Research Article - Journal of Gastroenterology and Digestive Diseases (2018) Volume 3, Issue 1

A study on the pathology of acute intestinal obstruction in Upper Egypt.

*Corresponding Author:

Dalia M. Badary
Faculty of Medicine, Department of Pathology, Assuit University, Al-Gamaa Street, Assiut, Egypt.
Tel: 00201066189050
E-mail: hamasat82@yahoo.com

Accepted date: May 16, 2016

Citation: Badary D, Hassan H, Omar AH, et al. A study on the pathology of acute intestinal obstruction in Upper Egypt. J Gastroenterol Dig Dis. 2018;3(1):22-28.

Abstract

Acute intestinal obstruction remains a major clinical presentation of Egyptian patients in Upper Egypt. The current study was conducted to speculate on cases of acute intestinal obstruction from a clinico-histopathological point of view. The study was retrospective, included 186 patients presented with acute intestinal obstruction during the period from January 2009 to December 2017. Male patients were a bit more commonly affected than females. It is apparent from this study that acute on top of chronic intestinal obstruction is still a major problem. The research was aiming at finding the most common histopathological findings in representative cases of acute intestinal obstruction. Adenocarcinoma of the intestine took the priority of cases in the represented biopsies (27%), followed by reactive hyperplasia of mesenteric lymph nodes (10%), non- Hodgkin's lymphoma (7%) and mesenteric vascular occlusion (5%). We observed that patients with biopsy diagnosis as adenocarcinoma and non-Hodgkin's lymphoma had been complaining of symptoms of chronic intestinal obstruction over many years before the development of acute obstruction. So, from this point, the doctors in all specialties (gastroenterology, surgery, and histopathology) must consider cases of chronic intestinal obstruction seriously, as these lesions often predispose to acute intestinal obstruction. They should always keep on eye to guard against any complication including acute intestinal obstruction. From this study, we could determine many pathological effects of acute intestinal obstruction such as hemorrhagic infarction, gangrene of the intestine and peritonitis. These effects represented in our study about (12%) of the studied cases, half of these cases presented by hemorrhagic infarction of intestine. For affected patients, high-quality surgical expertise coupled with sound clinical judgment and early surgery when needed, confirmed with the histopathological diagnosis will greatly prevent complications and improve survival. Furthermore, a general improvement in healthcare infrastructure, especially in the rural communities, could further reduce mortality as patients may then present early.

Keywords

Obstruction, Adenocarcinoma, Infarction.

Introduction

Intestinal obstruction involves a partial or complete blockage of the intestine that results in the failure of the intestinal contents to pass through [1]. The obstructing mechanism can be mechanical or non-mechanical. Mechanical factors can be anything that causes a narrowing of the intestinal lumen (e.g., inflammation or trauma to the bowel, neoplasms, adhesions, hernias, volvulus, or a compression from outside the intestinal tract [2] Nonmechanical factors include those that interfere with the muscle action or innervation of the bowel: paralytic ileus, mesenteric embolus or thrombus, and hypokalemia.

Eighty percent of bowel obstructions occur in the small intestine; the other 20% occur in the colon [3]. Intestinal obstructions are frequently seen in the ileum. Small intestinal obstructions are caused frequently by adhesions or hernias, whereas large intestinal obstructions are caused commonly by carcinomas, volvulus, or diverticulitis. The presentation of obstruction will relate to whether the small or large intestine is involved. The most common malignancies that cause bowel obstruction are cancers of the colon, stomach, and ovary. Extra-abdominal cancers (such as lung and breast cancers and melanoma) can spread to the abdomen, causing intestinal obstruction [4]. Patients who have had abdominal surgery or abdominal radiation are also at higher risk of developing intestinal obstruction. Intestinal obstructions are most common during advanced stages of disease [5].

Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive constipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis [6]. If left untreated, intestinal obstruction can cause serious complications. As the intestine becomes congested, its ability to absorb food and fluids decreases. Decreased absorption may cause vomiting, dehydration and, eventually, can result in kidney failure, which may cause shock. Intestinal obstruction can also cut off the blood supply to the affected portion of the intestine. If left untreated, lack of blood causes the intestinal wall to die it could result in infection and/or gangrene. Tissue death can result in a perforation of the intestinal wall, which can lead to peritonitis which leads to shock [7].

Intestinal obstruction is a serious medical emergency need rapid intervention. Management options include medical therapy, surgical therapy, endoscopic therapy and interventional radiologic therapy. Self- expandable metal stents (SEMS) have gained acceptance for alleviating acute malignant colonic obstruction and in some situations for the pre-operative relief of acute benign colonic obstruction [8].

This study is done aiming at:

1. Speculation of the common causes of acute intestinal obstruction in Upper Egypt.

2. Exploration of the types of lesions that cause the obstruction.

3. Determination of the pathological effects of obstruction in terms of infarction, gangrene, hemorrhage, toxemia, extra.

Materials and Methods

The present study was undertaken at the General Histopathology Laboratory, Pathology Department, Assuit University Hospitals, Assuit. Records and paraffin blocks of one hundred and eighty-six cases presented with acute intestinal obstruction and submitted for histopathological diagnosis during the period from January 2009 to December 2017 were retrieved and revised for speculating the common causes of acute intestinal obstruction and the pathological effects of the obstruction.

Clinical information

Clinical data were retrieved from the clinical referral reports for all cases including age and sex of patients as well as the clinical presentations and the operative findings of each case.

Histopathological information

The H&E stained sections were examined and additional paraffin sections were prepared when required. Each case was revised and the histopathological findings of each case were recorded. The histopathological, the clinical and the operative findings are tabulated and simple correlation between each finding is extracted from these tables to outline the pattern of acute intestinal obstruction in Upper Egypt.

Results

This study was undertaken primarily to establish the causes of acute intestinal obstruction, explore different types of lesions responsible for obstruction and find out various pathological effects of intestinal obstruction in upper Egyptian patients. One hundred and eighty-six cases presented with acute intestinal obstruction were delivered to histopathology laboratory of Assiut University throughout the nine-year period from January 2009 to December 2017.

They were 98 males and 87 females with a male to female ratio 1.1:1. Figure 1 shows the age distribution of cases presented with acute intestinal obstruction. There were two peaks of age found in the present study. The first and sixth decades of life represented the most common ages of presentation, representing (19%) of cases for each decade. The most common causes of acute intestinal obstruction in the first decade of life found in the present study are Non-Hodgkin's lymphoma and reactive hyperplasia of mesenteric lymph nodes representing (19.4%) of total cases presented at this age for each cause. However, in the fifth decade of life neoplastic lesions (adenocarcinoma) were found to be the most common cause of acute intestinal obstruction representing (47.2%) of total cases presented at this age.

Figure 1: Age distribution of 186 cases of acute intestinal obstruction.

Regarding the clinical presentations of the studied cases, we found that most cases of acute intestinal obstruction, (86%) were on top of chronic intestinal obstruction, (6.5%) were due to adhesive intestinal obstruction, (3.2%) were due to strangulated hernia, (3.2%) were due to intussusception and (1%) were due to volvulus (Figure 2). In (76%) of the studied cases the cause of acute intestinal obstruction was intestinal in origin. However, the remaining group (24%) the obstruction was due to extraintestinal causes e.g. bands of adhesions, peritoneal causes, retroperitoneal mass, pelvic masses and ovarian metastases. There were many operative findings found in cases of acute intestinal obstruction but the most common operative findings in our study was colonic masses which represents (25%), followed by gangrenous loops of intestine (11%), mesenteric lymph nodes enlargement (10%), small intestinal masses (9%) and intestinal perforation (8.6%). After histopathological examination of representative biopsies for each case of acute intestinal obstruction, we found that the most common type of lesion causing acute intestinal obstruction was adenocarcinoma of the intestine (27%) followed by reactive hyperplasia of mesenteric lymph nodes (10%), Non-Hodgkin’s lymphoma (7%) and mesenteric vascular occlusion (5%). We also observed that the most common effect of acute intestinal obstruction was hemorrhagic infarction of intestine (6%) (Table 1).

Figure 2: Clinical presentations of 186 cases of acute intestinal obstruction.

Table 1: Demonstrates the histopathological findings in cases presented by acute intestinal obstruction.

Discussion

Acute intestinal obstruction remains a frequently encountered problem in abdominal surgery and a common surgical emergency [9], which is a frequent cause of admissions to hospital emergency surgical departments [10]. Acute intestinal obstruction may occur at any age and may be mechanical or dynamic, simple or strangulated; may occur in the small or large intestine [11].

In our study group; there is the slight prevalence of cases of acute intestinal obstruction in males over females with a ratio 1.1:1. A finding is consistent with previous studies [12-16] However, other studies have opposite results were females more commonly affected than males [17-20]. These findings of different studies are demonstrated in Tables 2 and 3. From Table 2 we observed that studies done by Feldman et al., Fevang et al. and Franklin et al. [21-23] showed the wider incidence of occurrence of acute intestinal obstruction between males and females. Regarding the age of our patients, the first and sixth decades of life represent the most common age of presentation by acute intestinal obstruction. After comparison of our results with results of other literature we found variability in most common age of presentation, two of these studies are inconsistent with our study [24]. However other studies which made by Glenn et al. [25] showed different age incidence. In these studies, acute intestinal obstruction more commonly occurs in fourth and seventh decades of life (Table 3). These findings might be due to the group of study. Regarding the clinical presentations of the studied cases, we found that nearly all the cases presented by an acute intestinal obstruction on top of chronic (86%) and this finding is consistent with result observed by Gollub [26] in his study. However, other studies done by Gürleyik [27] found that adhesive intestinal obstruction is the most common cause which may represent late presentation of the cases of inflammatory and malignant conditions affected intestine and due to increased incidence of post-operative adhesions. Strangulated hernia represents the major cause of acute intestinal obstruction in studies done by Paran, Harouna and Harris [28-30] (Table 4). I think most of these groups are Japanese where colonic cancer is not common in this community since it was the most common cause of intestinal obstruction in our study group. Small intestinal obstruction represents the most common site of intestinal obstruction (37.1%) in our study group and this result is in agreement with all other studies done by Herbert, Hladik and Horton [31-33] (Table 5). Regarding the histopathological findings, only a few studies on acute intestinal obstruction have described the histopathological findings in their results, as they classified their causes as neoplastic and non-neoplastic findings but not in detail. In the studied cases we found that adenocarcinoma is the most common cause of acute intestinal obstruction (27%) [neoplastic and non-neoplastic causes] and it is mostly presented by colonic masses (20%), and after correlation of this result with other results of few studies did on the histopathological aetiologies of acute intestinal obstruction we found that [34] are in agreement with us that adenocarcinoma is the most common neoplasm causing intestinal obstruction however, study which done by in Italy found that lymphoma is the most common neoplasm causing intestinal obstruction, however, in our study lymphoma represents the second common cause of intestinal obstruction after adenocarcinoma (7%) and mainly presented by small intestinal masses (4%) (Table 6). This finding due to demographic distribution of cancer and also probably due to the difference in the age of the study group [35-42].

Table 2: Demonstrates sex distribution in different studies on acute intestinal obstruction.

Table 3: Demonstrates age distribution of acute intestinal obstruction in different studies.

Table 4: Demonstrates the clinical presentations of acute intestinal obstruction in different studies.

Table 5: Demonstrates different sites of acute intestinal obstruction in different studies.

Table 6: Demonstrates histopathological findings of cases presented by an acute intestinal obstruction in different studies.

Metastatic adenocarcinoma is the third cause of intestinal obstruction in the present study representing (4.3%) and all these cases are presented as extraintestinal masses predispose to intestinal obstruction mostly as omental masses (37.5%), disseminated intra-abdominal malignancy (25%) and (12.5%) were from peritoneal seedlings, retroperitoneal masses, and ovarian metastases [43-50]. Mucoid carcinoma represented (3%) of the present studied cases and operatively represented mostly by colonic masses. Carcinoid tumor and signet ring carcinoma are the histopathological findings in 2% of cases. 0.5% of the studied cases is considered the percentage of each undifferentiated carcinoma, malignant GIST, and adenocarcinoid tumor [51-62]. Benign neoplastic lesions presented by acute intestinal obstruction represent about 5.6% of cases. They were either polyps (4%), lymphangioma (1.1%) and (0.5%) of the studied cases for each lipoma and villous adenoma. Inflammatory conditions in different forms represent (10%) of cases. Crohn's disease and tuberculosis of the intestine were the most two common two causes of inflammatory conditions causing acute intestinal obstruction representing about (53%) of inflammatory cases.

Diverticulae are confirmed histopathologically as 2% of cases presented by acute intestinal obstruction, half of these cases are intestinal obstruction due to Meckel's diverticulum [63-72]. Intestinal adhesions are confirmed histopathologically in about 1% of cases presented by adhesive intestinal obstruction. In a study published by Miller and his colleagues in 2000 in Montreal, Canada shows that adhesions in their histopathological findings represent the most common cause of acute intestinal obstruction (Table 6).

In 4% of the studied cases marked lymphoid hyperplasia in the intestinal wall was the cause of acute intestinal obstruction and it has two forms of presentation operatively as intestinal masses and intestinal perforations. Reactive hyperplasia of mesenteric lymph nodes predisposes to acute intestinal obstruction in 10% of the studied cases and all these cases found operatively as enlarged mesenteric lymph nodes [73-80]. Mesenteric vascular occlusion was found in 0.5% of the studied cases of acute intestinal obstruction. Neonatal intestinal obstruction was presented histopathologically as congenital megacolon, necrotizing enterocolitis in about 14% of presented by an acute intestinal obstruction in the first decade of life. In 11.3% of cases of acute intestinal obstruction were presented by complications in form of hemorrhagic infarction (6%) of cases, peritonitis (3.2%) and gangrene (2.1%) [81-86].

Conclusion

From this study, we could determine many pathological effects of acute intestinal obstruction such as hemorrhagic infarction, gangrene of the intestine and peritonitis. These effects represented in our study about (12%) of the studied cases, half of these cases presented by hemorrhagic infarction of intestine. For affected patients, high-quality surgical expertise coupled with sound clinical judgment and early surgery when needed, confirmed with the histopathological diagnosis will greatly prevent complications and improve survival. Furthermore, a general improvement in health care infrastructure, especially in the rural communities, could further reduce mortality as patients may then present early.

References

1. Acosta S, Nilsson TK,Bjorck M. Preliminary study of D-dimer as a possible marker of acute bowel ischaemia. Br J Surg. 2001;88(3):385-8. 
2. Akcakaya A, Sahin M, Coskun A, et al. Comparison of mechanical bowel obstruction cases of intra-abdominal tumor and non-tumoral origin. World J Surg. 2006;30:1295–299.
3. Altinyollar H, Boyabatli M,Berberoglu U. D-dimer as a marker for early diagnosis of acute mesenteric ischemia. Thromb Res. 2006;117(4):463-7.
4. Antonucci A, Fronzoni L, Cogliandro L, et al. Chronic intestinal pseudo-obstruction.World J Gastroenterol. 2008;14(19):2953-61.
5. Baron TH. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med. 2001;344(22):1681-687.
6. Batke M, Cappell MS. Adynamic ileus and acute colonic pseudo-obstruction. Med Clin North Am. 2008;92:649-70.
7. Beers MH, Berkow BI. In: The Merck Manual of Diagnosis and Therapy 5th ed. Merck & Co. 2004:25-27.
8. Boudiaf M, Soyer P, Terem C, et al.Ct Evaluation of small bowel obstruction. Radiographics. 2001;21(3):613-24. 
9. Buffone A, Basile G, Veroux M, et al. Neoplastic small bowel obstruction: our experience with 21 cases and review of the literature. Chir Ital. 2008;60(2):267-72.
10. Camunez F, Echenagusia A,Simo G. Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology. 2000; 216(2):492-97.
11. Cappell MS,Batke M. Mechanical obstruction of the small bowel and colon. Med Clin North Am. 2008;92(3):575-97.
12. Casella IB, Bosch M, Sousa WO Jr. Isolated spontaneous dissection of the superior mesenteric artery treated by percutaneous stent placement: A case report. J Vasc Surg. 2008;47(1):197-200. 
13. KahiCJ,Douglas RK. Bowel obstruction and pseudo-obstruction. GastroenterolClin North Am. 2003;32(4):1229-247.
14. Chi CH, Chen KW, Huang JJ, et al. Gas composition in Clostridium septicum gas gangrene. J. Formos. Med. Assoc. 1995;94(12):757–9.
15. MacutkiewiczC, Carlson GL. Acute abdomen: Intestinal obstruction. Surgery. 2005;23(6):208-12.
16. Cotran RS, Kumar V, Robbins SL.Intestinal obstruction. In: Robbins Pathologic Basis of Disease 5th ed. Philadelphia 1994;787-89.
17. MaglinteDT, Thomas HJ, Keith LD. Small-bowel obstruction: State-of-the-art imaging and its role in clinical management. Clin. Gastroenterol. Hepatol. 2008; 6(2): 130-39.
18. Dener C, Bozoklu S, Bozoklu A, et al. Adult intussusception due to a malignant polyp: A case report. Am Surg. 2001;67(4):351-3.
19. Erkan N, Haciyanli M, Yildirim M, et al. Intussusception in adults: An unusual and challenging condition for surgeons. Int J Colorectal Dis. 2005;20:452-56.
20. Catena F, Ansaloni L, Gazzotti F, et al. Small bowel tumors in emergency surgery: Specificity of clinical presentation. ANZ J. Surg. 2005;75:997–99.
21. Feldman M, Friedman LS, Brandt LJ, et al. Intestinal obstruction and ileus. In: Sleisenger&Fordtran's Gastrointestinal and Liver Disease 8th ed. Elsevier Saunders, pp. 2006:530-52.
22. Fevang BT, Fevang J, Stangeland L, et al. Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience. Ann Surg. 2000;231(4):529-37. 
23. Franklin ME Jr, Gonzalez JJ Jr, Miter DB, et al. Laproscopic diagnosis and treatment of intestinal obstruction. SurgEndosc. 2004;18(1):26-30.
24. Gayer G, Zissin R, Apter S, et al. Pictorial review: Adult intussusception – A CT diagnosis. Br J Radiol. 2002;75:185-90.
25. Glenn EM, Todd BH, DominitzAJ, et al.Acute colonic pseudo-obstruction. ‎Gastrointest. Endosc.2002;56(6):789-92.
26. GollubMJ. Multidetector computed tomography enteroclysis of patients with small bowel obstruction: A volume-rendered surgical perspective. J Comput Assist Tomogr. 2005;29(3): 401-7. 
27. Gürleyik E, Gürleyik G. Small bowel volvulus: A common cause of mechanical intestinal obstruction in our region.  Eur J Surg. 1998;164(1):51-5.
28. Paran H, Silverberg D, Mayo A. Treatment of acute colonic pseudo-obstruction with neostigmine. J Am Coll Surg. 2000;190:315–18.
29. Harouna Y, Yaya H,Abdou T. Prognosis if strangulated inguinal hernia in the adult. Influence of intestinal necrosis. A propos of 34 cases. Bull SocPaltolExot. 2000;93:317–20.
30. Harris GJ, SenagoreAJ, Lavery IC.  The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices. Am J Surg. 181(6):499-06.
31. Herbert GS, Steele SR. Acute and chronic mesenteric ischemia. SurgClin North Am. 2007;87(5):1115-34.
32. Hladik P, Raupach J, Lojik M, et al. Treatment of acute mesenteric thrombosis/ischemia by transcatheterthromboaspiration. Surgery. 2005;137(1):122-3. 
33. Horton KM. Small bowel obstruction. Crit Rev ComputTomogr. 2003;44(3):119-28. 
34. Cherta I,Forne M, Quintana S. Prolonged treatment with neostigmine for resolution of acute colonic pseudo-obstruction. Aliment PharmacolTher. 2006;23:1678–679.
35. Ihedioha U, Alani A, Modak P, et al. Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction. Hernia. 2006;10(4):338-40.
36. Ihedioha U, Mackay G, Leung E, et al. Laparoscopic colorectal resection does not reduce incisional hernia rates when compared with open colorectal resection. SurgEndosc. 2007;22: 689–92.
37. Ramage JI, Baron TH. Percutaneous endoscopic cecostomy: A case series. GastrointestEndosc. 2003;57:752–55.
38. Jenkins JT, Taylor AJ, BehrnsKE. Secondary causes of intestinal obstruction: rigorous preoperative evaluation is required. Am Surg. 2000;66(7):662-6.
39. Jung GS, Song HY, Kang SG. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology. 2000;216(3):758-63.
40. Kaleya RN, BoleySJ. Acute mesenteric ischaemia. Crit Care Clin.1995;11(2):479-12.
41. Grossman K.  Complication of intestinal obstruction. Amber J. 2008;3:60-66.
42. Kazlauskiene V, Esbjørn M, Pfleger R, et al. Acute mesenteric ischaemia in a patient with Crohn's disease. UgeskrLaeger. 2007;169(4):323-4.
43. Khaikin M, Schneidereit N, Cera S, et al. Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness. SurgEndosc. 2007;21(5): 742-6. 
44. Kirkpatrick ID, Kroeker MA, Greenberg HM. Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience. Radiology. 2003;229(1): 91-8. 
45. KoGJ, Han KJ, Han SG, et al. A case of spontaneous dissection of the superior mesenteric artery treated by percutaneous stent placement. Korean J Gastroenterol. 2006;47(2):168-72. 
46. Kozuch PL, Brandt LJ. Diagnosis and management of mesenteric ischemia with an emphasis on pharmacotherapy. Aliment PharmacolTher. 2005;21(3):201-15. 
47. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med. 2001;345(23): 1683-8.
48. LappasJC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. AJR Am J Roentgenol. 2001; 176(1):167-74. 
49. Laredo J, Filtzer HS. Right colonic intussusception. Am J Surg. 2000;179(6):485.
50. Ohene-Yeboah M. Strangulated external hernias in Kumasi.West Afr J Med. 2004;22(4):310-3.
51. Saunders MD, Kimmey MB. Systematic review: Acute colonic pseudo-obstruction. Aliment Pharmacol Therap. 2005;22:917–25.
52. Norwood MG,Lykostratis H, Garcea G, et al. Acute colonic pseudo-obstruction following major orhtopedic surgery. Colorect Dis. 2005;7:496–99.
53. Madziga AG, Nuhu AI. Causes and treatment outcome of mechanical bowel obstruction in north eastern Nigeria. West Afr J Med. 2008;27(2):101-5.
54. Markogiannakis H, Messaris E, Dardamanis D, et al. Acute mechanical bowel obstruction: Clinical presentation, etiology, management and outcome. World J Gastroenterol. 2007;13(3): 432-37.
55. McConkeySJ. Case series of acute abdominal surgery in rural Sierra Leone. World J Surg. 2002;26(4):509–13.
56. Franco MH.  Intestinal occlusion in cancer. Rev Gastroenterol Mex. 2004;69(3):100-5.
57. SaundersMD. Acute colonic pseudo-obstruction. GastrointestEndoscClin N Am. 2007;17(2):341-60.
58. Yeboah MO. Case series of acute presentation of abdominal TB in Ghana. Trop Doct. 2006;36(4):241-43.
59. MiedemaBW, JohnsonJO. Methods for decreasing postoperative gut dysmotility. The Lancet Oncology. 2003;4(6):365–72.
60. Miller G, Boman J, Shrier I, et al. Etiology of small bowel obstruction. Am J Surg. 2000;180(1):33-6. 
61. Miyamoto N, Sakurai Y, Hirokami M, et al. Endovascular stent placement for isolated spontaneous dissection of the superior mesenteric artery: Report of a case. Radiat Med. 2005;23(7):520-4. 
62. Nicolaou S, Kai B, Ho S, et al. Imaging of acute small-bowel obstruction. AJR Am J Roentgenol. 2005;185(4):1036-44. 
63. GiorgioRD, Barbara G, Stanghellini V. The pharmacologic treatment of acute colonic pseudo-obstruction. Aliment PharmacolTher. 2001;15:1717–727.
64. Mehta R, John A, Nair P. Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: A prospective study. J GastroenterolHepatol. 2006;21: 459–61.
65. Sheikh RA, Yasmeen S, Pauly MP. Pseudomembranous colitis without diarrhea presenting clinically as acute intestinal pseudo-obstruction. J Gastroenterol. 2001;36:629–32.
66. Rajesh A, Maglinte DD. Multislice CT enteroclysis: Technique and clinical applications. ClinRadiol. 2006;61(1):31-9. 
67. Ripamonti C, Mercadante S, Groff L. Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial. J Pain Symptom Manage. 2000;19(1):23-34.
68. Safioleas MC, Moulakakis KG, Papavassiliou VG. Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome. Vasa. 2006;35(2):106-11.
69. Saito Y, Uraoka T, Matsuda T. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections. GastrointestEndosc. 2007;66:966–73.
70. Salvia G, Guarino A, Terrin G, et al. Neonatal onset intestinal failure: An Italian multicenter study. J Pediatr. 2008;12:99-101.
71. Sheedy SP, Earnest F, Fletcher JG, et al. CT of small-bowel ischemia associated with obstruction in emergency department patients: Diagnostic performance evaluation. Radiology. 2006;241(3):729-36. 
72. Sleisenger MH, FordtranJS.  Intestinal obstruction and ileus. In: Sleisenger&Fordtran'sJ Gastrointestin Liver Dis. 1993:1927-948.
73. SoetiknoRM, Gotoda T, Nakanishi Y, et al. Endoscopic mucosal resection. GastrointestEndosc. 2003;57:567–79.
74. Takeuchi K, Tsuzuki Y, Ando T, et al. The diagnosis and treatment of adult intussusception. J ClinGastroenterol. 2003;36(1):18-21.
75. Tamegai Y, Saito Y, Masaki N. Endoscopic sub-mucosal dissection: A safe technique for colorectal tumors. Endoscopy. 2007;39:418–22.
76. Tan KY, Tan SM, Tan AG, et al. Adult intussusception: Experience in Singapore. ANZ J Surg. 2003;73:1044-047.
77. Thompson WM, KilaniRK, Smith BB, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: Does reviewer experience matter?.AJR Am J Roentgenol. 2007;188(3):233-8. 
78. Tintinalli J, Kelen GD, StapczynskiJS. Intestinal obstruction. In: Emergency Medicine: A Comprehensive Study Guide 6th ed. McGraw-Hill. 2004:523-26.
79. Townsend CM, Beauchamp RD, Evers BM, et al. The biological basis of modern surgical practice. In: Sabiston Textbook of Surgery 17th ed. Elsevier Saunders. 2004:230-35.
80. TurnageRT, FeldmanBP, Friedman LS, et al. Intestinal obstruction and ileus. J Gastrointestin Liver Dis. 2002:2113-28.
81. VicartoSJ, Price TG. Intestinal obstruction. In: Emergency Medicine: A comprehensive study guide.McGraw-Hill. 2000:539-42.
82. Vokurka J, Olejnik J, Jedlicka V, et al. Acute mesenteric ischemia. Hepatogastroenterology. 2008;55(85):1349-52. 
83. Berger WL, Saeian K. Sigmoid stiffener for decompression tube placement in colonic pseudo-obstruction. Endoscopy. 2000;32:54–57.
84. Wyllie P, Robert S. Ileus, adhesions, intussusception, and closed-loop obstructions. In: Nelson Textbook of Pediatrics. 2004:430-43.
85. Wysocki A, Krzywo? J. Causes of intestinal obstruction. PrzeglLek. 2001;58(6):507-8.
86. Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: A retrospective review. DCR. 2006;49:1546-551.