BACKGROUND Small bowel obstruction (SBO) is a common surgical emergency, most frequently caused by postoperative adhesions or hernias. SBO resulting from migration of an intrauterine device (IUD) is exceedingly rare but can be life‑threatening. CASE REPORT We present 2 cases of postmenopausal women with long-term IUD retention (>30 years) who developed acute abdominal pain and clinical signs of intestinal obstruction. Preoperative abdominal CT revealed dilated small bowel loops with surrounding fluid and inflammatory changes, along with an ectopic ring-shaped IUD through which a segment of ileum herniated. Emergency laparotomy confirmed a strangulated obstruction and necrotic bowel in both cases, which required segmental bowel resection and primary anastomosis. Postoperative recovery was uneventful in both patients. A review of the literature indicates that such complications predominantly occur in postmenopausal women. Prolonged device retention, particularly with O-shaped IUDs, is associated with older age at presentation. Progressive uterine atrophy and myometrial thinning after menopause increase the risk of chronic erosion and eventual perforation with intraperitoneal migration. If the IUD is not encapsulated by the omentum, it provides an opportunity for small bowel loops to herniate through its central opening, ultimately resulting in strangulated intestinal obstruction. CONCLUSIONS These cases highlight the importance of recognizing IUD migration as a rare cause of mechanical small bowel obstruction, especially in women with a remote history of IUD placement. Prompt imaging evaluation and timely surgical intervention are critical to prevent bowel ischemia and reduce morbidity.

Mesenteric ischemia (MI) represents a spectrum of vascular intestinal injuries for which delayed diagnosis remains the leading determinant of outcomes. Despite advances in multidetector CTA technology and endovascular therapy, substantial variation persists in how mesenteric ischemia is defined, imaged, interpreted, and incorporated into clinical pathways. This AJR Expert Panel Narrative Review provides radiologists with pragmatic guidance for mesenteric ischemia evaluation on imaging. Key issues considered include the pathophysiologic spectrum and diagnosis of acute mesenteric ischemia (AMI); CT protocol optimization (including the role of spectral CT); vascular pathologies that lead to occlusive or nonocclusive AMI; CT features associated with ischemia and necrosis; scoring systems for estimating necrosis likelihood; interventional and surgical management; evaluation of postischemic reperfusion; chronic mesenteric ischemia; and the emerging role of dedicated mesenteric stroke centers in reducing time to revascularization. A simplified four-phase framework is presented to illustrate the temporal progression of CT findings in occlusive arterial AMI from occlusion without visible bowel ischemia, to early ischemia, late ischemia, and irreversible transmural necrosis. The article concludes with consensus statements addressing image acquisition, interpretation, and reporting, with the aim of supporting radiologists who serve as first-line decision makers in the diagnosis and management of mesenteric ischemia.

Nonocclusive mesenteric ischemia (NOMI) is an underappreciated and lethal sequelae of cardiogenic shock (CS), forming the bulk of acute mesenteric ischemia in critically ill patients. In the setting of CS, reduced cardiac output, exposure to high doses of vasopressors, and nonpulsatile mechanical circulatory support (MCS) result in a "perfect storm" of hemodynamic insults to the splanchnic circulation. Mortality from NOMI in this population exceeds 70-90%, largely attributable to late diagnosis after irreversible transmural necrosis has already occurred. In this review, we describe the pathophysiology of NOMI in the setting of CS, considering the effects of sympathoadrenergic and renin-angiotensin mediated vasoconstriction, the loss of mesenteric pulsatility due to contemporary MCS, and the gut-heart axis as an enhancer of systemic injury. We address topics such as the under detection of limb ischemia with current imaging modalities, the potential of new markers of gut dysfunction, such as intestinal fatty acid-binding protein and citrulline, and bedside imaging, including contrast-enhanced ultrasound and assessment of portal vein pulsatility. We review strategies for prevention and management, including early MCS escalation, minimizing vasopressor requirements, and careful enteral feeding. Finally, we recognize the need for prospective multicenter registries and AI-based risk stratification to facilitate the diagnosis of this under-recognized condition. Understanding that the gut is not a "mere" bystander in the pathophysiology of CS, but rather a central participant, it may be the gateway to reducing the ongoing high mortality of this syndrome.

Appendicitis is a common cause of acute abdominal emergencies, but mechanical small bowel obstruction due to appendicealtie syndrome is rare. We present a 30-year-old healthy female patient with a typical presentation of febrile intestinal obstruction with multiple central air-fluid levels on an erect abdominal X-ray. During laparotomy, a phlegmonous appendix was found encircling and strangulating the terminal ileum with no signs of bowel ischemia. A simple appendectomy was performed, relieving the obstruction. Postoperative recovery was uneventful aside from a superficial wound infection. Appendiceal tie syndrome is a rare entity that can present as febrile small bowel obstruction in patients of any age group. The diagnostic value of advanced imaging remains uncertain and clinical suspicion is of paramount importance. Timely surgical intervention leads to improved outcomes. Simple appendectomy may result in resolution of obstruction and clinical symptoms if affected bowel segments are viable despite delayed presentation.

Large bowel obstruction (LBO) accounts for approximately one-quarter of all intestinal obstructions. LBO may arise from mechanical obstruction due to benign or malignant etiologies, or from functional obstruction such as acute colonic pseudo-obstruction. Because clinical presentation varies by acuity, etiology, and ileocecal valve competency, early recognition and prompt evaluation are essential to prevent complications, including ischemia and perforation with potential for sepsis and mortality. Patients with acute obstruction typically present with abdominal pain, distension, and obstipation, whereas malignant obstruction often develops gradually with progressive constipation and abdominal distension, leading to dehydration, electrolyte abnormalities, and malnutrition. Computed tomography has become the preferred diagnostic modality due to its ability to identify the transition point, help define the cause and severity of obstruction, and potentially detect complications such as ischemia or perforation. Endoscopy serves both diagnostic and therapeutic roles in selected patients, including detorsion for sigmoid volvulus, decompression for pseudo-obstruction, and tissue diagnosis or stent placement in malignant obstruction. Initial management focuses on resuscitation, correction of electrolyte abnormalities, mitigation of aspiration risk, and gastrointestinal decompression. Definitive management depends on the underlying etiology. Malignant LBO requires individualized planning based on tumor location, patient physiology, and institutional expertise, with options including oncologic resection with or without colostomy, proximal surgical diversion and staged resection, or endoscopic stenting with staged resection. Self-expanding metallic stents may serve as bridges to surgery and reduce the need for a stoma. Benign causes, including diverticular strictures, volvulus, inflammatory bowel disease-related strictures, anastomotic strictures, and fecal impaction, require tailored endoscopic or operative interventions. Across etiologies, short delays to intervention may be appropriate for stable patients undergoing optimization; however, early definitive management should be the usual approach. In cases where intervention is delayed, careful surveillance for developing ischemia or perforation is mandatory (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved).

Small bowel obstruction due to ingested fruit pits is rare and often underrecognized. In exceptional cases, these foreign bodies may mimic the clinical and imaging features of gallstone ileus, a complication of cholelithiasis involving biliary-enteric fistula formation and gallstone migration into the intestinal lumen. Such presentations may lead to misdiagnosis and inappropriate management. This case highlights an uncommon but clinically relevant diagnostic pitfall: a pseudo-gallstone ileus caused by an impacted apricot pit in a patient with a prior ileocolic anastomosis. An Italian Caucasian 49-year-old woman presented with acute abdominal pain and vomiting. Her medical history included a remote ileocolic resection for intestinal ischemia. Physical examination revealed a diffusely tender abdomen without signs of peritonitis. Biochemical investigations showed mild hepatopancreatic enzyme elevation and a low-grade inflammatory response. Plain abdominal radiography demonstrated radiopaque intraluminal structures in the right iliac fossa and features of small bowel obstruction. Contrast-enhanced computed tomography confirmed mechanical obstruction above a prior ileocolic anastomosis, with three hyperdense intraluminal masses in the distal ileum and calcified gallstones in the gallbladder. Although no aerobilia or biliary-enteric fistula was detected, imaging raised suspicion of gallstone ileus. Colonoscopy revealed a stenotic ileocolic anastomosis and three hard, stone-like masses in the terminal ileum. Two were endoscopically mobilized into the colon; the third resisted lithotripsy. Magnetic resonance cholangiopancreatography showed no evidence of biliary-enteric fistula. On repeat endoscopy, after balloon dilation of the anastomosis, the remaining object was retrieved and identified as an apricot pit. Upon questioning, the patient recalled recent ingestion of stone fruits. The final diagnosis was mechanical small bowel obstruction from an impacted fruit pit mimicking gallstone ileus. The patient recovered fully and was discharged with dietary recommendations. This case underscores the importance of considering alternative diagnoses when imaging suggests gallstone ileus, especially in the absence of a biliary-enteric fistula. Radiologists and clinicians should be aware that ingested fruit pits may resemble calcified biliary calculi on cross-sectional imaging. A high index of suspicion and multidisciplinary collaboration are essential to avoid misdiagnosis and unnecessary surgical intervention.

Ileo-ileal knotting is a rare, life-threatening cause of small bowel strangulation. Preoperative diagnosis is challenging, and hemorrhagic ascites in reproductive-age women may mimic gynecologic emergencies. A 33-year-old Ethiopian female presented with sudden abdominal pain, vomiting, obstipation, and hemorrhagic shock. Ultrasonography showed dilated small bowel loops and echogenic free fluid, suggesting ruptured ovarian cyst. Due to instability, computed tomography was omitted. Emergency laparotomy revealed 2000 ml of hemorrhagic ascites with normal ovaries and no gynecologic bleeding. An ileo-ileal knot with 180 cm of gangrenous bowel was found; hemorrhagic ascites resulted from transmural ischemia with venous congestion. The gangrenous segment was resected, and stoma created. Short bowel syndrome ensued. Staged jejuno-ileal anastomosis was performed 1 week later with good recovery. This case confirms that hemorrhagic ascites in women does not exclude intestinal strangulation. Early surgical exploration is lifesaving when closed-loop obstruction is suspected.

Acute mesenteric ischemia (AMI) is the sudden onset of small intestinal hypoperfusion, commonly due to thromboembolic obstruction of mesenteric vessels. Due to nonspecific symptoms at presentation, diagnosis can often be delayed until the condition rapidly progresses. Additionally, these factors likely contribute to AMI's high mortality rate, highlighting the importance of early diagnosis and intervention. Traditionally, AMI is managed with open abdominal surgery (e.g., embolectomy, bowel resection). However, alternative treatment methods have evolved, including endovascular techniques such as thrombolysis, which offer targeted therapy while preserving bowel integrity. The following case presents the management of a patient with mild mesenteric ischemia treated with the lesser-utilized catheter-directed thrombolysis.

Acute mesenteric ischaemia is a life-threatening cause of abdominal pain caused by sudden intestinal hypoperfusion. While most cases are related to cardio-embolic events or thrombosis of a pre-existing atherosclerosed vessel in patients with significant cardiovascular risk factors, rarely, it may be the initial manifestation unmasking an underlying systemic vasculitis. We describe a case of polyarteritis nodosa causing mesenteric ischaemia, based on the presence of an inflammatory state and characteristic radiological findings of medium-vessel vasculitis. After treatment with high-dose intravenous corticosteroids and induction of cyclophosphamide therapy, the patient's symptoms resolved, inflammatory markers normalised, and he had stable radiological findings prior to discharge.

Hereditary protein S deficiency is a rare thrombotic disease caused by pathogenic variants in the PROS1 gene, predisposing individuals to an increased risk of venous thromboembolism. A 41-year-old male patient with a history of cerebral venous sinus thrombosis presented to the emergency department with acute abdominal pain and hematochezia. Contrast-enhanced computed tomography showed portal, splenic, and superior mesenteric venous thrombosis. Complicated by acute intestinal ischemia, the patient underwent emergency bowel resection. Laboratory assays demonstrated markedly reduced protein S activity. Next-generation sequencing identified a heterozygous deletion in the PROS1 gene, resulting in a frameshift mutation and the creation of a premature termination codon. To date, this variant has not been previously reported, representing a novel pathogenic mutation of the PROS1 gene. This case highlights the critical importance of investigating hereditary thrombophilia in young patients presenting with acute abdominal pain and unprovoked thrombosis at atypical sites, facilitating timely diagnosis and appropriate long-term management.