EBD is safe for both primary and post-surgical strictures. Stricture length and diameter of dilatation are predictive of success. In selected patients, treatment with EBD may reduce or delay the need for surgery.
Phytobezoars are a rare cause of small bowel obstruction (SBO), which consists of vegetable matter such as seeds, skins, fibres of fruit and vegetables that have solidified. We present the case of a 61-year-old man with no previous surgery who presented with central abdominal pain, nausea and vomiting. An abdominal CT scan demonstrated SBO with a transition point in the left anterior abdomen. He proceeded to a laparoscopy, which revealed multiple perforations throughout the small bowel, from the proximal jejunum to the terminal ileum. Laparotomy was performed, and undigested chestnuts were milked out through the largest perforation and the perforations were oversewn. While obstruction due to phytobezoars is rare, this case demonstrates the importance of considering small bowel trauma and perforation due to phytobezoars and highlights the need for close inspection of the entire gastrointestinal tract for complications in the setting of phytobezoar-related bowel obstruction.
There is a clinically significant baseline rate of asymptomatic pulmonary emboli in patients with stage III and IV colorectal cancer that can be demonstrated on the staging chest CT scan. Pulmonary emboli described as a post-operative event in previous series may have been present prior to surgery.
Faecal incontinence poses a difficult management scenario in the care of the critically ill. It has been established that faecal incontinence is a risk factor for pressure ulcers 1 and transmission of nosocomial infection. 2 Faecal incontinence in the critically ill can prolong stay and increase treatment cost and the rates of morbidity and mortality. 3 A current faecal containment strategy is the use of the Flexi-Seal faecal management system (FMS; Flexi-Seal FMS, ConvaTec, a Bristol-Meyers Squibb Company, Princeton, NJ, USA). It has a double lumen silicone catheter with a balloon that is inserted into the rectum and lies at the anorectal junction; this is filled with 45 mL of water. Indications for use include incontinence of semisolid or liquid stool. It is considered safe and used internationally in intensive care units (ICUs). 4 This case report describes rectal ulceration causing bleeding likely due to the use of the Flexi-Seal FMS.A 74-year-old male patient was transferred from a peripheral hospital with an occluded venous outflow of his radiocephalic arteriovenous fistula (AVF) formed 3 months prior and computed tomography (CT) proven sigmoid diverticulitis. His history included end-stage renal failure for which he had received dialysis for a year, a nephrectomy 1 month prior for renal cell carcinoma and gastroesophageal reflux disease. On ultrasound of his AVF, it was found that there was a non-occlusive thrombus of the subclavian vein for which he was treated with enoxaparin (70 mg daily). On day 6 of his admission, he developed haematemesis and melaena; subsequently, he underwent gastroscopy and his anticoagulation was ceased. Gastroscopy was repeated on day 9 for the same symptoms. Both studies demonstrated oesophagitis. He was admitted to the ICU; he had developed diarrhoea and perineal excoriation (Clostridium difficile toxin was present) and received a FMS on day 10 of his admission. After 1 day with the FMS, he passed bright red blood and fresh clots via the device. After 2 days the FMS was dislodged on passage of blood and clot and was replaced. A CT angiogram was performed and suggested extravasation of contrast in the rectum (Fig. 1). Colonoscopy was performed without bowel preparation, which demonstrated an almost circumferential ulceration in the rectum 12 cm from the anal verge (Fig. 2). The FMS was not replaced.He was discharged to the ward after 10 days in ICU and no further intervention was required for gastrointestinal bleeding.The FMS is an alternative means of faecal diversion without an invasive procedure and the associated skin complications of incontinence. However, the FMS is not without risk. Padmanabhan et al. conducted a prospective trial of 42 patients concerning the use of the FMS for incontinence and diarrhoea. They reported five deaths (12%), two patients (5%) with skin breakdown and fever in one patient (2%), which were all unrelated to the FMS. Eleven patients had colonoscopy prior to and post the use of the FMS, demonstrating no change to the rectal mucosa. The author rep...
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