases; Common Bile Duct; Dilatation, Pathologic; Diverticulum; Female; Gallstones; Humans; Incidental Findings; Jaundice, Obstructive; Male; Middle Aged; Pancreatic Diseases; Pancreatic Ducts; Radiography
PubMed: 26302495
DOI: 10.1097/MCG.0000000000000394 -
Journal of Crohn's & Colitis Feb 2018Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and... (Review)
Review
BACKGROUND
Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and stoma-free living. Pouch strictures are a complication with a reported incidence of 5-38%. The three areas where pouch strictures occur are in the pouch inlet, mid-pouch and pouch-anal anastomosis.
AIM
To undertake a systematic review of the literature and to identify management strategies available for pouch-anal, mid-pouch and pre-pouch ileal strictures and their outcomes.
METHODS
A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was performed. Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded.
RESULTS
Twenty-two articles were considered eligible. Pouch-anal strictures have been initially managed using predominately dilators which include bougie and Hegar dilators with various surgical procedures advocated when initial dilatation fails. Mid-pouch strictures are relatively unstudied with both medical, endoscopic and surgical management reported as successful. Pouch inlet strictures can be safely managed using a combined medical and endoscopic approach.
CONCLUSION
The limited evidence available suggests that pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical revision or resection. Management of mid-pouch strictures requires a combination of medical, endoscopic and surgical management. Pouch inlet strictures are best managed using a combined medical and endoscopic approach. Future studies should compare different treatment modalities on separate stricture locations to enable an evidenced-based treatment algorithm.
Topics: Colonic Pouches; Constriction, Pathologic; Digestive System Surgical Procedures; Dilatation; Endoscopy, Gastrointestinal; Humans; Ileum
PubMed: 29155985
DOI: 10.1093/ecco-jcc/jjx151 -
World Journal of Gastroenterology Dec 2017To evaluate the therapeutic role of double-balloon enteroscopy (DBE) in small bowel strictures and to propose a standard approach to small bowel strictures. (Review)
Review
AIM
To evaluate the therapeutic role of double-balloon enteroscopy (DBE) in small bowel strictures and to propose a standard approach to small bowel strictures.
METHODS
Systematic review of studies involving DBE in patients with small bowel strictures. Only studies limited to small bowel strictures were included and those with ileo-colonic strictures were excluded.
RESULTS
In total 13 studies were included, in which 310 patients were dilated. The average follow-up time was 31.8 mo per patient. The complication rate was 4.8% per patient and 2.6% per dilatation. Surgery was avoided in 80% of patients. After the first dilatation, 46% were treated with re-dilatation and only 17% required surgery.
CONCLUSION
DBE-assisted dilatation avoids surgery in 80% of patients with small bowel strictures and is safe and effective. We propose a standardized approach to small bowel strictures.
Topics: Constriction, Pathologic; Dilatation; Double-Balloon Enteroscopy; Humans; Intestinal Obstruction; Intestine, Small; Postoperative Complications; Treatment Outcome
PubMed: 29259383
DOI: 10.3748/wjg.v23.i45.8073 -
Journal of Endovascular Therapy : An... Feb 2017To provide an updated systematic literature review and summarize current evidence on proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To provide an updated systematic literature review and summarize current evidence on proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR).
METHODS
A review of the English-language medical literature from 1991 to 2015 was conducted using MEDLINE and EMBASE to identify studies reporting AND after EVAR. Studies considered for inclusion and full-text review fulfilled the following criteria: (1) reported AND after EVAR, (2) included at least 5 patients, and (3) provided data on AND quantification. The search identified 26 articles published between 1998 and 2015 that encompassed 9721 patients (median age 71.8 years; 9439 men).
RESULTS
AND occurred in 24.6% of patients (95% CI 18.6% to 31.8%) over a period ranging from 15 months to 9 years after EVAR. No significant dilatation of the suprarenal part of the aorta was reported by most studies. The incidence of combined clinical events (endoleak type I, migration, reintervention during follow-up) was higher in the AND group (26%) when compared with 2% in the group without AND (OR 28.7, 95% CI 5.43 to 151.67, p<0.001).
CONCLUSION
AND affects a considerable proportion of EVAR patients and was related to worse clinical outcome, as indicated by increased rates of type I endoleak, migration, and reinterventions. Future studies should focus on a better understanding of the pathophysiology, predictors, and risk factors of AND, which could identify patients who may warrant a different EVAR strategy and/or a closer post-EVAR surveillance strategy.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Chi-Square Distribution; Dilatation, Pathologic; Endoleak; Endovascular Procedures; Foreign-Body Migration; Humans; Odds Ratio; Retreatment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 27974495
DOI: 10.1177/1526602816673325 -
Inflammatory Bowel Diseases Jul 2023Crohn's disease (CD) is a chronic progressive condition that is complicated by intestinal or colonic stricture in nearly 30% of cases within 10 years of the initial... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Crohn's disease (CD) is a chronic progressive condition that is complicated by intestinal or colonic stricture in nearly 30% of cases within 10 years of the initial diagnosis. Endoscopic balloon dilation (EBD) is associated with a risk of perforations and recurrence rates of up to 60% at 5 years. Endoscopic stenting has been used as an alternative to EBD, but data on its safety and efficacy are limited. We conducted a systematic review and meta-analysis to assess the outcomes of endoscopic stenting in CD-related strictures.
METHODS
A systematic and detailed search was run in January 2022 with the assistance of a medical librarian for studies reporting on outcomes of endoscopic stenting in CD-related strictures. Meta-analysis was performed using random-effects model, and results were expressed in terms of pooled proportions along with relevant 95% confidence intervals (CIs).
RESULTS
Nine studies with 163 patients were included in the final analysis. Self-expanding metal stents (SEMS) including both partial and fully covered were used in 7 studies, whereas biodegradable stents were used in 2 studies. Pooled rate of clinical success and technical success was 60.9% (95% CI, 51.6-69.5; I2 = 13%) and 93% (95% CI, 87.3-96.3; I2 = 0%), respectively. Repeat stenting was needed in 9.6% of patients (95% CI, 5.3-16.7; I2 = 0%), whereas pooled rate of spontaneous stent migration was 43.9% (95% CI, 11.4-82.7; I2 = 88%). Pooled incidence of overall adverse events, proximal stent migration, perforation, and abdominal pain were 15.7%, 6.4%, 2.7%, and 17.9%, respectively. Mean follow-up period ranged from 3 months to 69 months.
DISCUSSION
Endoscopic stenting in CD-related strictures is a safe technique that can be performed with technical ease, albeit with a limited clinical success. Postprocedure abdominal pain and proximal stent migration are some of the common adverse events reported.
Topics: Humans; Crohn Disease; Constriction, Pathologic; Treatment Outcome; Abdominal Pain; Stents; Dilatation
PubMed: 35880681
DOI: 10.1093/ibd/izac153