A role and a place of ultrasound diagnosis of acute ileus

The main purpose of the authors is to present their view of a place of present-day ultrasonography in the diagnosis of acute small and large intestinal obstruction. A comparatively sizable material covering 218 verified cases of acute ileus, including 77 patients with large intestinal obstruction and 141 patients with impaired passage of the intestinal contents along the small bowel was used to outline the aspects of ultrasound techniques and the symptomatology of ileus, by differentiating its some types. Along with the general assessment of the methodological and semiotic aspects of ultrasound diagnosis of acute uleus, the authors emphasizes a role of sonography in the detection of large intestinal obstruction by outlining their modified procedure of ultrasound irrigoscopy. For greater objectivization of their positive assessment of the place of ultrasound in the diagnosis of acute ileus and large intestinal obstruction, the authors comparatively studied X-ray and ultrasound studies to reveal this pathology. In addition to their purely personal assessment of a role of ultrasound in the diagnosis of large intestinal obstruction, the lecture also shows its authors' opinion as to the organizational issues associated with the necessity of correcting the existing diagnostic algorithm to detect large intestinal obstruction.     

Ultrasound study in the diagnosis of colon obstruction

The authors present the results of their investigations into the use of routine transabdominal sonography and ultrasound irrigoscopy in the diagnosis of acute colon obstruction in 70 patients. In 55 patients, the cause of this pathology was tumor-induced obturation of colon lumen and in 15 cases, the pathology resulted from colon evacuation dysfunction due to congenital abnormalities, acquired stenosis due to inflammatory diseases. Ultrasound irrigoscopy was first applied to determine the presence and degree of colon obstruction and to establish its causes. The procedure and semiotics of ultrasound irrigoscopy and routine transabdominal sonography for this abnormality have been developed and are described in detail. Analysis of the findings has demonstrated that ultrasound irrigoscopy used in the diagnosis of acute colon obstruction is on a par with X-ray irrigoscopy in its informative value and may be widely employed in the used arsenal of diagnostic techniques.     

Ultrasonography in the diagnosis of colonic obstruction

The authors of the present paper outline the results of studying the use of routine transabdominal sonography and ultrasound irrigoscopy (UI) in the diagnosis of acute colonic obstruction (ACO) in 70 patients. The cause of ACO was tumor-induced colonic luminal obturation in 55 patients and colonic evacuatory dysfunction due to congenital anomalies and acquired constrictions of inflammatory genesis in 15 cases. UI was used to determine the presence, degree, and causes of colonic obstruction. The paper details the UI procedure developed by the authors and the ultrasound semiotics of ACO, shown by routine transabdominal sonography and UI. Analysis of the results of the studies allows the authors to state that UI is as highly informative as X-ray irrigoscopy in the diagnosis of ACO and may be included into a diagnostic algorithm in these patients.     

Intestinal obstruction

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus. Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation. Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

INTESTINAL OBSTRUCTION

Despite improvements in knowledge of the pathologic physiology of intestinal obstruction, the introduction of gastrointestinal decompression, and more effective antibiotics, obstruction remains a serious disease with a high mortality rate. Although the diagnosis is often obscure, it can usually be made with a fair degree of accuracy by the history alone; pain is fairly constant and characteristically is of a cramping type simulated by very few other lesions. Distention is present in low lesions but absent in high lesions; on the contrary, vomiting is minimal in low lesions but prominent in high lesions. Visible peristaltic waves are almost pathognomonic of intestinal obstruction. Increased peristaltic sounds, as noted by auscultation, are extremely helpful in diagnosis; they are absent in paralytic ileus.Although intestinal obstruction is a surgical lesion, it must be remembered that in the type produced by adhesions the obstruction can be relieved by gastrointestinal decompression in 80 to 90 per cent of cases. Operation is usually indicated a short time after relief because of the probability of recurrence. In practically all other types of obstruction decompression is indicated only while the patient is being prepared for operation. Obviously any type of strangulation demands early operation. Strangulation can usually be diagnosed, particularly if it develops while the patient is under observation. Increase in pain, muscle spasm and pulse rate are important indications of development of strangulation.Dehydration and electrolytic imbalance are produced almost universally in high obstruction. Usually, it is unwise to wait until these two deficiencies are corrected before operation is undertaken, but correction must be well under way at the time of operation. Resections should be avoided in the presence of intestinal obstruction, but obviously will be necessary in strangulation. Operative technique must be expert and carried out with minimal trauma. Postoperative care is very important; important features are decompression, for two to three days, accurate fluid and electrolytic replacement, and transfusions.     

Ultrasonographic evaluation of the equine placenta by transrectal and transabdominal approach in the normal pregnant mare

The objective of this study was to determine normal variations in the utero placental thickness during mid- and late gestation in the mare. Normal, healthy pregnant mares (n = 9) were examined monthly from 4 mo of gestation until parturition by transrectal and transabdominal ultrasonography. At each examination, the combined thickness of the uterus and the placenta (CTUP) was measured at the placento-cervical junction (transrectally) and at the uterine body or the uterine horns (transabdominally). In addition, the echogenicity of the amniotic and allantoic fluids was evaluated by transrectal ultrasonography. Following parturition and expulsion of the fetal membranes, the allantochorion was measured and visually examined for abnormalities. At all examinations, both transrectal and transabdominal, the chorioallantois and the uterus were indistinguishable from each other on the ultrasound image. The CTUP, measured by transrectal ultrasonography did not change between 4 and 8 mo of gestation, but increased significantly for each month between 10 and 12 mo of gestation (P < 0.001). A change in the CTUP was detected between months when measured by transabdominal ultrasonography, but no distinct pattern in these changes was observed. No correlation was found between transabdominal and transrectal measurements of the CTUP. The echogenicity of the amniotic and allantoic fluids did not consistently change over time during mid- and late gestation. The amniotic fluid was more echogenic than the allantoic fluid at most examinations from 6 mo of pregnancy and throughout gestation (P < 0.05). It was concluded that transrectal ultrasonographic examination to assess the CTUP and the echogenicity of the fetal fluids is superior to the transabdominal approach. We suggest that transrectal ultrasonographic examination should be added to current diagnostic tools during late gestation and that it be part of the biophysical profile of high risk equine pregnancies.     

Ultrasound study in the diagnosis of small and large intestinal obstruction

The results of ultrasound study were analyzed in 148 and 26 patients with acute small and intestinal obstruction, respectively, the causes of the latter included different diseases of the intestine and abdominal organs. The commonest ultrasound symptoms based on the diameter of the bowel, on the thickness and structure of the intestinal wall, on the status of mucosal motility folds of intestinal loops and on the pattern of motility were defined. They enable one to differentiate large and small intestinal obstruction and to define its degree with a high degree of validity. Abdominal ultrasonography used in the emergency surgical setting may rapidly solve problem in the diagnosis of abnormal changes, differential mechanical and functional ileus in most cases. Dynamic ultrasound monitoring allows the efficiency of the treatment performed to be evaluated.     

Alpha2-adrenergic regulation of NO production alters postoperative intestinal smooth muscle dysfunction in rodents

Alpha2-adrenergic receptor activation plays an important role in the development of postoperative ileus. Alpha2-adrenergic receptors also regulate nitric oxide (NO) production by the mononuclear phagocyte system. We have previously shown that intestinal manipulation leads to a significant increase in NO production by infiltrating monocytes within the intestinal muscularis. The purpose of this study was to investigate whether alpha2-adrenergic blockade with yohimbine would alter postsurgical intestinal smooth muscle dysfunction and NO production by infiltrating monocytes and macrophages within the intestinal muscularis. Rats underwent small bowel intestinal manipulation with or without yohimbine. In vivo gastrointestinal transit and in vitro jejunal circular muscle contractility was measured 24 h postoperatively. RT-PCR was used to detect inducible NO synthase (iNOS) expression. NO levels in tissue culture supernatants were measured. Immunohistochemistry was used to localize alpha2-adrenergic receptor expression in the intestinal muscularis. Yohimbine significantly decreased manipulation-induced delay in gastrointestinal transit and reversed the postoperative decrease in intestinal muscle contractility. Intestinal manipulation resulted in significant iNOS mRNA induction in the intestinal muscularis, which was markedly attenuated after yohimbine treatment. Yohimbine also significantly decreased the postoperative increase in NO released into intestinal muscularis tissue culture supernatant. Immunohistochemistry identified alpha2-adrenergic receptors on monocytes recruited postoperatively into the intestinal muscularis. This study demonstrates that alpha2-adrenergic receptor stimulation of the inflamed postoperative intestinal muscularis plays a significant role in aggravating postoperative ileus through an enhanced induction of iNOS mRNA and increased release of NO from manipulated intestinal muscularis.     

The use of slaughterhouse-obtained small intestinal tissue as control material in histological studies should be applied with prudence

This study aimed to evaluate the reliability of slaughterhouse-obtained small intestinal tissue as control material in equine colic research where molecular stress responses in small intestinal tissue are investigated. For this purpose, small intestinal samples from colic horses were collected during surgery or immediately after euthanasia at the oral border of strangulation resection sites and routinely processed for histopathology (i.c. rinsed with 4°C Krebs' solution, fixated overnight with 4% neutral buffered formaldehyde (FH) at room temperature). Control samples consisted of pieces of mid-jejunum, collected at the slaughterhouse and routinely processed for histopathology under 4 different conditions. The 4 conditions differed with regard to incubation and fixation temperature and whether or not oxygenated Krebs' solution was used. Histological scoring revealed that slaughterhouse samples had a higher mean lesion score (P<0.001) than colic samples. In addition, more slaughterhouse samples had a higher mean inflammation score than colic samples (P=0.001). The inflammatory cells in the small intestine consisted mostly of eosinophils and as such were very suggestive for parasitic infestation. Hypoxia-inducible factor-1α (HIF1α) nuclear immunoreactivity was more pronounced in slaughterhouse tissue, probably as a result of the delay between slaughter and sampling (P=0.034). The histopathological score (P=0.291), the inflammation score (P=0.248) and the HIF1α nuclear immunoreactivity (P=0.538) did not differ between the different collection protocols. It is concluded that slaughterhouse-obtained small intestinal tissue shows distinct alterations and that its use as control tissue when evaluating molecular stress responses should be applied with prudence.     

Radiographic and ultrasonographic findings in a dog with emphysematous pyometra

Background

Emphysematous pyometra is a rare canine disease characterized by gas-forming bacteria infecting the uterus and causing an accumulation of both gas and infectious exudate in the uterine lumen. While radiological features of emphysematous pyometra have been previously described in dogs, the ultrasonographic appearance has not been reported.

Case presentation

A 7-year-old intact female Labrador Retriever was presented because of a 1 day history of vomiting, anorexia, mild polyuria/polydipsia and signs of fatigue. On physical examination the dog had a swollen vulva with a sparse amount of yellow discharge. Lateral and ventrodorsal radiographs showed a dilated predominantly gas-filled tubular structure located in the mid and cranial abdomen traversing from left to right and ending dorsally at the level of the 12th thoracic vertebra. A small intestinal ileus was initially suspected. Following the radiographic examination, abdominal ultrasound was performed. In the left mid and caudal abdomen there were two thin-walled gas-containing tubular structures. One had the typical layered appearance of an intestinal wall and represented the descending colon. The second structure had a similar thickness but homogenously hypoechoic wall and contained gas and echogenic fluid in the lumen. By use of several positional changes of the dog aiming to alter the location of the intraluminal gas, the second structure was traced to the right ovary cranially and the uterine body caudally, confirming that the structure was the right uterine horn. A final diagnosis of emphysematous pyometra was made.

Conclusion

Ultrasound can be used as a non-invasive diagnostic method to differentiate between small intestinal ileus and emphysematous pyometra.

     

Capacities of transabdominal ultrasound study in the diagnosis of polyps of the stomach and colon

The data obtained from studies of 84 patients with polyps of the stomach and colonic were used to consider the capacities of transabdominal and transrectal ultrasound studies and their diagnostic efficiency in the diagnosis of polyps of the stomach and colon. The ultrasound semiotics of polyps of the gastric and colon was described. A place of transabdominal ultrasound sonography (US) in the algorithm of radiation and endoscopic studies was established. This investigation led to the conclusion that transabdominal US, along with indirect diagnosis, permits solution of number of fundamental problems facing prior to polypectomy--these are primarily to define the nature of a detected polyp (epithelial and non-epithelial), based on an analysis of the laminar structure of the wall of an organ at the polyp base, a possible polyp malignancy and the degree of invasion into the depths of the gastric wall, as well as to detect a feeding vessel (in the CDC mode) and to predict the likelihood of possible complications. It is advisable to use transabdominal US in a complex of diagnostic techniques for polyps of the stomach and colon.     

Comparison of accuracy of transabdominal ultrasonography, progesterone and pregnancy-associated glycoproteins tests for discrimination between single and multiple pregnancy in sheep

The aim of the present study was to evaluate and, compare the accuracy of transabdominal ultrasonographic (US) and the progesterone (P4-RIA) and ovine pregnancy-associated glycoprotein (ovPAG-RIA) tests for the discrimination between single and multiple pregnancy in sheep. One hundred pregnant AwassixMerino ewes were scanned by transabdominal ultrasonography (3.5 MHz linear-array transducer) at Days 43-56 and 81 of these ewes were scanned at Days 76-87 of gestation. The ewes were scanned in dorsal recumbency at the bare area of the inguinal regions (without pre-scanning shaving of the ventral abdominal wall). After each scan, blood samples were withdrawn from the jugular vein to estimate the levels of P4 and ovPAG by radioimmunoassay. At lambing, 61 ewes gave birth to single lambs and 39 ewes gave birth to multiples. The sensitivity of the transabdominal US, the P4-RIA and the ovPAG-RIA tests for determining ewes carrying multiples was 54, 64.1 and 64.1% at Days 43-56. At Days 76-87 of gestation these accuracies were 60.0, 66.7 and 76.6% for the US, P4-RIA and PAG-RIA tests, respectively. The specificity of the transabdominal US, the P4-RIA and the ovPAG-RIA tests for determining ewes carrying singles, was 78.6, 60.7 and 62.3% at Days 43-56 and 78.4, 64.7 and 70.6% at Days 76-87 of gestation, respectively. It is concluded that the accuracy of transabdominal ultrasonographic (without pre-scanning shaving of the ventral abdominal wall), the P4- and the ovPAG-RIA tests for determination of the fetal numbers in AwassixMerino crossbred ewes is too low to be used in the field.     

Possibilities of radiologic methods (ultrasonography, computed tomography) in the preoperative evaluation of intramural invasion of gastric cancer

By analyzing the findings in 72 patients with gastric cancer, the authors show the potentialities of noninvasive techniques of radiation diagnosis (transabdominal ultrasonography (USG) and X-ray computed tomography (CT) in the preoperative evaluation of the T-stage of gastric cancer. Ultrasound and computed tomographic semiotics of intramural invasion of gastric carcinoma is made. Ultrasonography was found to have the highest specificity in detecting early-stage gastric cancers prior to computed tomography. In the authors' opinion, a complex use of the data obtained by these techniques reveals the degree of invasion of gastric carcinoma and its extent with high precision. Transabdominal USG and CT should rank with the initial methods used for diagnosing gastric cancer. Transabdominal USG should be most expediently used as an initial technique of the above studies, by taking into account its wide accessibility, easiness-to-use, and lack of radiation load.     

Potential use of current X-ray contrast studies in the detection of small intestinal polyps in the Peutz-Jeghers syndrome

The paper presents the results of studies of the small bowel in 9 patients with the Peutz-Jeghers syndrome. The indications for the study were the clinical picture of gastrointestinal bleeding and the symptoms of ileus. The author's intubation enterographic procedure using the better composition of barium suspension and an infusion system for administering contract substances into the small bowel, an improved fractional contrasting procedure, and a procedure employing the agent Entero-view was applied for contrasting the small bowel. All the procedures revealed an obvious picture of polyposis of the small bowel. The minimum size of detected tumors was 0.3-0.4 cm in diameter. Emphasis is laid on the quantitative image of neoplasms with Entero-view and the therapeutic effect of intubation enterography in evolving small-small intestinal intussusception.     

Electron microscopic studies on the small intestinal mucosa of rats after mechanical intestinal obstruction and ischemia

Ultrastructural changes in the small intestine during the early phase following mechanical obstruction were compared with those after vascular ligation. In both experiments (the early phase of mechanical ileus and ischemia) intestinal epithelial cells at the tips of villi showed common features. One of the most significant changes was an alteration in microvilli, with fragmentation into vesicles, narrowing of apical microvilli and decrease in number. The other change was fatty degeneration of the epithelial cells, which was accompanied by vesiculation of smooth endoplasmic reticulum beneath the terminal webs, fat deposition and dilated Golgi complex containing fat. These observations suggest that in the early phase of mechanical ileus, ischemic damage plays an important role.     

Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation: a case report

Background

Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation is extremely rare. This type of internal hernia has rarely been described before. Preoperative diagnosis is difficult and prone to misdiagnosis.

Case presentation

A 38-year-old Chinese woman was an emergency admission to our hospital with a sudden onset of acute epigastralgia for the past 14 hours. We made a presumptive diagnosis of gastrointestinal perforation and septic shock. Due to the acute onset and rapid progress, she received timely surgical treatment. During operation, we observed that her small intestine herniated into the hepatogastric ligament and ligamentum gastrocolicum hiatus accompanied with intestinal malrotation that resulted in internal hernia. We found a diverticulum of approximately 3.0?×?6.0 cm sited at a distance of 80 cm from the ileocecal intestine. We resected the strangulated intestinal loop and the diverticulum, performed an appendicectomy, and closed the ligamentous fissure. Postoperation, she recovered smoothly, without any complications, and was discharged on day 6.

Conclusions

A case of internal hernia formation is quite rare; accurate preoperative diagnosis and timely surgery are essential because it can cause strangulation of the ileus. However, the incidence of this internal herniation is low and preoperative diagnosis is difficult. An accurate preoperative diagnosis of internal hernia is still a challenge.

     

Íleo biliar como causa de dolor abdominal en el paciente anciano

Gallstone ileus is a rare and potentially serious complication of cholelithiasis. It is defined as a mechanical intestinal obstruction secondary to the presence of a gallstone in the intestinal luz. The most frequent cause is impaction of the calculus in the ileum after passing through a bilioenteric fístula. It has a high morbidity and mortality rate, mainly due to the difficulty and delay in its diagnosis. A retrospective study is presented of 4 cases of gallstone ileus treated between 2013 and 2017 in the Hospital Nuestra Señora del Prado. An analysis was performed on the clinical characteristics, diagnostic tests, and surgical treatment.     

New capacities of X-ray diagnosis in detection of small intestine pathology

The paper based on the data of more than 200 studies of the small bowel with the new agent Entero-VU specially designed for X-ray study of the bowel gives an objective evaluation of this agent. The authors of the paper analyze the capacities of Entero-VU in diagnosing 38 cases of Crohn's disease, tuberculosis and tumors of the small bowel. Moreover, as a separate section the paper provides an assessment of the agent in mapping the X-ray standards of the small bowel. In the authors' opinion, the use of this agent as though fills the existing gap in the X-ray study of the small bowel.